9/24/2015

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Welcome to

“Findings from the Nutrition Services 

Program Process Study and Meal Cost 

Analysis”

Presenters: Holly Greuling, Susan Jenkins, James Mabli and Jessica Ziegler

Facilitator: Magda Hageman

The webinar will begin at 3:30 p.m. Eastern Daylight Time

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Administration for Community Living Team

Holly Greuling, RD

Susan Jenkins, PhD
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Findings from the AOA Nutrition 

Programs Process Study and 

Meal Cost Analysis 

National Evaluation Results Webinar 

The National Resource Center on Nutrition and Aging

James Mabli• Jessica Ziegler• Rhoda Cohen• 

Erin Panzarella• Mindy Hu

September 24, 2015

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Title III-C Nutrition Services Program

(AOA Nutrition Programs) 

• Adequate nutrition is critical for people of all ages, 

but especially important for older adults

• Title III-C Nutrition Services Program (AOA Nutrition 

Programs) plays a vital role in ensuring needs of 

older adults are met

• Nutrition services

– Congregate and home-delivered meals

– Nutrition screening, assessment, education and counseling

• Other types of services

– Health promotion

– Medical screening

– Social or recreational activities
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Administration of AOA Nutrition Programs 

Administration on Aging (AoA) within 

Administration for Community Living (ACL)

AoA Central and 

Regional Offices

State Units on Aging (SUAs)

Area Agencies on Aging (AAAs)

Local Service Providers (LSPs)

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Overview of AOA Nutrition Programs 

• Funding and administration

– ACL awards grants to SUAs based on share of population aged 60 and older

– AAAs administer programs within planning and service area (PSAs)

– AAAs award grants/contracts to LSPs to provide services

– Other funding (e.g., in-kind and participant contributions, and donations)

– Congregate meals and services provided at LSP meal sites; home-delivered meals 

provided to homebound clients by meal sites, central kitchens, or other organizations

• Target population

– People aged 60 and older and their spouses of any age

– Those with greatest economic or social need

– Low-income, minority, rural, limited English proficiency, at risk of institutionalization

• Program services

– Congregate/home-delivered meals that comply with Federal nutrition standards

– Nutrition screening, education, assessment, and counseling services
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AOA Nutrition Programs Evaluation Objectives

1. Process study

– Provide information to support program planning

– Analyze program structure, administration, staffing, coordination, 

processes, and service delivery

2. Cost study

– Estimate the average cost of a congregate and a home-delivered meal

– Assess variation in costs by select characteristics of local providers

– Provide information to make funding decisions

3. Client outcomes study (ongoing)

– Assess program effectiveness using a variety of outcomes:

• Diet quality based on 24-hour dietary recall

• Food security, socialization, longer-term health and institutionalization

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Process Study
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Study Design

199 LSPs responded

(85% response rate*)

333 AAAs responded 

(92% response rate*)

56 SUAs responded 

(100% response rate*) Census of SUAs

Sample of AAAs

Sample of LSPs from 

Responding AAAs

*Response rate for web surveys; agencies also received fax-back surveys

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Survey Topic Areas

Access to Services Budget and Fiscal Consumer 

Direction

Emergency 

Services and 

Planning

Facilities and 

Equipment

Food Safety Funding/Resource 

Allocation

Integration with 

Other Programs 

and Partnerships

Medicaid Waivers

Nutrition 

Counseling, 

Education, 

Assessments

Organizational 

Structure

Quality Assurance 

and Monitoring

Participant 

Contributions

Prioritization of 

Services and 

Waiting Lists

Program 

Characteristics

Referrals State and Area 

Plans Targeting Technology and Data

Training and 

Technical 

Assistance
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Analysis Methods

• Descriptive analysis: percentages, means, and medians

• Grouping agencies together

– Statistics for SUAs include SUAs that also function as AAAs, where possible

– Statistics for AAAs include AAAs that also function as LSPs, where possible

• Analysis weights

– Weights not needed for SUA analysis 

– Weights used for AAA and LSP analyses 

• Based on weighted data, the AAA and LSP findings are nationally-representative of 

population of AAAs and LSPs

• Study limitations

– Sampling error

– Item nonresponse

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Organizational Structure of National Aging Network

• SUAs

– 56 SUAs: one in 50 States, DC, and 5 territories

– SUAs oversee a median of 12 AAAs, with a low of 1 and high of 59

– 80 percent have a Nutrition Program Administrator (NPA)

• For many agencies, this is a registered dietitian or state-credentialed nutrition professional

• AAAs

– 629 AAAs in Title III-C NSP, down from 668 in 1995

– 62 percent are public organizations

– Provide nutrition services to an average of 2,561 people per year 

(congregate nutrition) and 1,376 people per year (home-delivered)

• LSPs

– 61 percent are private, nonprofit agencies, similar to 1995

– Provide nutrition services to an average of 942 people per year (congregate 

nutrition) and 443 people per year (home-delivered)

Source: SUA survey; AAA survey and LSP survey, weighted data; Tables III.1, III.2, and III.3.
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Congregate Meal Program Characteristics

95 93

0

10

20

30

40

50

60

70

80

90

100

Congregate Meals

Percentage of LSPs Providing 

Congregate Meals

1995 2015

60% 23%

8%

9%

Number of Congregate Sites per LSP, 

2015

1 2 to 5 6 to 10 11 or more

Source: LSP survey, weighted data, Tables III.7 and III.8.

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Congregate Meal Program Characteristics

4

14

0

2

4

6

8

10

12

14

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Provide Weekend Meals

LSP Provision of Congregate Meals on 

Weekends (Percentage)

1995 2015

11

100

11

0

20

40

60

80

100

120

Breakfast Lunch Dinner

Percentage of Congregate Sites Offering 

Breakfast, Lunch, or Dinner, 2015

Source: LSP survey, weighted data, Tables III.7 and III.8.
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Home-Delivered Meal Program Characteristics

81

87

78

79

80

81

82

83

84

85

86

87

88

Home-Delivered Meals

Percentage of LSPs Providing 

Home-Delivered Meals

1995 2015

10%

88%

2%

Number of Days Per Week Deliveries 

Made to Clients’ Homes

1 to 4 5 6 or 7

Source: LSP survey, weighted data, Tables III.7 and III.11.

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Home-Delivered Meal Program Characteristics

80%

7%

8%

4%

Number of Meals Provided to a 

Client at Each Visit1

1 2 to 4 5 6 or more

44

40

53

0

10

20

30

40

50

60

Central Kitchen On-site

Production

Catering or

Vendor Contract

Meal Production Methods2

(Percentage of LSPs)

Source: LSP survey, weighted data, Tables III.11 and III.12. 

1

 Percentages do not sum to 100 due to rounding.

2

 Multiple answers allowed
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Percentage of LSPs that Offer 

Special or Therapeutic Diets

24

42

10

5 5

63

34

51

12 10 9

79

0

10

20

30

40

50

60

70

80

90

Diabetic Low-sodium Modified-texture Vegetarian Kosher Any

Congregate Meals Home-Delivered Meals

Source: LSP survey, weighted data, Tables III.10 and III.12.

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Other Nutrition and Non-Nutrition Services

• Nutrition services provided by LSPs

– Nutrition education (77 percent)

– Nutrition screening and assessment (52 percent)

– Nutrition counseling (28 percent)

• Non-nutrition services

– Transportation to and from meal sites (76 percent)

– Health promotion and disease prevention activities (63 percent)

– Social activities (62 percent)

– Case management (53 percent)

– Assistance with chores or housekeeping (34 percent)

– Grocery assistance (28 percent)

Source: LSP survey, weighted data, Table III.7.
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Clients’ Referrals to and From Congregate 

and Home-Delivered Meal Programs

86

59

64

64

93

48

49

76

77

98

0 20 40 60 80 100

Hospital, Health Care

Facility, or

Discharge Planner

Case Management

System

Self

Information and

Assistance System

Family and Friends

Referrals To Meal Programs 

(Percentage of AAAs)

Congregate Meals Home-Delivered Meals

61

62

68

65

53

68

58

62

64

67

75

77

0 20 40 60 80 100

Low-Income

Home Energy

Assistance Program

SNAP

Veterans Affairs

Medicare Part D

Adult Protective

Services

Transportation

Services

Referrals From Meal Programs

(Percentage of AAAs)

Congregate Meals Home-Delivered Meals

Source: AAA survey, weighted data, Tables III.20, III.21, and III.22.

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Quality of Program Services Provided

• AAAs use variety of methods to ensure quality of nutrition 

education

– 58 percent of AAAs require credentialed nutrition professional to conduct 

education

– 45 percent of AAAs conduct survey of program participant needs and use of 

evidence-based education programs 

– 68 percent use curricula from a reliable, science-based organization

• Nearly all (96 percent) AAAs and LSPs require service personnel 

to have food safety and sanitation training

• Reported instances of food-borne illness are very rare

– 5 incidents total in past three years across all 333 AAAs in sample

Source: LSP survey, AAA survey, weighted data, Tables III.32 and III.33.
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LSP Recommended Participant Contributions

30%

40%

24%

6%

Congregate Meal 

Participants

$0.00 to $1.50

$1.51 to $3.00

$3.01 to $4.50

$4.51 or more

22%

39%

31%

8%

Home-Delivered Meal 

Participants

$0.00 to $1.50

$1.51 to $3.00

$3.01 to $4.50

$4.51 or more

Source: LSP survey, weighted data, Table III.41. Percentages may not sum to 100 due to rounding. Meal contributions are 

voluntary.

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Program Process Study Takeaways

• AoA nutrition programs provide a continuum of nutrition services, in 

addition to meals, to participants. This includes nutrition screening, 

assessment, education, and counseling.

• AoA nutrition programs are closely linked to other parts of the nation’s 

home- and community-based care system through cross-referrals and 

coordination of service delivery

• From 1995 to 2015: 

– LSPs congregate meal provision has decreased slightly and home-delivered meal 

provision has increased

– There has been an expansion in weekend meals by congregate meal providers

– There has been an increase in the percentage of congregate meal and home-delivered 

meal providers that make “modified” meals available (e.g., low in fat, sodium, calories)
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Meal Cost Analysis

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Meal Cost Analysis Objectives

• Answer two key research questions:

1.What is the average cost of a congregate and home-delivered 

meal provided under the AOA Nutrition Programs?

2.Do these average costs vary by how meals are prepared or by 

other program characteristics? 

• Enable providers to assess their own total costs for 

meals relative to similar providers

• Provide ACL with information about the cost 

effectiveness of meal preparation and service 

approaches
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Collected LSP-level data from 103 LSPs that: 

• Completed the LSP survey

• Provided information about their congregate and home-delivery 

distribution meal sites 

1 congregate meal site from each of 

the 98 LSPs with a congregate meal 

program

1 home-delivery distribution site 

from each of the 94 LSPs with a 

home-delivered meal program

1 home-delivery route from each 

home-delivery distribution site

Meal Cost Analysis Sample

Final sample included LSPs (1) that used various meal preparation methods; (2) from 

different geographic regions; (3) served rural, suburban, and urban areas; and (4) that 

were both large and small

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Meal Cost Analysis Methods

• Used a three-step “build up” approach:

1.Identified a standard set of resources used to prepare, serve, 

and deliver meals (includes donated or in-kind resources)

2.Collected data from each LSP on the cost of each resource

– Most data collected at the LSP-level

– Some data collected at the selected meal site- and route-levels

3.Calculated, or “built up,” weighted estimates of the average 

cost of a congregate and a home-delivered meal 

• Compared costs over time

• Analyzed costs by program characteristics
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Resources Used to 

Prepare, Serve, and Deliver Meals 

Paid labor

Meal delivery

(gasoline)

Volunteer labor

Food Vendor 

payments

Supplies

Food

Facilities Equipment

Meal delivery 

(vehicles, 

gasoline, 

insurance)

Facilities

Other insurance Other

Purchased resources Donated or in-kind resources

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Average Total Meal Cost: Congregate Meal

Source: AOA Nutrition Programs Evaluation meal cost analysis, Table II1 and Figure II.1. Weighted data.

35%

52%

8%

5%

Average total cost: $10.69 Average paid cost: $9.30

Paid Labor

$3.69

Donated 

nonlabor

$0.49

Volunteer 

labor

$0.90

Purchased 

nonlabor

$5.61

Component Cost, as 

Percentage of Total Cost

Breakdown of purchased nonlabor

costs ($5.61): 

• Food $1.28

• Vendor payments $3.06

• Nonfood meal supplies $0.20

• Facilities $0.69

• Equipment $0.15

• Delivery to sites (vehicles, gasoline, 

car insurance) $0.02

• Insurance $0.09

• Other resources $0.12
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Average Total Meal Cost: Home-Delivered Meal

Average total cost: $11.06 Average paid cost: $9.00 

28%

54%

14%

4%

Paid labor

$3.05

Donated 

nonlabor

$0.49

Volunteer 

labor

$1.57

Purchased 

nonlabor

$5.95

Component Cost, as 

Percentage of Total Cost

Breakdown of purchased nonlabor

costs ($5.95): 

• Food $1.14

• Vendor payments $3.42

• Nonfood meal supplies $0.22

• Facilities $0.48

• Equipment $0.14

• Delivery to sites and homes

(vehicles, gasoline, car insurance)

$0.33

• Insurance $0.08

• Other resources $0.14

Source: AOA Nutrition Programs Evaluation meal cost analysis Table II1 and Figure II.1. Weighted data.

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Changes in Average Total Meal Costs Over Time

$8.07 $8.29

$10.69 $11.06

$0

$2

$4

$6

$8

$10

$12

Congregate meal Home-delivered meal

1995 2015

Source: AOA Nutrition Programs Evaluation meal cost analysis, Table II.2; Ponza et al. (data collected in 1995, reported in 

1996). Weighted data. Adjusted to 2015 dollars. Average cost (in 2015 dollars)
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Average Total Meal Cost, 1995 and 2015

Average cost (in 2015 dollars)

Congregate meal Home-delivered meal 

$2.79 

$2.72 

$1.47 

$0.67 

$0.44 

$3.06 

$2.68 

$1.40 

$0.73 

$0.41 

$3.69 

$4.34 

$1.27 

$0.90 

$0.49 

$3.05 

$4.56 

$1.39 

$1.57 

$0.49 

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

$3.00

$3.50

$4.00

$4.50

$5.00

Paid labor

Purchased food and

vendor

Purchased other

resources

Volunteer labor

Donated nonlabor

resources

Paid labor

Purchased food and

vendor

Purchased other

resources

Volunteer labor

Donated nonlabor

resources

1995 2015

Source: AOA Nutrition Programs Evaluation meal cost analysis, Table II.2; Ponza et al. (data collected in 1995, reported in 1996). Weighted data. 2015 dollars.

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Average Total Meal Cost

by Meal Production Method

Source: AOA Nutrition Programs Evaluation meal cost analysis, Tables III.1 and III.2; LSP and AAA process study surveys. 

Weighted data.

$8.88 $9.43 $9.91 $9.30 

$1.66 $1.44 $1.62 

$1.39 

$0

$2

$4

$6

$8

$10

$12

Central or

off-site

kitchen

On-site

kitchen

Vendor or

restaurant

All

programs

Congregate meal

$8.07 

$9.46 $9.46 $9.00 

$2.07 

$2.54 $2.03 $2.06 

$0

$2

$4

$6

$8

$10

$12

Central or

off-site

kitchen

On-site

kitchen

Vendor or

restaurant

All

programs

Home-delivered meal

Value of donations Paid costs

Average cost
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Average Total Meal Cost

by LSP Service Area Urbanicity

$8.14 

$9.25 $9.35 $9.30 

$1.16 

$1.34 $1.17 $1.39 

$0

$2

$4

$6

$8

$10

$12

Urban Suburban Rural or

frontier

All

programs

Congregate meal

$9.71 $9.13 $8.84 $9.00 

$2.05 $2.70 

$2.02 $2.06 

$0

$2

$4

$6

$8

$10

$12

Urban Suburban Rural or

frontier

All

programs

Home-delivered meal

Value of donations Paid costs

Source: AOA Nutrition Programs Evaluation meal cost analysis, Tables III.3 and III.4; LSP and AAA process study 

surveys. Weighted data. Average cost

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Average Total Meal Cost

by Geographic Region

$6.58 

$7.63 

$9.30 

$13.16 

$9.00 

$2.90 

$2.98 

$1.16 

$2.06 

$0

$2

$4

$6

$8

$10

$12

$14

Home-delivered meal

$9.21 $8.75 $9.14 $10.52 $9.30 

$1.82 $1.83 

$1.61 

$1.39 

$0

$2

$4

$6

$8

$10

$12

$14

Congregate meal

$0.39

Value of 

donations

Paid costs

Source: AOA Nutrition Programs Evaluation meal cost analysis, Tables III.5 and III.6; LSP and AAA process study surveys. Weighted data. Average cost

$0.59
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Average Total Meal Cost

by Program Size

Value of 

donations

Paid costs

Source: AOA Nutrition Programs 

Evaluation meal cost analysis, 

Tables III.7 and III.8; LSP and AAA 

process study surveys. Weighted 

data. Average cost

Note: Large congregate meal programs 

and large home-delivery meal programs 

are those that serve 1,000 or more 

meals a week.

$9.50

$6.95

$9.30

$1.39

$1.20

$1.39

$0

$2

$4

$6

$8

$10

$12

Small Large All programs

Congregate meal

$9.93

$7.18

$9.00

$1.99

$1.98

$2.06

$0

$2

$4

$6

$8

$10

$12

Small Large All programs

Home-delivered meal

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Meal Cost Analysis Takeaways

• AOA Nutrition Programs total meal costs have risen since 1995, in 

large part due to a rise in food costs

• Program characteristics that appeared to have lower costs in 

1995 still appear most cost-effective: 

– Central or off-site kitchen prepared meals cost less than other methods

– Meals in southern region have lowest cost, and meals in western region 

have highest cost

– Meals produced in large programs cost less than those produced in small 

programs

– Congregate meals cost less in urban service areas, while home-delivered 

meals cost less in rural service areas

Note: 1995 data collected by Ponza et al. in 1995, but reported in 1996.
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For More Information

• Susan Jenkins (AoA/ACL Project Officer)

– Susan.Jenkins@acl.hhs.gov

• Rhoda Cohen (Evaluation Project Director) 

– RCohen@mathematica-mpr.com

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Thank you!

Mathematica extends our sincerest thank you to all of 

the SUA, AAA, and LSP staff that completed study 

surveys and provided data for the meal cost analysis.