FINAL REPORT

Process Evaluation of Older 

Americans Act Title III-C 

Nutrition Services Program

September 30, 2015

James Mabli

Nicholas Redel

Rhoda Cohen

Erin Panzarella

Mindy Hu

Barbara Carlson

Submitted to:

Center for Disability and Aging Policy

Administration for Community Living 

U.S. Department of Health and Human Services

1 Massachusetts Ave., NW

Washington, DC 20201

Project Officer: Susan Jenkins, Social Science Analyst

Contract Number: GS10F0050L/HHSP233201200606G

Submitted by:

Mathematica Policy Research

955 Massachusetts Avenue

Suite 801

Cambridge, MA 02139

Telephone: (617) 491-7900

Facsimile: (617) 491-8044

Project Director: Rhoda Cohen

Reference Number: 40121.321
This page has been left blank for double-sided copying.
CONTENTS

EXECUTIVE SUMMARY .............................................................................................................................vii

I INTRODUCTION.............................................................................................................................. 1

A. Overview of the Title III-C Nutrition Services Program.............................................................. 2

1. Funding and administration................................................................................................. 2

2. Nutrition Services Program eligibility requirements ............................................................ 3

3. Benefits and participation.................................................................................................... 3

B. Nutrition Services Program evaluation objectives and research questions .............................. 4

1. Support program planning (process study)......................................................................... 4

2. Program efficiency and costs (cost study) .......................................................................... 4

3. Program effectiveness (client outcomes study).................................................................. 4

C. Organization of the report.......................................................................................................... 5

II OVERVIEW OF DATA AND METHODOLOGY............................................................................... 7

A. Sampling design ........................................................................................................................ 7

B. Survey topic areas..................................................................................................................... 7

C. Survey modes and response rates............................................................................................ 8

D. Analysis methods .................................................................................................................... 10

E. Analysis weights ...................................................................................................................... 10

F. Study limitations ...................................................................................................................... 11

III TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY............................. 13

A. Organizational structure of the National Aging Network ......................................................... 13

1. SUAs ................................................................................................................................. 13

2. AAAs ................................................................................................................................. 15

3. LSPs.................................................................................................................................. 18

B. Nutrition and support services ................................................................................................. 20

1. Overview of NSP characteristics....................................................................................... 20

2. Nutrition education and counseling................................................................................... 30

3. Needs assessments and referrals .................................................................................... 34

4. Emergency nutrition services............................................................................................ 37

iii
CONTENTS MATHEMATICA POLICY RESEARCH

C. Training and technical assistance, data collection and reporting, and interactions with 

other agencies and programs.................................................................................................. 39

1. Training and technical assistance..................................................................................... 39

2. Data systems and reporting .............................................................................................. 40

3. Collaboration, integration, and partnerships with other programs .................................... 42

D. Quality of nutrition-related program services provided............................................................ 46

1. Nutrition program quality at SUAs..................................................................................... 46

2. Nutrition program quality at AAAs and LSPs .................................................................... 47

3. Food safety policies and practices in NSPs...................................................................... 49

E. Program resources .................................................................................................................. 51

1. SUA budget and fiscal year guidelines ............................................................................. 51

2. Program resources............................................................................................................ 52

F. Program contributions, private pay, and waivers .................................................................... 54

1. Participant contributions.................................................................................................... 54

2. Private pay ........................................................................................................................ 55

3. Medicaid waivers............................................................................................................... 57

G. Prioritization of services, access to services, and waiting lists ............................................... 58

1. SUAs’ prioritization of services ......................................................................................... 58

2. Access to services ............................................................................................................ 59

3. Waiting list policies............................................................................................................ 61

IV CONCLUSION ............................................................................................................................... 65

REFERENCES............................................................................................................................................ 69

APPENDIX A: PROCESS STUDY SURVEY METHODOLOGY ...............................................................A.1

APPENDIX B: SAMPLE DESIGN FOR THE SURVEYS OF AAAS AND LSP..........................................B.1

APPENDIX C: ANALYSIS WEIGHTS FOR THE SURVEYS OF AAAS AND LSPS.................................C.1

APPENDIX D: ADDITIONAL TABLES FOR SUAS THAT OPERATE AS AAAS......................................D.1

iv
TABLES

Table II.1. List of topics by survey................................................................................................................. 8

Table II.2. Response rates for SUA, AAA, and LSP surveys........................................................................ 9

Table III.1. Organizational structure and staff composition at SUAs .......................................................... 14

Table III.2. Organizational structure of AAAs.............................................................................................. 16

Table III.3. Organizational structure of LSPs .............................................................................................. 18

Table III.4. Populations served by AAAs and LSPsa................................................................................... 20

Table III.5. Program services available through AAAs ............................................................................... 21

Table III.6. AAAs’ availability of NSPs ........................................................................................................ 23

Table III.7. Services provided by LSPs ....................................................................................................... 24

Table III.8. Congregate nutrition program characteristics........................................................................... 25

Table III.9. Meal capacity of congregate nutrition programs....................................................................... 26

Table III.10. Congregate nutrition program meal production methods, menus, and special diets ............. 27

Table III.11. Home-delivered nutrition program characteristics .................................................................. 28

Table III.12. Home-delivered nutrition program meal preparation methods, menus, and diets.................. 30

Table III.13. SUA nutrition education and counseling................................................................................. 31

Table III.14. Nutrition education available through AAAs ........................................................................... 32

Table III.15. Nutrition education available through local service providers................................................. 32

Table III.16. Nutrition counseling available through AAAs.......................................................................... 33

Table III.17. Nutrition counseling available through local service providers ............................................... 33

Table III.18. Nutrition needs assessment by SUAs .................................................................................... 35

Table III.19. Assessment of clients’ service needs by AAAs and LSPs ..................................................... 35

Table III.20. Most common client referral sources for the congregate meal programa,b............................ 36

Table III.21. Most common client referral sources for the home-delivered meal programa,b ...................... 37

Table III.22. Referrals to other programs.................................................................................................... 38

Table III.23. Emergency nutrition services (percentages) .......................................................................... 39

Table III.24. Training and technical assistance provided by SUAs............................................................. 40

Table III.25. SUA data systems and reporting ............................................................................................ 41

Table III.26. AAA and LSP data systems and reporting ............................................................................. 42

Table III.27. Most important partners or collaborators for the NSP ............................................................ 43

v 
TABLES MATHEMATICA POLICY RESEARCH

Table III.28. Collaboration with other food and nutrition programs (percentages of SUAs) ....................... 44

Table III.29. Integration with nonfood and nutrition programs .................................................................... 45

Table III.30. SUA coordination and collaboration with Title VI programs ................................................... 45

Table III.31. Nutrition program quality at SUAs........................................................................................... 46

Table III.32. Nutrition program quality at AAAs and LSPs .......................................................................... 48

Table III.33. Food safety policies and practices in the NSP ....................................................................... 49

Table III.34. Food safety policies and practices in SUAs............................................................................ 50

Table III.35. SUA budget and fiscal activities.............................................................................................. 51

Table III.36. Statewide unit rate for nutrition services programs................................................................. 52

Table III.37. Facilities and equipment provided by the SUA....................................................................... 52

Table III.38. AAA response to increased service costs .............................................................................. 53

Table III.39. LSP program resources .......................................................................................................... 53

Table III.40. Participant contributions.......................................................................................................... 54

Table III.41. LSP recommended participant contributions .......................................................................... 55

Table III.42. AAA private pay and fee-for-service operations ..................................................................... 55

Table III.43. LSP private pay and fee-for-service operations...................................................................... 56

Table III.44. Medicaid waivers .................................................................................................................... 57

Table III.45. SUAs’ prioritization of services ............................................................................................... 58

Table III.46. SUA policy criteria to determine NSP prioritya ........................................................................ 59

Table III.47. Access to services .................................................................................................................. 60

Table III.48. Access to servicesa ................................................................................................................. 61

Table III.49. SUA waiting list policies for the NSP ...................................................................................... 62

Table III.50. Waiting list policies.................................................................................................................. 63

Table A.1. Shows the final disposition and response rate for each survey instrument. ............................A.6

Table A.2. LSP Web (Part A) and Fax-Back (Part B) Survey Completes Among Stand-Alone 

LSPs..............................................................................................................................................A.6

Table A.3. LSP Fax-Back (Part B) Survey Completes Among AAA/LSP Combinations...........................A.6

Table D.1. SUA data systems and reporting..............................................................................................D.3

Table D.2. Food safety policies and practices in SUAs .............................................................................D.4

Table D.3. Participant contributions ...........................................................................................................D.5

Table D.4. SUAs’ prioritization of services.................................................................................................D.6

vi
EXECUTIVE SUMMARY

The Title III-C Nutrition Services Program (NSP), administered by the Administration on 

Aging (AoA) within the Administration for Community Living of the U.S. Department of Health 

and Human Services (DHHS) under the Older Americans Act (OAA), represents a key 

component of America’s strategy for ensuring that the health and social needs of older adults are 

adequately met. By promoting access to nutritious meals, facilitating social contact, supporting 

family caregivers, and helping older adults maintain their dignity in their homes and 

communities, the NSP fits squarely within the strategic goals of the AoA to rebalance long-term 

care provision away from institutionalization and toward home- and community-based services.

Nutrition services are an important component of any overall package of home- and 

community-based services for older adults. Adequate nutrition is critical to health, functioning, 

and quality of life for people of all ages. For older adults, nutrition can be especially important, 

because of their vulnerability to health problems and physical and cognitive impairments. The 

NSP’s key nutrition services include nutritious meals, as well as nutrition screening, assessment, 

education, and counseling, to promote the health and wellbeing of older adults. For participants 

in congregate meals, Title III-C meals also provide an opportunity to socialize with peers.

Furthermore, many other services, such as health promotion, social/recreational activities, and 

medical screening, are often are provided at senior centers and other Title III-C sites, allowing 

older adults participating in congregate meals to connect to these services as well. For many 

home-delivered meal recipients, the person delivering the meal (often a volunteer) may be the 

recipient’s only human contact of the day. Together, these meals and services help congregate 

meal and home-delivered meal participants meet their health and nutrition needs.

An important aspect of the NSP, and critical in understanding how it functions, is the way in 

which it has developed mechanisms to mobilize several levels of constituencies to serve older 

adults. Although AoA’s central and regional offices provide federal coordination, the State Units 

on Aging (SUAs) and the Area Agencies on Aging (AAAs) support key aspects of program 

operations. In turn, usually the Local Service Providers (LSPs) provide the nutritional services 

directly. In addition, many other governmental agencies and nonprofit groups are involved in 

serving older adults under the NSP. Together, these organizations make up the National Aging 

Network, one of the nation’s largest provider networks of home- and community-based services 

for older people and their caregivers. 

The mission of the AoA, now a part of DHHS’s Administration for Community Living, is to 

develop a comprehensive, coordinated, and cost-effective system of long-term care that helps 

older adults maintain their dignity in their homes and communities. As part of its ongoing efforts 

to support program planning, improve program efficiency, and strengthen program effectiveness, 

AoA contracted with Mathematica Policy Research to conduct the Title III-C NSP Evaluation. 

The three-part evaluation consists of (1) a process evaluation of program administration and 

service delivery, (2) an analysis of program costs, and (3) an evaluation of the impact of the 

program on client outcomes. This report summarizes the findings of the process evaluation, 

using data collected from SUAs, AAAs, and LSPs, to assess the ways in which the program 

operates to serve older adults. 

vii
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

Background

The NSP is authorized under Title III of the OAA.1 Under Title III, SUAs receive federal 

grants from ACL, DHHS for provision of support services (authorized under Part B), congregate 

nutrition services (authorized under Part C-1), and home-delivered nutrition services (authorized 

under Part C-2). 

SUAs support the provision of daily meals and related nutrition services in group 

(congregate) or home settings to people ages 60 and older. The NSP does not have a means test, 

but services target older people with the greatest economic or social need. Participants are not 

charged for meals, but they are encouraged to make a voluntary contribution toward the meal 

costs. However, participants cannot be denied meals or other services because of an inability to 

contribute or an unwillingness to do so. Congregate meals and support services are provided at 

LSPs’ meal sites (such as senior centers, religious facilities, schools, or public or low-income 

housing facilities). Home-delivered meals are prepared for homebound clients by the congregate 

meal sites, affiliated central kitchens, or nonaffiliated food service organizations. 

Congregate and home-delivered LSPs must provide meals that comply with the most recent 

Dietary Guidelines for Americans and provide a minimum of one-third of the Dietary Reference 

Intakes (DRIs) established by the Food and Nutrition Board of the Institute of Medicine (IOM) 

of the National Academy of Sciences. In addition to meals, nutrition service providers also 

provide for nutrition screening, nutrition education, and nutrition assessment and counseling, if 

appropriate.2

In fiscal year (FY) 2013, OAA Title III-C funding was $416 million for congregate nutrition 

services and $205 million for home-delivered nutrition services (Administration for Community 

Living 2014). In that year, 83 million meals were served to 1.6 million people at congregate 

sites, and 136 million home-delivered meals were provided to 830,000 homebound older adults 

(Administration for Community Living 2015).

Evaluation objectives and research approach

The objectives of the Title III-C NSP evaluation were to:

• Provide information to support program planning by analyzing program structure, 

administration, staffing, coordination, and service delivery as well as the interactions 

between the many levels and types of organizations that provide congregate meals, homedelivered meals, and collateral services under the Title III-C NSP (referred to as the process 

study) 

• Estimate the costs of program operations, the most important being the cost of the 

congregate and home-delivered meals provided using Title III funds, and to examine cost 

1 Similar nutrition and supportive services for elderly American Indians, Alaska Natives and Native Hawaiians are 

authorized separately under Title VI. This report focusses on the Title III NSP.

2 Additional LSP requirements can be found in Section 339 of the OAA.

viii

 
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

variation within the program by cost component and program characteristics (referred to as 

the cost study) 

• Assess program effectiveness, as measured by the program’s effects on a variety of 

important outcomes (including nutrient adequacy, socialization opportunities, and health 

outcomes and, ultimately, helping older adults avoid institutionalization) through comparing 

program participants’ outcomes with those from a matched comparison group of eligible 

nonparticipants (referred to as the client outcomes study). 

This report describes the findings from the process study. A separate report presents the cost 

study findings (Ziegler et al. 2015). The client outcomes study is ongoing, with data to be 

collected in 2015 and 2016. 

The process evaluation’s assessment of program planning, processes, and administration 

draws on information obtained from comprehensive surveys of staff from SUAs, AAAs, and 

LSPs. The SUA survey was administered to a census of all 56 SUAs, one in each of the 50 states, 

the District of Columbia, and five U.S. territories. For AAAs, the survey was administered to a 

probability sample of AAAs. For LSPs, the survey was administered to a probability sample of 

LSPs from the sampled responding AAAs. Each survey requested information on a diverse set of 

topic areas covering organizational structure and staffing, access to services, nutrition education 

and counseling, nutrition needs assessment, food safety, and other topics critical to the effective 

implementation of the NSP. Descriptive, tabular analysis was used to characterize program 

administration and service delivery of SUAs, AAAs, and LSPs. 

Study findings

Following are key findings of the evaluation. Where appropriate, the findings are compared 

to those in the last NSP evaluation conducted between 1993 and 1995, here referred to as the 

1995 evaluation (Ponza et al. 1996). 

Organizational structure of the National Aging Network

SUAs, AAAs, and LSPs comprise core components of the National Aging Network. 

Agencies were asked to provide information about their organizational structure. 

• SUAs administer the NSP at the state level. There are 56 SUAs, one in each of the 50 states, 

the District of Columbia, and five territories (American Samoa, Guam, the Northern

Mariana Islands, Puerto Rico, and the Virgin Islands). SUAs oversee an average of 12 

AAAs (one more than in 1995), although this number varies considerably from state to state

with a low of 1 and a high of 59. 

• Each AAA operates within a planning and service area (PSA) designated by the SUA. At the 

time of the data collection there were 618 AAAs in the NSP (down from 668 AAAs in the 

Title III program in 1995). 

• The OAA requires that AAAs be public or private nonprofit organizations. In practice, the 

AAAs are more likely to be public organizations than private nonprofit organizations (62 

and 38 percent, respectively). 

ix
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

• Aging and Disability Resource Centers (ADRCs) are entities established by a state as part of 

the state system of long-term care to provide comprehensive information on the full range of 

long-term care programs and services within a community, personal counseling assessing 

care needs and developing individual care plans, and consumers access to a range of 

programs for which consumers may be eligible.3 Although ADRCs may have a physical 

location in a state, they may also be a consortia of providers that serve a wide area of the 

state. ADRCs serve adults in the PSAs of more than three-quarters (79 percent) of AAAs. 

An ADRC is under development in the PSA of another 9 percent of AAAs. 

• Sixty-one percent of LSPs are private nonprofit organizations. Most of the rest (35 percent) 

are public entities (such as divisions of city or county governments or parts of a council of 

governments or regional planning agencies). These percentages are similar to those in 1995. 

Program characteristics

LSPs provide a variety of nutrition and non-nutrition services. 

• The most common service that LSPs provide is congregate meals, provided by nearly all (93 

percent) LSPs. Most (87 percent) also provide home-delivered meals. In the 1995 

evaluation, these percentages were 95 and 81 percent, respectively. Thus, LSPs’ congregate 

meal provision has decreased slightly, and home-delivered meal provision has increased. 

• All NSP congregate programs serve lunch. In addition, about 11 percent of Title III-C 

congregate programs serve breakfast, up from only 4 percent in 1995. Similarly, 11 percent 

of programs serve dinner, up from 1 percent in 1995. 

• Most congregate sites operate only on weekdays; however, about 15 percent of sites also 

serve weekend meals. This is sizably higher than in the 1995 evaluation, when only 4 

percent of sites served weekend meals. 

• Most (90 percent) of the LSPs that provide home-delivered meals deliver at least five meals 

a week. A delivery usually includes only a single meal (typically a hot lunch), but some 

deliveries include more than one meal at a time. These findings are similar to those in 1995. 

• Sixty-three percent of congregate meal sites make “modified” meals available (such as those 

that are low in fat or sodium), and 79 percent of home-delivered providers offer these meal 

types. This prevalence is noticeably higher than in 1995 (49 and 63 percent, respectively). 

• Many programs prepare home-delivered meals on-site at congregate meal sites (40 percent), 

where they are packaged and then distributed. However, more than half (52 percent) of LSPs 

with home-delivered meal programs contract for these meals with outside vendors or 

caterers, and 44 percent prepare home-delivered meals at a project-affiliated central kitchen. 

The preparation of meals at a central kitchen has increased greatly from 1995, when only 17 

percent of LSPs used them. 

• LSPs provide other nutrition-related services in addition to meals. About three-quarters (77 

percent) provide nutrition education, about one-half (52 percent) provide nutrition screening 

and assessment, and about one-quarter (28 percent) provide nutrition counseling. 

3 Public Law 109 –365—OCT. 17, 2006, Title I, Section 101[44]. 

x 

 
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

• Non-nutrition services are also common. Nearly two-thirds of LSPs provide non-nutrition 

services related to social activities (62 percent) and health promotion and disease prevention 

activities (63 percent). Other common non-nutrition services include transportation to and 

from meal sites, case management, and chores and housekeeping services. 

Clients’ needs assessments

NSP agencies strive to understand the needs of program participants by seeking information 

on how clients learn about program services and how nutrition programs help meet the nonnutritional needs of clients by making it easier for them to access other programs. 

• Twenty percent of SUAs have conducted a statewide community needs assessment in the 

past five years, but 60 percent have conducted at least one local community needs 

assessment during that time. However, many SUAs reported that they require AAAs or 

LSPs to perform consistent individual nutrition needs assessments for the NSP, and many 

SUAs issue formal polices or guidance on how to conduct these assessments. 

• Eighty-three percent of AAAs have a formal process for assessing nutrition needs, and 71 

percent have a formal process for assessing the non-nutrition needs of NSP congregate meal 

program participants. These proportions are lower at the LSP level (65 and 44 percent, 

respectively). These formal processes are more common for the home-delivered meal 

program. 

• More than three-quarters of AAAs and LSPs reassess service needs for congregate meal and 

home-delivered meal program participants at least once a year, but nearly 20 percent of 

AAAs and LSPs have no policy to define how frequently congregate meal program 

participants’ service needs should be reassessed. 

• AAAs reported that clients are typically referred to the congregate and home-delivered meal 

programs through family and friends. For congregate meal programs, it is also common for 

clients to be referred through the OAA information and assistance system, which helps older 

adults access social and health services across the country. For home-delivered meal 

programs, it is also common for clients to be referred through hospitals, health care 

facilities, and discharge planners. 

Collaboration, integration, and partnerships with other programs 

Many SUAs partner with organizations or groups to engage in such activities as advocacy, 

strategic planning, public education, senior activities, service delivery, fundraising, and outreach. 

Therefore, agencies were asked to provide information about the organizations with which they 

partner.

• The ADRC was cited as the most important partner or collaborator for the NSP at the SUA 

level. Eighty-four percent of SUAs selected these organizations as one of the top five most 

important partners. Elder abuse prevention programs (or Adult Protective Services) and state 

public health departments or agencies were also important partners. 

• Most SUAs reported that they also collaborate with the Supplemental Nutrition Assistance 

Program (SNAP; 56 percent) and the Senior Farmers’ Market Nutrition Program (SFMDP; 

62 percent), but there is minimal collaboration with other programs, such as the Community 

xi
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

Supplemental Food Program (CSFP), Child and Adult Care Food Program (CACFP), and 

The Emergency Food Assistance Program (TEFAP). 

Quality of program services provided

The ability to meet client dietary needs is perhaps the most important aspect of the NSP. 

Accordingly, the data collection included several indicators of nutrition program quality, as well 

as food safety policy and practices used in preparing and serving meals. 

• AAAs and LSPs use a variety of methods to ensure the quality of nutrition education, 

nutrition counseling, and the nutrient quality of meals. Most AAAs and LSPs use 

credentialed nutrition professionals to conduct education (58 and 64 percent, respectively). 

Many AAAs also report employing surveys to measure program participant needs and using 

evidence-based education programs and curricula from a reliable, science-based 

organization. For nutrition counseling, AAAs and LSPs also use credentialed nutrition 

professionals to conduct counseling (76 and 52 percent, respectively). Finally, LSPs 

contribute to the nutrient quality of meals by using computer-assisted menu analysis, meal 

patterns, or the services of a dietitian or state-credentialed nutrition professional, and by 

relying on guidance from the SUAs.

• Food safety is also a critical indicator of the quality of program services offered. Nearly all 

AAAs and LSPs (96 percent) require their service personnel to have food safety and 

sanitation training. Many SUAs have formal policies, guidance, or regulations for managing 

food-borne illnesses in the NSP, although it is less common to have formal policies, 

guidance, or regulations for managing food recalls. 

• Reported instances of such illness do occur, but they are rare. In more than 330 AAAs 

surveyed (more than half of the 618 AAAs in the country), only five incidents of illness 

associated with NSP food were reported to have occurred in the past three years. 

Furthermore, only 3.4 people became ill, on average, per incident. 

Program resources

The degree to which SUA program staff can effectively monitor income and expenditures, 

track funding sources, manage budgetary concerns, and distribute resources across their service 

area has a direct impact on AAA and LSP operations. 

• Seventy-four percent of SUAs monitor expenditures per meal at the SUA or AAA level, 74 

percent monitor program income, and 70 percent monitor funding sources. 

• Thirty-six percent of SUAs provide equipment for the home-delivered or congregate 

nutrition programs, either directly to the site or through designated funding. A smaller, 

though still sizable, percentage of SUAs (20 percent) provide facilities for the programs.

• AAAs were asked to identify how they respond to increases in the total cost of a meal (such 

as labor, fuel, or food costs) for the NSP. The most frequently selected responses indicate 

that AAAs reduce program services to offset these cost increases or look for efficiencies 

without reducing services. Many agencies reported reducing staff or staff hours, reducing 

the number of days of service per week at congregate locations, reducing the number of 

congregate nutrition sites, and reducing the frequency of home-delivered meals. However, 

xii
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

many agencies also reported modifying menus or, in the home-delivered nutrition program, 

increasing the use of frozen meals. 

Program contributions, private pay, and waivers 

Participant contributions to the NSP, the extent to which private pay services are offered, 

and the use of Medicaid waivers are important subjects because they affect service delivery, as 

well as participants’ experiences with the program. 

• Nearly all SUAs (98 percent) have policies related to the collection, management, and 

spending of participant contributions. Almost two-thirds (65 percent) of SUAs monitor 

program data such as service units and people served in relation to participant contributions 

reported. Fifty-one percent of SUAs require AAAs and LSPs to spend participant 

contributions first and then use other funds. 

• LSPs vary in their recommended participant contribution for a single congregate meal. 

Thirty percent of LSPs recommend less than $1.50, and 93 percent recommend less than 

$4.50. For home-delivered meals, 22 percent recommend less than $1.50, and 92 percent 

recommend less than $4.50. 

• Forty percent of AAAs have specific policies to permit, encourage, or prohibit the 

operations of private or fee-for-service nutrition programs for older adults. However, the 

level of encouragement or discouragement varies. Having a private pay or fee-for-service 

meal program is not uncommon across LSPs. Twenty-two percent of LSPs have it in the 

congregate nutrition program, and 31 percent have it in the home-delivered meal program.

• As part of a coordinated system of services for Medicaid participants at risk of 

institutionalization, a state can obtain a Medicaid waiver that allows Medicaid funds to be 

used to pay for the costs of providing services to these individuals. One-half of SUAs 

administer a Medicaid waiver program for older adults. For those that do, the most common 

services provided under the waiver are home-delivered meals, nutrition assessments, and 

nutritional supplements. 

Prioritization of services and waiting lists

Although all people ages 60 and older are eligible to participate in the NSP, the program 

must sometimes decide to serve some adults before others when resources are limited. 

• Although required by law, only 89 percent of SUAs report having a prioritization policy. 

• For congregate meal programs, prioritization criteria are most commonly based on racial or 

ethnic minority status, nutrition risk assessments, economic need, and geographic isolation. 

For home-delivered meal programs, prioritization criteria are most commonly based on 

whether a person is homebound, meets the Activities of Daily Living impairments 

minimums, is geographically isolated, or has low income. 

• About one-half (51 percent) of the LSPs that arrange or provide home-delivered meals 

report having a waiting list for potential participants, compared to 41 percent in the 1995 

evaluation. For LSPs that maintain waiting lists, the mean number of people on the lists is 

28. This is substantially lower than in 1995, when it was 85 people. Therefore, waitlists are 

slightly more common now, but they contain many fewer people than in 1995. 

xiii
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

• Waiting lists are much less common for congregate meal programs. Twenty-nine percent of 

LSPs arranging or providing congregate meals report having waiting lists. For LSPs that 

maintain waiting lists, the mean number of people on the lists is 19, less than half as many 

as in the 1995 evaluation, when an average of 52 people were on a waiting list. 

Conclusion

Findings from the process study demonstrate an elaborate National Aging Network of 

SUAs, AAAs, and LSPs that interact to provide older people with congregate and homedelivered meals and services to help meet their health and nutrition needs. Although comparisons 

with the 1995 evaluation findings are limited due to differences in survey modules and content, 

several findings revealed key changes to program administration and service delivery: 

• There has been robust expansion in meal provision since 1995. Eighty-seven percent of 

LSPs now provide home-delivered meals, up from 81 percent in 1995. Although the 

percentage of LSP providing congregate meal programs decreased slightly (from 95 to 93 

percent), there was a substantial increase in the percentage of congregate meal programs that 

offer breakfast and dinner (all programs served lunch both in 1995 and in the current study). 

The percentage of LSPs that offered breakfast is about 3 times larger than it was in 1995, 

and the percentage of LSPs that offer dinner is more than 10 times larger than it was in 

1995. Similarly, the percentage of LSPs that offer congregate meals on weekends is almost 

four times larger than in 1995. 

• Meal offerings and preparation have changed. “Modified” meals that are low in fat, 

sodium, or calories are offered by many more LSPs than in 1995. There has also been a shift 

toward preparing home-delivered meals at a central kitchen. 

• Waiting lists for home-delivered meals are slightly more common than in 1995. About 

one-half (51 percent) of LSPs have waiting lists, compared to 41 percent in 1995. However, 

the waiting lists contain far fewer people, on average, than in 1995 (28 versus 85 people). 

The waiting lists for congregate meals also contain less than half as many people (19 versus 

52 people). These findings generally suggest an increase in program access across both 

program types. 

In addition to these changes, the National Aging Network continues to try to meet client 

dietary needs through ensuring nutrition program quality. AAAs and LSPs use many methods to 

improve the quality of nutrition services (such as using credentialed nutrition professionals, 

assessing needs through surveys, and using evidence-based curricula from reliable, science-based 

organizations). Agencies also continue to partner and collaborate with organizations (most 

notably, SNAP and SFMNP) to engage in advocacy, strategic planning, and service delivery. 

The data suggest that assessment of clients’ needs is one area for further exploration and 

improvement. Twenty percent of SUAs have conducted a statewide community needs 

assessment in the past five years, and more than a third (40 percent) of SUAs have not conducted 

at least one local community needs assessment during that time. Furthermore, many AAAs and 

LSPs do not have a formal process for assessing nutrition needs of NSP congregate meal and 

home-delivered meal participants, and even fewer have a formal process for assessing nonxiv
EXECUTIVE SUMMARY MATHEMATICA POLICY RESEARCH

nutrition needs. Finally, nearly 20 percent of AAAs and LSPs have no policy to define how 

frequently participants’ service needs should be reassessed. 

Examining the program administration and service delivery data collected in this evaluation 

in conjunction with the evaluation’s cost and client outcomes data will shed additional light on 

how (1) program efficiency varies by core administrative and service-oriented components (such 

as program size, meal preparation method, and other program characteristics); and (2) program 

effectiveness varies by programs’ policies and practices related to ensuring the nutritional quality 

of program meals. Studying these data will help identify the best ways to use available resources 

to make sure that older people participating in the NSP receive adequate services to meet their 

health and nutrition needs.

xv
This page has been left blank for double-sided copying.
I. INTRODUCTION

The Title III-C Nutrition Services Program (NSP), administered by the Administration on 

Aging (AoA) within the Administration for Community Living of the U.S. Department of Health 

and Human Services (DHHS) under the Older Americans Act (OAA), represents a key 

component of America’s strategy for ensuring that the health and social needs of older adults are 

adequately met. By promoting access to nutritious meals, facilitating social contact, supporting 

family caregivers, and helping older adults to maintain their dignity in their homes and 

communities, the NSP fits squarely within the strategic goals of the AoA to rebalance long-term 

care provision away from institutionalization and toward home and community-based services.

Every day, millions of Americans, most of them more than 60 years of age, receive a 

nutritious meal at a senior center or other congregate meal site as part of the NSP. Many others 

consume a home-delivered meal provided under a different component of the program. For many 

older adults, the Title III-C meal is the main meal of the day (Ponza et al. 1996). The value of 

these services to participants goes far beyond the meals themselves, however. Particularly for 

participants in congregate meals, Title III-C meals provide an opportunity to socialize with peers. 

Further, many other services—from tax preparation to health promoting activities to medical 

screening—are often provided at senior centers and other Title III-C sites, allowing the 

congregate meals to provide a context for helping seniors connect to these services as well. Even 

for home-delivered meals, which by definition are less focused on social interaction, the daily 

visit by the meal deliverer, often a volunteer, can represent an older adult recipient’s only human 

contact of the day. The NSP also provides a range of related services, such as nutrition screening, 

assessment, education, and counseling, that help congregate meal and home-delivered meal 

participants meet their health and nutrition needs.

An important aspect of the NSP, critical to understanding how it functions, is the way in 

which it has developed mechanisms for mobilizing multiple levels of constituencies in the work 

of serving older adults. While overall federal coordination is provided by AoA’s central and 

regional offices, the State Units on Aging (SUAs) and the Area Agencies on Aging (AAAs) both 

support key aspects of program operations. In turn, the direct nutritional services are generally 

provided by Local Service Providers (LSPs), and many other governmental and nonprofit groups 

are also involved in serving older adults under the program. Together, these organizations make 

up the National Aging Network, which is one of the nation’s largest provider networks of homeand community-based care for older persons and their caregivers. 

While the diversity of the organizations involved is a key strength of the Title III-C 

program, it also creates particular challenges for evaluating the program. Indeed, this diversity 

makes it particularly complicated (and also particularly important) to examine whether the 

system operates efficiently overall and whether it succeeds in delivering services that are of 

benefit to older adults, as evidenced by such important outcomes as nutrition, socialization, 

health, and—ultimately —avoidance of institutionalization. It is also important to examine the 

“targeting” of the program to assess whether its services are reaching older adults who need them 

most and to determine whether there may be underserved populations that somehow fall 

“between the seams” of the overall program.

1 
I. INTRODUCTION MATHEMATICA POLICY RESEARCH

The mission of the AoA, now a part of DHHS’s Administration on Community Living 

(ACL), is to develop a comprehensive, coordinated, and cost-effective system of long-term care 

that helps older adults to maintain their dignity in their homes and communities. As part of its 

ongoing efforts to support program planning, improve program efficiency, and strengthen 

program effectiveness, AoA contracted with Mathematica Policy Research to conduct the Title 

III-C NSP Evaluation. The three-part evaluation consists of a process evaluation of program 

administration and service delivery, a program cost analysis, and an evaluation of the impact of 

the program on client outcomes. This report summarizes the findings of the process evaluation 

using data collected from SUAs, AAAs, and LSPs to assess the ways in which the program 

operates to serve older adults. The findings from the cost and client outcomes components of the 

evaluation are presented separately. The remainder of this chapter provides an overview of the 

NSP, summarizes the research objectives of the evaluation, and describes the organization of the 

report.

A. Overview of the Title III-C Nutrition Services Program

The NSP is authorized under Title III of the OAA. Through Title III, SUAs implement a 

system of coordinated, community-based services targeted to older adults. Title III authorized the 

provision of nutrition and supportive services, such as meals, nutrition education, transportation, 

personal and homemaker services, and information and referrals.4 The OAA has been amended 

frequently since the creation of the NSP in 1972. These amendments have added new 

responsibilities for agencies in the aging network and clarified responsibilities that were 

performed under the original legislation.

Under Title III-C of the OAA, AoA provides grants to SUAs to support the provision of 

daily meals and related nutrition services in either group (congregate) or home settings to 

persons age 60 and older. The program specifically targets older people with the greatest 

economic or social need, with special attention given to low-income minorities and rural older 

people as well as other populations listed in Section A.2. In fiscal year (FY) 2013, OAA Title IIIC funding was $416 million for congregate nutrition services and $205 million for homedelivered nutrition services (Administration for Community Living 2014). In that year, 83 

million meals were served to 1.6 million people at congregate sites, and 136 million homedelivered meals were provided to 830,000 homebound older adults (Administration for 

Community Living 2015). 

1. Funding and administration

Under Title III, SUAs receive federal grants from AoA for provision of congregate nutrition 

services (authorized under Part C-1), home-delivered nutrition services (authorized under Part C2), and supportive services (authorized under Part B). Funds are allocated to states and territories 

according to a formula that is largely based on the state's or territory's share of the population 

aged 60 or older among all states and territories.

SUAs distribute the funds to AAAs, which administer the nutrition services program within 

their respective planning and service areas (PSAs). AAAs receive funds from SUAs on the basis 

4 Similar nutrition and supportive services for elderly American Indians, Alaska Natives and Native Hawaiians are 

authorized separately under Title VI.

2 

 
I. INTRODUCTION MATHEMATICA POLICY RESEARCH

of state-determined formulas that reflect the proportion of older people in their PSAs and other 

factors. The AAAs award grants to and contract with LSPs to provide nutritional and supportive 

services in their planning areas. AAAs, with a waiver from their state, can be direct providers of 

nutrition services, as well. In addition to receiving AoA funds, AAAs and LSPs receive financial 

support from state and local government, in-kind contributions, private donations, and voluntary 

contributions from participants. Congregate meals and supportive services are provided at LSPs’ 

meal sites (such as senior centers, religious facilities, schools, public or low-income housing, or 

residential care facilities). Home-delivered meals are provided to homebound clients, either by 

the congregate meals sites, affiliated central kitchens, or nonaffiliated food service organizations. 

2. Nutrition Services Program eligibility requirements 

Persons aged 60 and older, and their spouses of any age, may participate in the NSP’s 

congregate meals. In addition, the members of the following groups are also eligible receive 

congregate meals:

• Disabled persons under age 60 who reside in housing facilities, occupied primarily by older 

adults where congregate meals are served

• Disabled persons who reside at home with, and accompany, persons age 60 and older to 

meal sites 

• Nutrition service volunteers 

For home-delivered meals, persons who are homebound as a result of disability, illness, or 

isolation and are 60 years of age or older are eligible, as are their spouses of any age. Disabled 

persons younger than age 60 living with older adults are also eligible. 

The NSP is not an entitlement program. It also does not have a means test, but services are 

targeted at older persons with the greatest economic or social need with particular attention to 

low-income adults, minority adults, older adults, adults in rural communities, older adults with 

limited English proficiency, and older adults at risk of institutional care. Participants are not 

charged for meals but are encouraged to make a voluntary contribution toward the total cost of 

the meal. However, within site capacity, participants are not denied meals or other services 

because of an inability or an unwillingness to contribute. 

3. Benefits and participation 

Congregate and home-delivered LSPs must provide meals that comply with the most recent 

Dietary Guidelines for Americans and provide a minimum of one-third of the Dietary Reference 

Intakes established by the Food and Nutrition Board of the Institute of Medicine of the National 

Academy of Sciences. In addition to meals, nutrition service providers also provide for nutrition 

screening, nutrition education, and nutrition assessment and counseling if appropriate.5

5 Additional LSP requirements can be found in Section 339 of the OAA.

3 

 
I. INTRODUCTION MATHEMATICA POLICY RESEARCH

B. Nutrition Services Program evaluation objectives and research questions

The objectives of the Title III-C NSP evaluation were to:

• Provide information to support program planning, including an analysis of program 

processes (referred to as the process study) 

• Develop information about program efficiency and cost issues (referred to as the cost study) 

• Assess program effectiveness, as measured by the program’s effects on a variety of 

important outcomes, including nutrient adequacy, socialization opportunities, health 

outcomes, and—ultimately—helping older adults avoid institutionalization (referred to as 

the client outcomes study) 

This report describes the findings solely from the process study. A separate report presents 

the cost study findings (Ziegler et al. 2015). Client outcomes data will be collected in 2015 and 

2016 to assess program effectiveness. To offer a comprehensive understanding of the larger Title 

III-C NSP evaluation, the three research objectives are described in greater detail below.

1. Support program planning (process study)

The overarching objective of the process study is to support the program-planning process 

by analyzing program structure, administration, staffing, coordination, processes, and service 

delivery. Many levels and types of organizations interact to provide congregate meals, homedelivered meals, and collateral services under the Title III-C NSP. To better support program 

planning, this report explores these interactions as fully as possible. In addition to understanding 

the organizational structure and staffing of agencies and providers, improving program planning 

and quality requires knowing the nutrition and supportive services that agencies offer; 

differences in client access to services, prioritization of services, and the use of waiting lists; and 

program resources. This line of inquiry can help explore ways to streamline program operations 

and ensure efficient use of technology to guide management decisions within the program. 

2. Program efficiency and costs (cost study)

ACL program staff routinely strive to ensure the efficiency of their program. Therefore, a

second major objective of the Title III-C NSP evaluation is to estimate the costs of program 

operations, the most important being the cost of the congregate and home-delivered meals 

provided using Title III funds. Program efficiency is assessed by generating unit cost estimates 

for individual LSPs and examining cost variation within the program by cost component, meal 

preparation method, program size, and other program characteristics. This may help set standards 

for efficiency and will allow analysis of whether any particular modes of program operations 

appear to be especially efficient or inefficient. By examining sources and amounts of program 

funding, this component can also identify approaches for best leveraging available resources and 

eliminating redundancy. 

3. Program effectiveness (client outcomes study)

The Title III-C program is intended to improve the nutrient adequacy of participants’ diets in 

the short run and thereby improve health outcomes in the longer run, allowing participants to 

stay in their homes and communities and avoid or delay institutionalization. Thus, a third major 

4 
I. INTRODUCTION MATHEMATICA POLICY RESEARCH

objective of the Title III-C NSP evaluation is to assess whether these outcomes are being 

achieved. This evaluation compares program participants’ outcomes with those from a matched 

comparison group of eligible nonparticipants. The outcomes consist of measures of diet quality 

based on 24-hour dietary recall information provided by NSP program participants and eligible 

nonparticipants, as well as other outcomes including food security and socialization 

opportunities. Longer-term outcomes related to health and avoidance of institutionalization are 

also being explored. Other dimensions of program effectiveness explored under this objective 

include whether the NSP programs are successfully targeting services to older adults with the 

greatest economic or social need and whether NSP clients feel that the services they are 

receiving are adequate and meet their needs.

C. Organization of the report

The remaining chapters of this report discuss the methodology used in the analysis and 

present findings. Chapter II provides an overview of the study design and the data and 

methodology used in the analysis. Chapter III presents detailed tables describing the Title III-C 

program administration and service delivery using information collected in the SUA, AAA, and 

LSP surveys. Finally, Chapter IV summarizes findings to inform policy and discusses 

implications for future research. 

The appendices of the report provide supporting material and additional tables. Appendix A 

supplements Chapter II with a more detailed discussion of the survey methodology. Appendix B 

presents details of the survey sampling methodology and Appendix C presents the details of the 

survey weight construction process. Finally, Appendix D contains additional tables describing 

NSP organizations’ program administration and service delivery. 

5 
This page has been left blank for double-sided copying.
II. OVERVIEW OF DATA AND METHODOLOGY 

The Nutrition Services Program (NSP) evaluation’s assessment of program planning, 

processes, and administration draws on information obtained from comprehensive surveys of 

staff from State Units on Aging (SUAs), Area Agencies on Aging (AAAs), and Local Service 

Providers (LSPs). This chapter focuses on the sampling design, topics covered in the surveys, 

data collection procedures and response rates, and analysis. A final section discusses study 

limitations.

A. Sampling design

The NSP evaluation used a multistage clustered sample design. The SUA survey was 

administered to a census of all 56 SUAs, one in each of the 50 states, the District of Columbia, 

and five U.S. territories (Guam, the Virgin Islands, the Northern Mariana Islands, American 

Samoa, and Puerto Rico). For AAAs, the survey was administered to a probability sample of 

AAAs. Most of the AAAs were selected using an equal probability random sample, though the 

six largest AAAs were selected with certainty (with size defined using a composite measure 

based on information provided by SUAs and by the National Association of States United for 

Aging and Disabilities (NASUAD) on the total, unduplicated number of people who received 

NSP congregate nutrition services and home-delivered nutrition services during the most 

recently completed fiscal year in each of the AAAs (see Appendix B for details)). For LSPs, the 

survey was administered to a probability sample of LSPs from the sampled and participating 

AAAs. The sample frame was formed using lists of LSPs obtained from these AAAs. LSPs were 

selected within AAAs using sequential sampling with probability proportional to size, with the 

measure of size being a composite measure incorporating both congregate and home-delivered 

meals, this time at the LSP level (see Appendix B for details).

B. Survey topic areas

Each survey requested information on a diverse set of topic areas covering organizational 

structure and staffing, access to services, nutrition education and counseling, nutrition needs 

assessment, food safety, and other topics that are critical to the effective implementation of the 

NSP. These topics are listed in Table II.1. 

7 
II. OVERVIEW OF DATA AND METHODOLOGY MATHEMATICA POLICY RESEARCH

Table II.1. List of topics by survey

. SUA AAA LSP 

Access to services x x x 

Aging and Disability Resource Center . x x 

Budget and fiscal x . . 

Consumer direction x . . 

Emergency nutrition service x . . 

Emergency planning . x x 

Facilities and equipment x . . 

Food safety x x x 

Funding/resource allocation x . . 

Integration with other programs x . . 

Medicaid waiver . x x 

Nutrition counseling . x x 

Nutrition education . x x 

Nutrition needs assessments (community/individual) x . . 

Nutrition program quality/monitoring/site visits x . . 

Nutrition service operation and quality assurance . x x 

Organizational structure and staff x x x 

Partnerships x x x 

Prioritization of services x . . 

Private pay/fee-for-service and Medicaid waiver . . x 

Program resources . x x 

Programming contribution x . . 

Referrals and needs assessments . x x 

Self-directed care and private pay/fee-for-service . x . 

State and area plans x . . 

Targeting x x x 

Technology and data x x x 

Title III-C Nutrition Program Services (NSP) characteristics . x x 

Training and technical assistance x . . 

Waiting lists x x x 

C. Survey modes and response rates

We fielded the SUA survey using an editable PDF format that allows respondents to enter 

and return data in an electronic form. Since 13 of the 56 SUAs have a single planning and 

service area, they also function as the AAA (Table II.2). These SUAs received a version of the 

survey that excluded questions about their AAAs, since those questions were not applicable. All 

56 SUAs completed the survey, yielding a 100 percent response rate. 

8 
II. OVERVIEW OF DATA AND METHODOLOGY MATHEMATICA POLICY RESEARCH

Table II.2. Response rates for SUA, AAA, and LSP surveys 

. Initial 

sample Ineligible Refusal Complete Partial 

Response rate

(Percentage)

SUA survey 56 0 0 56 0 100

AAA survey 360 1a 3 328 (web)

292c (fax back)

5 (web)

0 (fax back)

92

81

LSP survey 230 4b 0 (web)

2 (fax back)

193 (web)

140 (fax back)

6 (web)

0 (fax back)

85

62

a One AAA lost its designation and was therefore ineligible.

b One LSP only contracted for cash-in-lieu funds to help with its resident nutrition program. During the fielding, three 

LSPs were found to be duplicates of other LSPs in the sample.

c AAAs were expected to complete the web survey before the fax-back survey. However, 6 completed the fax-back 

but not the web survey (that is, 292 of the 298 fax-back surveys were as directed). AAAs that completed the fax-back 

survey without the web survey were assigned a weight of 0 in the analysis. 

The AAA survey consisted of two parts: a web survey and a fax-back form. The majority of 

the questions were in the web survey, which included questions that a respondent could likely 

answer without referring to other data sources, such as organizational structure. A much smaller 

number of items were included in the fax-back form, which contained questions that were 

expected to require the respondent to look up the data from sources such as financial reports on 

program expenditures. The survey team emailed all sampled AAAs the link to the web survey 

and a PDF version of the fax-back form and asked them to complete both instruments. The email 

asked sample members to print the fax-back form, complete it on paper, and then fax it to a 

designated study fax number. A total of 328 of 359 eligible AAAs completed the web survey, 

yielding a response rate of 92 percent (Table II.2). Of the AAAs that participated in the web 

survey, 292 also completed the fax-back form, yielding a response rate of 81 percent of all 

eligible AAAs.

The LSP survey also consisted of two parts: an LSP web survey (Part A) and an LSP faxback form (Part B). The survey team emailed the LSPs the link to the web survey and asked 

them to log in to complete it. After completing the web survey, the final screen asked 

respondents to download Part B as an editable PDF, complete it, and return it to us 

electronically.

Of the 230 sampled LSPs, 28 also functioned as AAAs and had already completed the AAA 

survey. However, the AAA web survey for agencies operating as both an AAA and an LSP 

included an additional module of questions about services the AAAs administer directly (in other 

words, the direct services module). As a result, we did not need to send them a separate LSP 

survey because the questions would have been redundant. The LSP survey included a small 

number of questions that were not in the AAA survey with the direct services module. Therefore, 

liaisons on the evaluation team called agencies that operate as both an AAA and an LSP to 

obtain responses to these questions. These agencies were also asked to complete Part B. 

A total of 193 of 226 eligible LSPs completed the web survey (in other words, either the 

LSP survey or the AAA survey with direct services module), yielding a response rate of 85 

percent (Table II.2). A total of 140 LSPs completed Part B, yielding a response rate of 62 percent 

of all eligible LSPs.

9 
II. OVERVIEW OF DATA AND METHODOLOGY MATHEMATICA POLICY RESEARCH

D. Analysis methods

We used descriptive, tabular analysis to characterize program administration and service 

delivery of SUAs, AAAs, and LSPs. As noted, the thirteen SUAs that also function as AAAs 

received a slightly different version of the survey (one that excluded questions about their AAAs, 

since these questions were not applicable). For questions that were asked in the same way in both 

surveys, we present combined results for the two groups. When question stems or response 

categories differed between the two surveys, we present results separately for SUAs and SUAs 

that function as AAAs. In these instances, SUA results are presented in the body of the chapter 

and results for SUAs that function as AAAs are presented in Appendix D. 

For categorical variables, we estimated the percentage of agencies that responded in each 

category (for example, the percentage of SUAs that require AAAs or LSPs to offer nutrition 

education monthly, quarterly, semiannually, or annually). For continuous variables, we present 

the mean value of the distribution or the percentages of agencies with values in different ranges 

of the distribution. For example, we present the mean number of congregate sites currently in 

operation and the mean number of congregate sites that offer breakfast, lunch, or dinner. In cases 

in which the distribution of the variable was skewed, we used the median or 50th percentile, 

which is less sensitive than the mean to outliers in the distribution, as well as the 25th and 75th

percentiles. A percentile is the value at or below which a given percentage of observations in a 

group of observations fall. For example, the 50th percentile is the value for which 50 percent of 

the observations are less than or equal to. Finally, in some cases we estimated the percentage of 

agencies with values of a continuous variable in a specific range. For example, when presenting 

the number of days per week that congregate nutrition services are offered, we used breakpoints 

of 1 day, 2 to 4 days, and 5 or more days per week. For these variables, we first examined the 

distribution of responses to determine the appropriate breakpoints to define the ranges. 

E. Analysis weights

The purpose of analysis weights is to allow for the computation of unbiased estimates based 

on sample survey responses from the study population. Weights take into account for both the 

probability of selection into the sample and the differential response patterns that may exist in 

the respondent sample. All SUAs were included in the study, and all responded to the survey, so 

no analysis weights were needed for the analysis of data from the SUAs. We constructed weights 

for the AAA and LSP web and fax-back surveys, as those involved both sampling and 

nonresponse. 

We constructed different sets of weights for the AAA and LSP samples, but the process was 

the same. As described in detail in Appendix C, the AAA weights are the products of several 

weighting factors that fall into two groups: (1) adjustments for AAA selection probabilities and 

(2) nonresponse adjustments at the AAA level for the web and fax-back surveys. Similarly, the 

LSP weights are the products of (1) adjustments for LSP selection probabilities within sampled 

and participating AAAs and (2) nonresponse adjustments at the LSP level for the web and faxback surveys. Based on weighted data, the AAA and LSP findings in this report are nationally 

representative of the population of AAAs and LSPs. 

10
II. OVERVIEW OF DATA AND METHODOLOGY MATHEMATICA POLICY RESEARCH

F. Study limitations

This report represents the most comprehensive assessment in 20 years of the program 

administration and service delivery of the Title III-C NSP. When interpreting the report’s 

findings, it is important to consider a few limitations.

Sampling error. Unlike the data collected from SUAs, the data collected from the AAAs 

and LSPs in this study were based on samples of agencies and providers. As a result, the 

numerical estimates reported here are subject to possible error resulting from random statistical 

variation. In general, however, the sample sizes are large enough that any sampling errors are 

probably too small to affect the overall conclusions. 

Item nonresponse. Because the agency surveys were self-administered on the web, 

respondents were able to skip questions as well as respond “don’t know.” The percentages and 

estimates presented in this report are based on responses that exclude both types of missing data. 

As a result, item nonresponse bias is possible for any estimate presented in this report. It was not 

a serious program for most survey questions, however. We evaluated whether any question had a 

particularly high percentages of item nonresponse, which was defined as less than an 80 percent 

response rate. The following items presented in this report had high nonresponse: 

• Criteria that AAAs use for prioritization of services (AAA web survey, question F2) 

• The length of time a person has been on the current congregate meal program or home 

delivered meal program waiting list (for AAAs) (AAA web survey, questions K4 and K7) 

• The longest route that the LSP provides home-delivered meals to participants (LSP web 

survey, question O6) 

• The recommended participant contribution for home-delivered meal clients (LSP web 

survey, question O12) 

In the corresponding tables we have indicated that these estimates should be interpreted with 

caution due to item nonresponse. 

11
This page has been left blank for double-sided copying.
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY

In the Title III-C Nutrition Services Program (NSP), a multilayered administrative structure 

of public and private agencies delivers nutrition and social support services to address the needs 

of older adults. This National Agency Network consists of six levels: (1) DHHS; (2) the AoA 

central office; (3) the AoA regional offices; (4) SUAs; (5) AAAs; and (6) LSPs.

The Older Americans Act (OAA) has broad guidelines on the responsibilities of the agencies 

within this administrative hierarchy. For example, the AoA central office is required to distribute 

grants to SUAs who, in turn, must designate planning and service areas (PSAs) and develop rules 

for allocating funds among areas in their states. They also designate and oversee the AAAs, 

which develop and implement programs and services for older people at the local level. Finally, 

the AAAs make grants and/or contract awards to LSPs. Within the framework of these 

guidelines, however, program operations often vary widely in different parts of the country and 

even in different parts of the same state.

This chapter describes the program administration and service delivery of SUAs, AAAs, and 

LSPs to learn more about how the program operates to serve older adults and to identify ways of 

improving the program planning process by analyzing program structure, administration, 

staffing, coordination, processes, and service delivery. As described in Chapter II, findings are 

based on survey data collected from staff at SUAs, AAAs, and LSPs in the network that 

administers and operates the program. 

Section A describes the organizational structure of the network that administers the NSP. 

Section B examines the nutrition and support services provided to NSP participants. Section C 

examines program participants’ needs assessments, referrals, and emergency services. Section D 

describes agencies’ training and technical assistance, data collection and monitoring, and 

interactions with other agencies and programs. The quality of program services provided is 

discussed in Section E, followed by program resources in Section F. Section G examines 

prioritization and access to services and waiting lists. Finally, Section H examines participants’ 

program contributions, private pay policies, and waivers. 

A. Organizational structure of the National Aging Network

Although the NSP typically is administered at three levels below the ACL regional office 

(the SUA, AAA, and LSP), in some instances the levels are collapsed so that one organization 

performs the tasks of more than one level. For example, in 13 states and territories that are 

designated as single-state PSAs, there are no AAAs—the SUA functions as the AAA. In many 

PSAs, the AAA also functions as a direct provider of nutrition services (an LSP); sometimes, it is 

the only service provider. Next, we describe organizational characteristics of each of these 

entities.

1. SUAs

States are required to assign responsibility for administering the NSP to a separate agency 

responsible for general issues and programs related to older people. The SUA is the agency that 

performs this administrative function at the state level. There are 56 SUAs, one in each of the 50 

13
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

states, the District of Columbia, and five territories (American Samoa, Guam, the Northern 

Mariana Islands, Puerto Rico, and the Virgin Islands). 

SUAs have a median of 39 full-time equivalent (FTE) employees working at the agency 

(Table III.1). Of the total number of full-time employees at an SUA, two is the median number 

that work on the NSP and are funded in whole or in part by the OAA. These numbers vary 

greatly across agencies, however. At least one-quarter of SUAs have fewer than 19 FTE 

employees, and another quarter have at least 131 FTE employees. The number of FTE 

employees who work on the NSP and are funded in whole or in part by the OAA also varies 

across agencies, ranging from one in more than a quarter of all SUAs to six or more in another 

quarter of SUAs.

Table III.1. Organizational structure and staff composition at SUAs

. . 

Number of FTEs at the agency 

Minimum 5 

25th percentile 19

50th percentile (median) 39

75th percentile 131 

Maximum 1,267

Number of FTEs who work on the NSP at the SUA and are funded in whole or in part by the OAA . 

Minimum 0 

25th percentile 1 

50th percentile (median) 2 

75th percentile 6 

Maximum 53

Number of AAAs in statea . 

Minimum 2 

25th percentile 7 

50th percentile (median) 12 

75th percentile 16

Maximum 59

Percentage of SUAs that employ a Nutrition Program Administrator (NPA) for the NSP 80

Percentage of SUAs that employ an NPA for the NSP who is a registered dietitian or statecredentialed nutritional professional 61 

Program responsibilities of NPA (other than NSP) b c . 

Other food and nutrition programs 40

Nonfood and nutrition programs 76 

No other program responsibilities 18 

Percentage of SUAs that employ at least one registered dietitian and/or state credentialed nutrition 

professional who works at least part-time at the NSP 64

Sources: SUA surveys.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

a Among SUAs that do not function as AAAs. 

b Percentages of SUAs that employ an NPA.

c Multiple answers allowed.

14
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

The median number of AAAs that SUAs oversee is 12, although this number varies 

considerably from state to state. At least one-quarter of SUAs have 7 or fewer AAAs, but at least 

another quarter have 16 or more. 

Most (80 percent) of SUAs have a nutrition program administrator (NPA) who plans, 

develops, administers, implements, and evaluates the NSP. Among those agencies that have an 

NPA, 61 percent have an NPA who is a registered dietitian or state-credentialed nutritional 

professional. In 40 percent of SUAs with an NPA, the NPA has program responsibilities in other 

food and nutrition programs such as the Supplemental Nutrition Assistance Program (SNAP) and 

the Senior Farmers’ Market Nutrition Program (SFMNP), in addition to being responsible for the 

NSP. In 76 percent of SUAs with NPAs, these administrators have responsibilities in nonfood 

and nutrition programs such as transportation services and senior centers. 

2. AAAs

AAAs establish, coordinate, and make accessible a network of services that older people 

may need for independent living. Each AAA operates within a specific geographic planning and 

service area (PSA), designated by the SUA. At the time of data collection, there were 618 AAAs 

in the Title III-C NSP. In 13 states and territories designated as single-state PSAs, the SUA 

fulfills the role of the AAA.6

 

AAAs have a median of 25 full-time equivalent (FTE) employees working at the agency 

(Table III.2). Of the total number of full-time employees at a AAA, 4 is the median number that 

work on the NSP and are funded in whole or in part by the OAA. These numbers vary greatly 

across agencies, however. At least one-quarter of AAAs have at most 12 FTE employees, and 

another quarter have at least 53 FTE employees. The number of FTE employees who work on 

the NSP and are funded in whole or in part by the OAA also varies across agencies. At least onequarter of AAAs have at most 2 FTE employees, and another quarter have at least 11 FTE 

employees.

The OAA allows AAAs to be public or private nonprofit organizations. In practice, the 

AAAs are more likely to be public organizations than private nonprofit organizations (55 and 39 

percent, respectively; Table III.2).7 About 30 percent of AAAs are a division of city or county 

governments; 24 percent are also organizations created by consortia of governments (including 

government councils and regional commissions). Nearly half (47 percent) of AAAs are standalone organizations; the remaining AAAs are part of another organization. 

AAAs’ PSAs cover a wide range of geographic areas. Most AAAs (87 percent) have PSAs 

that include a rural area, and just over half (57 percent) have PSAs that include an urban area 

(Table III.2). Many AAAs (46 percent) have PSAs that also serve suburban areas, while 7 

percent serve frontier areas. More than half of AAAs (59 percent) have PSAs that cover more 

than one county; most of the remaining AAAs (37 percent) cover a single county. 

6 These SUAs are not included in the count of 618 AAAs.

7 Most of an additional 7 percent of AAAs that reported “other” can be labelled as “public”, although the responses 

cannot be placed within the existing response options. 

15

 
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.2. Organizational structure of AAAs

. . 

Number of FTEs at the agency . 

Minimum 1 

25th percentile 12

50th percentile (median) 25

75th percentile 53

Maximum 654

Number of FTEs who work on the NSP at the AAA and are funded in whole or in part by the OAA . 

Minimum 0 

25th percentile 2 

50th percentile (median) 4 

75th percentile 11

Maximum 79

Management structure of AAAs (%) . 

Nonprofit private agency (nongovernmental) 39

Division of city or county government 30

Part of a council of governments or regional planning and development agency 24

Educational institution 1 

Other 7 

Percentage of AAAs that are stand-alone organizations (not part of another organization) 47

Areas in an AAA’s PSAa (%) . 

Urban area 57

Suburban area 46

Rural area 87

Frontier area 7 

Boundaries of the AAA’s PSA best described asa (%) . 

Single county 37

Multicounty 59

Single city/metro area 1 

Multiple city/metro area 1 

Other 3 

Presence of ADRCs in AAA’s PSA (%) . 

Yes 79

Under development or in progress 9 

No 12

Relationship of the AAA to the ADRCb (%) . 

AAA is lead agency of the ADRC 70

AAA partners with the ADRC 23

AAA has a different relationship with the ADRC 6 

AAA has no relationship with the ADRC 1 

Nutrition program staff were involved in developing the ADRCb (%) 28

Nutrition program staff are or were involved in operating the ADRC.b (%) 23

Total, unduplicated number of people in most recently completed fiscal year who received 

congregate nutrition program services supported in whole or in part by OAA Title IIIc . 

0 to 500 24

501 to 1,000 19

1,001 to 1,500 11

1,501 to 2,000 9 

2,001 to 3,000 15

3,000 or more 21

Mean 2,561

Median 1,287

16
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.2 (continued)

. . 

Total, unduplicated number of people in most recently completed fiscal year who received homedelivered nutrition program services supported in whole or in part by OAA Title IIIc . 

0 to 500 34

501 to 1,000 31

1,001 to 1,500 13

1,501 to 2,000 5 

2,001 to 3,000 9 

3,000 or more 8 

Mean 1,376

Median 708

Source: AAA survey, weighted data. 

Note: Except where noted, tabulations are based on an unweighted sample size of 333 AAAs. Individual 

estimates within the table may have slightly fewer observations due to item nonresponse to individual 

questions.

aMultiple answers allowed.

bPercentage of AAAs with ADRC in PSA or one under development or in progress.

cEstimates based on 298 AAAs that responded to the AAA fax-back survey. 

Aging and Disability Resource Centers (ADRCs) play an important role in the National 

Aging Network. The OAA, as amended in 2006, defines ADRCs as entities established by a state 

as part of the state system of long-term care to provide comprehensive information on the full 

range of long-term care programs and services within a community, personal counseling 

assessing care needs and developing individual care plans, and consumers access to a range of 

programs for which consumers may be eligible (Public Law 109–365. Title I, Section 101 

October 17, 2006). 

Although ADRCs may have a physical location in a state, they may also be a consortia of 

providers that serve a wide area of the state. ADRCs serve adults in the PSAs of more than threequarters (79 percent) of AAAs (Table III.2). An ADRC is under development in the PSA of 

another 9 percent of AAAs. Among those AAAs with an ADRC providing services in their PSA, 

or with one under development, 70 percent of AAAs are the lead agency of the ADRC; another 

23 percent partner with the ADRC. Few AAAs (1 percent) reported not having a relationship 

with the ADRC. The remaining AAAs report having a different relationship with the ADRC, 

most commonly contracting with the ADRC to provide services or serving as both the AAA and 

ADRC. For most (72 percent) AAAs with an ADRC in their PSA or with one under 

development, the AAAs’ nutrition program staff were not involved in developing the ADRC. 

Similarly, the nutrition staff in most of these AAAs (77 percent) have not been involved in 

operating the ADRC.

During the most recently completed year prior to the interview, AAAs provided congregate 

nutrition services to an average of 2,561 unduplicated people. About half of AAAs provided 

services to up to 1,500 people, while almost a quarter provided services to at least 3,000 people 

(Table III.2). The total number that were provided home-delivered services was lower. AAAs 

provided home-delivered services to an average of 1,376 unduplicated people, with almost twothirds of agencies serving fewer than 1,000 unduplicated people. 

17
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

3. LSPs

The Local Service Provider (LSP) is the administrative agency responsible for providing 

nutrition and in some cases additional support services within a defined community. The median 

number of people who work on the NSP and are funded in whole or in part by the OAA is four 

(Table III.3). This varies greatly across agencies, however. At least one-quarter of LSPs have at 

most 2 FTE employees, and another quarter have at least 8 FTE employees. 

Table III.3. Organizational structure of LSPs

. . 

Number of FTEs who work on the NSP at the LSP and are funded in whole or in part by 

the OAA 

Minimum 0 

25th percentile 2 

50th percentile (median) 4 

75th percentile 8 

Maximum 115

Management structure of LSPs (%) 

Nonprofit private agency (nongovernmental) 61

For profit 1 

Division of city or county government 32

Part of a council of governments or regional planning and development agency 2 

Tribal government entity 1 

Educational institution <1

Other 2 

Percentage of LSPs that are stand-alone organizations (not part of another organization) 52

Percentage of LSPs that are faith based 7 

Areas in the congregate nutrition service areaa (%) 

Urban area 39

Suburban area 29

Rural area 72

Frontier area 4 

Boundaries of the LSP congregate nutrition service areaa (%) 

Single county 51

Multicounty 21

Single city/metro area 11

Multiple city/metro area 4 

Other 12

Areas in the LSP home-delivered service areaa (%) 

Urban area 37

Suburban area 28

Rural area 77

Boundaries of the LSP home-delivered service areaa (%) 

Single county 53

Multicounty 18

Single city/metro area 9 

Multiple city/metro area 5 

Other 15

18
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.3 (continued)

. . 

Total, unduplicated number of people who received congregate nutrition program services 

supported in whole or in part by OAA Title IIIb 

0 to 250 39

251 to 500 17

501 to 750 14

751 to 1,000 6 

1,001 to 1,500 11

1,501 or more 14

Mean 942

Median 360

Total, unduplicated number of people who received home-delivered nutrition program 

services supported in whole or in part by OAA Title IIIb 

0 to 250 66

251 to 500 9 

501 to 750 8 

751 to 1,000 5 

1,001 to 1,500 5 

1,501 or more 6 

Mean 443

Median 200

Source: LSP survey, weighted data.

Note: Except where noted, tabulations are based on an unweighted sample size of 199 LSPs. Individual 

estimates within the table may have slightly fewer observations due to item nonresponse to individual 

questions.

aMultiple answers allowed.

bEstimates based on 140 LSPs that responded to the LSP fax-back survey.

About three-fifths (61 percent) of LSPs are private nonprofit organizations (Table III.3). 

Most of the rest (35 percent) are public entities, such as divisions of city or county governments 

or part of a council of governments or regional planning agency. About half (52 percent) of LSPs 

are stand-alone organizations; the remaining LSPs are part of another organization. Seven 

percent of LSPs are faith based.

LSPs’ congregate nutrition service areas and home-delivered service areas cover a wide 

range of geographic areas. Most LSP service areas include a rural area (72 percent for congregate 

nutrition service areas and 77 percent for home-delivered service areas), and just over one-third 

include an urban area (39 percent for congregate nutrition service areas and 37 percent for homedelivered service areas; Table III.3). More than half of LSPs have service areas that cover only a 

single county (51 and 53 percent for congregate nutrition service areas and home-delivered 

service areas, respectively); most of the remaining LSPs have service areas that cover more than 

one county or a single city. 

During the most recently completed year prior to the interview, LSPs provided congregate 

nutrition services to an average of 942 unduplicated people (Table III.3). Thirty-nine percent of 

LSPs provided services to up to 250 people, while a quarter provided services to at least 1,000 

people. The total number that were provided home-delivered services was lower. LSPs provided 

home-delivered services to an average of 443 unduplicated people, with two-thirds of agencies 

serving fewer than 250 unduplicated people. 

19
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

B. Nutrition and support services

LSPs have primary responsibility for providing services to adults under the NSP; However, 

AAAs also contribute extensively to the provision of nutrition and support services to older 

people, through their role in planning and coordinating services within their prescribed service 

areas, as well as sometimes through the direct provision of services. Our examination of the 

types of nutrition and support services offered under the program supported in whole or in part 

by Title III-C funding draws on information from these two levels of the program hierarchy. 

Subsection B.1 provides an overview of the characteristics of populations that these agencies 

serve, the nutrition and support services offered by AAAs and LSPs, and congregate meal 

program and home-delivered meal program characteristics and operations. Subsection B.2 

examines nutrition education and counseling. Clients’ referrals and needs assessments are 

discussed in subsection B.3, and subsection B.4 describes emergency nutrition services and 

preparedness plans. 

1. Overview of NSP characteristics

 a. Populations served by AAAs and LSPs

AAAs and LSPs serve a diverse set of populations through their programs and services.8 All 

AAAs and LSPs serve adults ages 60 and older (Table III.4). The next most common populations 

served are family caregivers and adults with physical disabilities, regardless of age (90 and 68 

percent of AAAs, respectively, and 42 and 49 percent of LSPs, respectively). Forty percent of 

AAAs and 31 percent of LSPs also serve adults with intellectual disabilities or developmental 

disability, regardless of age. Although less common, a nontrivial percentage of agencies serve 

children with physical disabilities (17 and 13 percent of AAAs and LSPs, respectively) and 

children with intellectual or developmental disability (12 and 11 percent of AAAs and LSPs, 

respectively).

Table III.4. Populations served by AAAs and LSPsa

. 

Percentage 

of AAAs

Percentage 

of LSPs

Adults 60 and older 100 100

Adults with physical disabilities, regardless of age 68 49

Adults with intellectual or developmental disabilities, regardless of age 40 31

Children with physical disabilities 17 13

Children with intellectual or developmental disabilities 12 11

Family caregivers 90 42

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed

8 Agencies responded to a question asking which populations they served through all of their programs and services. 

Thus, this was not limited to populations served through the OAA or the Title III-C nutrition program.

20

 
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

b. Overview of program services available through AAAs 

Nutrition services through AAAs. AAAs have a variety of nutrition services available in 

their PSA. Nearly all AAAs (98 percent) have nutrition education services in their PSA (Table 

III.5), defined as a program to promote better health by providing nutrition, physical fitness, and 

nutrition-related health information and instruction in a group or individual setting. Many AAAs 

have nutrition screening (89 percent) or nutrition counseling (63 percent) available in their PSA. 

Nutrition counseling is defined as individualized guidance provided one-on-one to address 

options and methods for improving nutritional status. 

Table III.5. Program services available through AAAs

 Percentage of AAAs

Percentage of AAAs with the following services available in the PSA: 

Nutrition education 98

Nutrition counseling 63

Nutrition screening 89

Nutrition education is provideda . 

By AAA 53

Through a contract between the AAA and another organization 51

Through a grant provided by the AAA to another organization 8 

Nutrition screening is provideda . 

By AAA 58

Through a contract between the AAA and another organization 50

Through a grant provided by the AAA to another organization 8 

Nutrition counseling is provideda,b . 

By AAA 42

Through a contract between the AAA and another organization 46

Through a grant provided by the AAA to another organization 8 

The congregate nutrition program is provideda,b . 

By AAA 40

Through a contract between the AAA and another organization 65

Through a grant provided by the AAA to another organization 10

The home-delivered nutrition program is provideda,b . 

By AAA 36

Through a contract between the AAA and another organization 66

Through a grant provided by the AAA to another organization 10

Types of contracts that AAA enters into with NSP service providersa,c . 

Unit rate 81

Performance based 17

Cost reimbursement 37

Other 6 

The following are included in the AAAs’ contracts with NSP service providersa,c . 

Quality assurance component 91

Targets or goals 67

Source: AAA survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages estimated out of the AAAs providing the service indicated (e.g. nutrition education). 

cPercentages estimated out of the AAAs that provide nutrition services (nutrition education, screening, or counseling; 

congregate nutrition program; or home-delivered nutrition program), through a contract between AAA and another 

organization

21
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Nutrition services are provided in AAAs’ PSAs in different ways. For nutrition education, 

more than half (53 percent) of AAAs provide services directly, 51 percent provide services 

through a contract between the AAA and another organization, and a small percentage (8 

percent) provide services through a grant between the AAA and another organization (Table 

III.5). The percentages for nutrition screening were generally similar to those for nutrition 

education. Compared to nutrition education, AAAs were less likely to provide nutrition 

counseling services directly (42 percent) or through a contract (46 percent).

AAAs also provide the congregate meal and home-delivered meal programs in different 

ways (Table III.5). Over one-third of AAAs provide services directly (40 percent for the 

congregate meal program and 36 percent for the home-delivered meal program). Most AAAs 

(65 percent for the congregate meal program and 66 percent for the home-delivered meal 

program) provide services through a contract between the AAA and another organization. As 

with nutrition services more generally, a small percentage of AAAs provide these programs 

through a grant. 

For AAAs that provide nutrition services through a contract between the AAA and another 

organization, most agencies (81 percent) enter into a unit rate contract (Table III.5). A cost 

reimbursement contract is another common type (37 percent of AAAs with contracts); 

performance-based contracts are less common (17 percent of AAAs with contracts). Most AAAs 

(91 percent) providing services through a contract include a quality assurance component, such 

as a Hazard Analysis Critical Control point, food safety, or program participation satisfaction. 

For two-thirds of AAAs providing services through a contract, the contract includes targets or 

goals.

Availability of congregate and home-delivered meals across AAAs. AAAs have, on 

average, 21 congregate nutrition locations, which are any group dining settings, such as senior 

centers, adult day care centers, community centers, faith-based locations, or restaurants (Table 

III.6). These numbers vary across AAAs, however. Fourteen percent have 5 locations at most, 

and another 24 percent have 6 to 10 locations. Nearly one-quarter of AAAs have at least 26 

locations. 

All AAAs offer congregate meals in their PSAs. However, AAAs differ in the availability of 

congregate nutrition services in their PSAs. Over two-thirds (70 percent) of agencies offer them 

five or more days a week, 23 percent offer them two to four days a week, and 7 percent offer 

them one day a week. The availability of home-delivered services also varies. For nearly twothirds of AAAs (63 percent), all areas of the AAA’s PSA have home-delivered nutrition services. 

Rural areas are least likely to have these services: 31 percent of AAAs do not provide homedelivered meal services in rural areas.

22
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.6. AAAs’ availability of NSPs 

 Percentage of 

AAAs

Number of congregate nutrition locations in the PSA 

1 to 5 14

6 to 10 24

11 to 15 18

16 to 20 10

21 to 25 10

26 or more 23

Mean 21

Median 13

Congregate nutrition services are offered in all areas of the PSA: . 

Five or more days a week 70

Two to four days a week 23

One day a week 7 

Areas that do not have home-delivered nutrition servicesa . 

Some urban areas 3 

Some suburban areas 5 

Some rural areas 31

Some frontier areas 5 

Some mixed areas 4 

All areas of the PSA receive home-delivered nutrition services 63

Source: AAA survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

c. Overview of program services available through LSPs 

LSPs provide a variety of nutrition and non-nutrition services. The most common service is 

congregate meals, provided by nearly all (93 percent) of LSPs (Table III.7). Most (87 percent) 

also provide home-delivered meals. Eighty percent of LSPs provide both congregate meals and 

home-delivered meals, while 13 percent of LSPs provide only congregate meals and 7 percent 

provide only home-delivered meals.

LSPs also provide other nutrition services. Seventy-seven percent of LSPs report that they 

provide nutrition education. More than half (52 percent) provide nutrition screening to 

congregate and/or home-delivered participants. Nutrition counseling is also available at just over 

one-quarter of LSPs.

Non-nutrition services are also common. Nearly two-thirds of agencies provide nonnutrition services related to social activities (62 percent) and health promotion and disease 

prevention activities (63 percent). Other common non-nutrition services include transportation to 

and from meal sites, case management, and chores and housekeeping services. 

23
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.7. Services provided by LSPs

. Percentage of 

LSPs 

Services LSPs provide to older adults or their caregivers through a grant or contract with the 

AAAa b 

Congregate meal services 93

Home-delivered meal services 87

Congregate meal services and home-delivered meal services 80

Congregate meal services, but not home-delivered meal services 13

Home-delivered meal services, but not congregate meal services 7 

Nutrition screening and assessment 52

Nutrition education 77

Nutrition counseling 28

Social activities 62

Health promotion and disease prevention activities 63

Other non-nutrition services 63

Other non-nutrition services LSPs provide through grant or contract with AAAa b . 

Housing 11

Chores/housekeeping 34

Grocery assistance 28

Personal care 29

Home health 12

Transportation 76

Case management 53

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

b LSPs were asked to report provision of services to older adults or their caregivers through a grant or contract with 

the AAA. 

d. Congregate nutrition program characteristics and operations

LSPs have extensive experience operating congregate nutrition programs. LSP have, on 

average, offered congregate nutrition programs for 28 years (Table III.8). Over seventy percent 

have been involved with the program for more than 20 years; nearly 90 percent have offered the 

program for more than 10 years. 

24
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.8. Congregate nutrition program characteristics

 . 

Number of years the program has been offereda . 

0 to 2 1 

3 to 5 5 

6 to 10 8 

11 to 15 4 

16 to 20 10

21 or more 73

Mean 28

Median 30

Number of congregate sites currently in operationa . 

1 60

2 to 5 23

6 to 10 8 

11 to 20 6 

21 or more 3 

Mean 4 

Median 1 

Percentage of sites that meet Americans with Disabilities Act Standards for Accessible Design 100

Percentage of congregate sites that offer meals . 

More than 5 days a week 6 

5 days a week 77

4 days a week 7 

3 days a week 8 

2 days a week 3 

1 day a week 2 

Percentage of sites that offer meals on weekends 14

Percentage of congregate sites that offerb . 

Breakfast 11

Lunch 100

Dinner 11

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aEstimate represents the percentage of LSPs, except for mean and median 

bMultiple answers allowed.

The majority of LSPs operate one congregate site. The range of congregate sites that each 

LSP supervises varies considerably: about two-thirds administer only one meal site, another 23 

percent administer two to five sites, and 17 percent administer more than five sites. 

All sites meet the Americans with Disabilities Act Standards for Accessible Design. The 

standards set minimum requirements for “newly designed and constructed or altered State and 

local government facilities, public accommodations, and commercial facilities to be readily 

accessible to and usable by adults with disabilities.”

Meal service schedule. Many congregate meal sites (83 percent) serve lunch at least five 

days a week (Table III.8). Fourteen percent of congregate sites serve meals on weekends, 11 

percent provide breakfast, and 11 percent provide dinner. 

25
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Meal service capacity. LSPs reported that their congregate nutrition program could serve 

192 people, on average, at one sitting if all sites were open and operating (Table III.9). The 

average number of people who could be served ranged from 61 at the smallest site to 101 at the 

largest site. Finally, LSPs served an average of 641 lunches in the week before the interview. 

The number of lunches ranged from 138 or fewer for one-quarter of LSPs to at least 650 for 

another quarter of LSPs. 

Table III.9. Meal capacity of congregate nutrition programs 

. Number

Number of people the program can serve at one meal (including all sites) 

Minimum 14

25th percentile 36

Mean 192

75th percentile 200

Maximum 4,500

Number of people the largest site can serve at one meal 

Minimum 14

25th percentile 40

Mean 101

75th percentile 139

Maximum 1,000

Number of people the smallest site can serve at one meal 

Minimum 1 

25th percentile 20

Mean 61

75th percentile 80

Maximum 1,000

Number of lunches served by the LSP last week 

Minimum 10

25th percentile 138

Mean 641

75th percentile 650 

Maximum 22,105

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

Meal production methods. Most congregate sites serve meals prepared by the LSP, either 

by staff at a LSP-affiliated central kitchen (45 percent) or by provider staff at the congregate 

meal site (47 percent; Table III.10). Forty-two percent of the congregate sites serve program 

meals prepared by an outside catering or vendor contractor. Restaurant vouchers were 

uncommon, with only 3 percent of LSPs offering them. 

26
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.10. Congregate nutrition program meal production methods, menus, 

and special diets

. Percentage 

of LSPs

Meal production methodsa 

Central kitchen 45

On-site production 47

Catering or vendor contract 42

Restaurant vouchers 3 

Congregate nutrition program menu . 

Set menu that does not offer the participant any choice of food 78

Choice of different complete meal options 14

Choice of different food items within the meal 9 

Percentage of LSPs with sites that are operated for specific populations or religious, cultural, or 

ethnic groups 14

The following therapeutic diets are offered:a b . 

Liberal geriatric diet 4 

Diabetic 24

Low-sodium 42

Modified-texture 10

Vegetarian 5 

Kosher 5 

Halal <1

No special diets offered 37

Source: LSP survey.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bA liberal diet is one that relaxes the restrictions of a therapeutic diet, with the goal of preventing malnutrition among 

the elderly.

Menus and special diets. Over three-quarters of LSPs provide a set menu for the 

congregate nutrition program that does not offer the client any choice of food items (Table 

III.10). Other menu options are less common: 14 percent of LSPs provide a choice of different 

complete meal options (such as choosing between two types of meals), and 9 percent of LSPs 

provide a choice of different food items within the meal (such as a choice of entrée and choice of 

vegetables, fruit, dessert, or salad bar). 

Only 14 percent of LSPs offer congregate nutrition services operated for specific 

populations or religious, cultural, or ethnic groups (Table III.10). However, many LSPs (63 

percent) offer special or therapeutic diets in the congregate nutrition program. The most common 

are low-sodium (42 percent), diabetic (24 percent), and modified texture (10 percent). 

e. Home-delivered nutrition program characteristics and operations

LSPs have extensive experience operating home-delivered nutrition programs. LSP have, on 

average, offered home-delivered meals for 28 years (Table III.11). Seventy-two percent have 

been involved with the program for more than 20 years; 89 percent have been offering the 

program for more than 10 years. 

27
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.11. Home-delivered nutrition program characteristics

 

Number of years the program has been offered 

0 to 2 1 

3 to 5 1 

6 to 10 8 

11 to 15 10

16 to 20 7 

21 or more 72

Mean 28

Median 30

Mileage on the longest route for which the organization provides home-delivered nutrition services . 

25th percentile 15

Mean 49

75th percentile 61

Mileage on the shortest route for which the organization provides home-delivered nutrition services . 

25th percentile 2 

Mean 14

75th percentile 17

Number of days per week deliveries are made to clients’ homes . 

1 1 

2 1 

3 2 

4 6 

5 88

6 or 7 2 

Mean 5 

Number of meals provided to a client at each visit . 

1 80

2 6 

3 1 

4 0 

5 8 

6 or more 4 

Mean 2 

Number of meals provided to a client at each visit among clients receiving one delivery per week . 

Mean 8 

Median 10

Number of meals provided to a client at each visit among clients receiving more than one delivery per 

week . 

Mean 2 

Median 1 

Percentage of LSPs that deliver meals to clients’ homes on the weekends 12

Percentage of LSPs that offer home-delivered meals for the following meals:a . 

Breakfast 4 

Lunch 96

Dinner 15

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

28
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

LSPs provide home-delivered nutrition services both near the agency and far away from it 

(Table III.11). On average, the shortest route for which an LSP provides services is 14 miles, and 

the longest route is 49 miles. At least one-quarter of agencies travel within 15 miles to the 

farthest client, and another quarter travel 61 or more miles.

Meal service schedule. With few exceptions, meal deliveries are made to clients’ homes 

five days a week (Table III.11). Eighty-eight percent of LSPs deliver five days a week, 10 

percent delivery fewer than five days, and 2 percent deliver six or seven days a week. In general, 

only one meal is provided per delivery (80 percent). Four percent of programs provide at least 

six meals in a single delivery. For LSPs that make one delivery to clients’ homes per week, eight 

meals are typically provided per visit. This compares to two meals per visit for LSPs that make 

more than one delivery to clients’ homes per week. Only 12 percent of home-delivered programs 

deliver meals to clients’ homes on weekends. Most programs (96 percent) provide lunch. Fifteen 

percent deliver dinner, and 4 percent deliver breakfast.

Meal preparation methods. Many programs prepare home-delivered meals on-site at 

congregate meal sites (40 percent), where they are packaged and then distributed (Table III.12). 

However, 52 percent of LSPs with home-delivered meal programs contract for these meals with 

outside vendors or caterers, and 44 percent prepare home-delivered meals at a project-affiliated 

central kitchen. The most common type of meal is delivered hot (76 percent). Some LSPs deliver 

meals in other forms, including frozen, to be reheated (17 percent); cold, to be eaten cold 

(2 percent); shelf-stable meals, such as “disaster meals” (3 percent); and combination meals 

(2 percent).

Special diets. More than four-fifths (85 percent) of LSPs provide a set menu for the homedelivered meal program that does not offer the client any choice of food items (Table III.12). 

Other menu options are less common: 10 percent of LSPs provide a choice of different complete 

meal options (such as choosing between two types of meals), and 5 percent of LSPs provide a 

choice of different food items within the meal (such as a choice of entrée and choice of 

vegetables, fruit, or dessert). 

More than three-quarters (79 percent) of LSPs offer special or therapeutic diets in the homedelivered nutrition program. The most common are low-sodium (51 percent), diabetic (34 

percent), and modified texture (12 percent). 

29
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.12. Home-delivered nutrition program meal preparation methods, 

menus, and diets

 

Meal production methodsa 

Central kitchen 44

On-site production 40

Catering or vendor contract 52

Average percentage of meals delivered in the past week of each of the following types:b . 

Hot meals 76

Frozen meals 17

Cold meals 2 

Shelf-stable meals 3 

Combination 2 

Home-delivered nutrition program menu . 

Set menu that does not offer the participant any choice of food 85

Choice of different complete meal options 10

Choice of different food items within the meal 5 

The following therapeutic diets are offered:a c . 

Liberal geriatric diet 4 

Diabetic 34

Low-sodium 51

Modified-texture 12

Vegetarian 10

Kosher 9 

Halal 0 

No special diets offered 21

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages for each meal type were calculated based on number of meals for each LSP. Next, average 

percentages across LSPs were calculated for each meal type.

cA liberal diet is one that relaxes the restrictions of a therapeutic diet, with the goal of preventing malnutrition among 

the elderly.

 

2. Nutrition education and counseling

a. SUA nutrition education and counseling

SUAs play an important role in the development and administration of nutrition education 

and counseling. SUAs can specify the frequency with which education and counseling are 

provided, they can influence the development of AAA and LSP education and counseling plans, 

and they can implement policies and guidelines that affect many aspects of these plans.

Forty-six percent of SUAs require AAAs, either directly or through their LSP, to offer 

nutrition education at least quarterly, and 23 percent require it to be offered semi-annually or 

annually (Table III.13). Twenty-one percent of SUAs have no policy to specify the frequency 

with which nutrition education is offered at the AAA or LSP-level. Of SUAs that require either 

the AAA or LSP to develop a nutrition education plan, 45 percent provide guidance on the 

development of AAA and LSP-level nutrition education plans, and 55 percent monitor the extent 

to which the plan is followed, but only 18 percent of SUAs requiring a plan must approve AAA 

and LSP-level plans.

30
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.13. SUA nutrition education and counseling

. Percentage of 

SUAs

Frequency with which the SUA requires that the AAA or LSP offer nutrition education 

Monthly 30

Quarterly 16

Semiannually 16

Annually 7 

No policy exists at the SUA level on frequency of nutrition education 21

Nutrition education provided only by the SUA and not by the AAA or LSP 0 

SUA has formal policies, guidance, or regulation on the qualifications of the staff who provide 

nutrition education at the AAA or LSP level. 

59

SUA requires that the AAA or LSP develop a nutrition education plan. 50

SUA’s role with regard to the AAA/LSP nutrition education plana,b 

Must approve plan 18

Provides guidance on developing plan 45

Sets plan’s minimum components 41

Monitors plan 55

SUA requires that nutrition counseling be available in each PSA. 45

SUA has policies, guidance, or regulations related to nutrition counseling on any of the 

following topics:a

 

Criteria for authorizing nutrition counseling 32

Qualifications of the nutrition counseling staff 68

Content of the nutrition counseling 25

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of SUAs that require AAAs or LSPs develop a nutrition education plan.

b. Nutrition education available through AAAs and LSPs

Almost all (98 percent) of AAAs offer nutrition education (Table III.14). Among those 

AAAs offering nutrition education, nutrition education is offered at approximately 93 percent of 

congregate meal sites in the PSA. Eighty-seven percent of AAAs offer nutrition education to all 

of their home-delivered meal program participants, 9 percent offer nutrition education to portions 

of their home-delivered program participants, and only 3 percent do not offer nutrition education 

to participants in the home-delivered meal program.

31
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.14. Nutrition education available through AAAs

. Percentage of 

AAAs 

Nutrition education is available in the PSA. 98

Average percentage of congregate meal sites in the PSA that provide nutrition education, 

among AAAs offering nutrition education 93

Availability of nutrition education for home-delivered nutrition program participants 

Available through entire PSA 87

Available in a portion of PSA 9 

Not available in PSA 3 

Source: AAA survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

Seventy-seven percent of LSPs offer nutrition education (Table III.15). At the LSP-level, 82 

percent of LSPs offer nutrition education to all of their home-delivered meal program 

participants, 5 percent offer nutrition education to portions of their home-delivered program 

participants, and 13 percent do not offer nutrition education as part of their home-delivered meal 

program. 

Table III.15. Nutrition education available through local service providers

. Percentage of 

LSPs 

Nutrition education available in the LSP 77

Availability of nutrition education for home-delivered nutrition program participantsa 

Available in the service area 82

Available in a portion of the service area 5 

Not available in the service area 13

Source: LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of LSPs that offer nutrition education.

c. Nutrition counseling available through AAAs and LSPs

Sixty-three percent of AAAs offer nutrition counseling (Table III.16). Among those AAAs 

offering nutrition counseling, nutrition counseling is offered at approximately 83 percent of 

congregate meal sites in the PSA. Eighty-one percent of AAAs offer nutrition counseling to all 

of their home-delivered meal program participants, 13 percent offer nutrition counseling to 

portions of their home-delivered program participants, and only 6 percent do not offer nutrition 

counseling to participants in the home-delivered meal program.

32
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.16. Nutrition counseling available through AAAs

. Percentage of 

AAAs 

Nutrition counseling is available in the PSA. 63

Average percentage of congregate meal sites in the PSA that provide nutrition counseling, 

among AAAs offering nutrition counseling 83

Availability of nutrition counseling for home-delivered nutrition program participants 

Available through entire PSA 81

Available in a portion of PSA 13

Not available in PSA 6 

Source: AAA survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

Fifty-one percent of LSPs offer nutrition counseling (Table III.17). Sixty-four percent of 

LSPs offer nutrition counseling to all of their home-delivered meal program participants, 3 

percent offer nutrition counseling to portions of their home-delivered program participants, and 

33 percent do not offer nutrition counseling as part of their home-delivered meal program.

Table III.17. Nutrition counseling available through local service providers

. Percentage 

of LSPs

Nutrition counseling available in the LSP 51

Availability of nutrition counseling for home-delivered nutrition program participants 

Available throughout the service area 64

Available in a portion of the service area 3 

Not available in the service area 33

Need for nutrition counseling is determined by:a,b 

Nutrition needs assessment 62

Nutrition screening assessment 25

Presence of nutrition-related chronic disease 23

Food insecurity assessment 12

Frequency of assessment of need for nutrition counseling with NSP participants:a,b 

At program enrollment/entry only 46

On a regular basis (such as annually or monthly) 51

When staff notice a change in the participant 42

Program participant, caregiver, family request 42

Health care professional request 27

Percentage of LSPs with a formal mechanism for following up with program participants who have 

had nutrition counseling 35

Source: LSP survey.

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of LSPs that offer nutrition counseling.

33
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Most LSPs determine the need for nutrition counseling by conducting a needs assessment. 

Sixty-two percent of LSPs identify the need for nutrition counseling by conducting a needs 

assessment and 25 percent do so through a nutrition screening assessment. The impetus for 

conducting these assessments can vary (for example, assessment might be conducted as a result 

of a health care professional or family member request). However, most LSPs conduct 

assessments on a regular basis: 46 percent assess the need for nutrition counseling at program 

enrollment, and 51 percent do so on a schedule (such as annually or monthly). 

3. Needs assessments and referrals

NSP agencies strive to understand the needs of program participants by seeking information 

on how clients learn about program services and how nutrition programs help meet the nonnutritional needs of clients by making it easier for them to access other programs. In addition, 

many agencies provide services even if an emergency arises. This section explores these 

important topics. Subsection a examines nutritional needs assessments conducted by SUAs, and 

subsection b examines assessment of client needs at the AAA and LSP levels. Subsection c 

discusses client referrals.

a. Assessing service needs: SUAs

Only 20 percent of SUAs reported having completed a statewide community needs 

assessment in the previous five years, but 60 percent had conducted at least one local community 

needs assessment during that time (Table III.18). Sixty-eight percent of SUAs reported that they 

require AAAs or LSPs to perform consistent individual nutrition needs assessments for the NSP, 

and 65 percent of SUAs issue formal polices or guidance on how to conduct these assessments. 

The information reported at the AAA and LSP levels corresponds to these numbers. 

b. Assessing service needs: AAAs and LSPs 

About 76 to 86 percent of AAAs and LSPs reassess service needs for congregate meal and 

home-delivered meal program participants at least once a year. However, nearly 20 percent of 

AAAs and LSPs (18 and 24 percent, respectively) have no policy to define how frequently 

congregate meal program participants’ service needs should be reassessed (Table III.19). 

34
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.18. Nutrition needs assessment by SUAs

. 

Percentage of 

SUAs

SUAs conduct a community needs assessment for the NSP 

In the past five years, a statewide community needs assessment that includes nutrition has 

been done. 20

In the past five years, one or more local (PSA-level) community needs assessments that 

include nutrition have been done. 60

No assessment has been done in the past five years. 20

Local-level community needs assessments follow a consistent protocol that includes nutrition.a 48

SUAs used results from the community needs assessments pertaining to nutrition used or 

incorporated into the state plan.b 75

SUAs issue formal polices or guidance to the AAAs or LSPs on the conduct of individual 

nutrition needs assessment in the NSP. 65

SUAs require a consistent individual nutrition needs assessment at the local level (AAA or 

LSP) for the NSP. 68

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions. 

aPercentage of SUAs conducting a local community needs assessment within the past five years.

bPercentage of SUAs conducting either statewide or local-level community needs assessment within the past five 

years.

Table III.19. Assessment of clients’ service needs by AAAs and LSPs

 

AAA 

Congregate 

meal 

programs

AAA 

Homedelivered 

meal 

programs

LSP 

Congregate 

meal 

programs

LSP 

Homedelivered 

meal 

programs

Has a formal process for assessing service needs for 

NSP participants 

 

Nutrition needs 83 90 65 84

Non-nutrition needs 71 83 44 56

Frequency with which NSP participants are reassessed 

for service needsa

. . . . 

No policy 18 2 24 4 

Monthly NA NA 0 2 

At least yearly 76 85 86 72

Less than once a year 3 3 0 9 

After acute-care episode 8 17 5 5 

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 171 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

NA = not applicable because the response option was not included in the AAA survey. 

35
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Eighty-three percent of AAAs report that they have a formal process for assessing 

nutritional needs, and 71 percent have a formal process for assessing the non-nutrition needs of 

NSP congregate meal program participants. At the LSP level, 65 percent of providers have a 

formal process for assessing nutritional needs, and 44 percent have a formal process for 

assessing the non-nutrition needs of congregate meal program participants. These numbers are 

slightly higher for the home-delivered meal programs. Eighty-four percent of LSPs have a formal 

process for assessing nutritional needs, and 56 percent have a formal process for assessing the 

non-nutrition needs of home-delivered meal program participants.

c. Client referrals

Client referrals to congregate and home-delivered meal programs. Understanding how 

clients come to participate in the NSP can help agencies improve their outreach. For AAAs, the 

top five client referral sources for the congregate and home-delivered meal programs are (1) 

family and friends, (2) information and assistance system, (3) self-referral, (4) case management 

system, and (5) hospital/health care facility/discharge planner (Tables III.20 and III.21). 

Reflecting differences in the health of the target populations, home-delivered meal participants 

are substantially more likely to be referred to the NSP through hospital/health care/discharge 

planner avenues than congregate meal participants (86 versus 48 percent). 

Table III.20. Most common client referral sources for the congregate meal 

programa,b

. . 

Family and friends 98

Information and assistance system 77

Self 76

Case management system 49

Hospital/health care facility/discharge planner 48

Aging and Disability Resource Center 41

Faith-based organizations 36

Physician 25

Other food or nutrition program 23

Other 15

Medicaid Waiver 7 

Nursing homes 5 

Source: AAA survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aEstimates are the percentages of agencies that included the referral source in their top five sources.

bMultiple answers allowed.

36
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.21. Most common client referral sources for the home-delivered 

meal programa,b

. . 

Family and friends 93

Hospital/health care facility/discharge planner 86

Self 64

Information and assistance system 64

Case management system 59

Aging and Disability Resource Center 34

Physician 34

Medicaid Waiver 18

Faith-based organizations 18

Nursing homes 11

Other food or nutrition program 10

Other 9 

Source: AAA survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aEstimates are the percentages of agencies that included the referral source in their top five sources.

bMultiple answers allowed.

Client referrals to other programs. AAAs and LSPs help many participants in the NSP 

access other programs. AAAs and LSPs reported that they most often provide assistance 

accessing transportation services, Adult Protective Services, Medicare Part D, Medicaid waiver 

programs, Veterans Affairs services, and evidence-based health promotion and disease 

prevention programs (Table III.22). 

4. Emergency nutrition services

Emergency preparedness plans. Sixty-eight percent of SUAs have an emergency plan that 

includes nutrition services. All of these have a plan for short-term emergencies, and 25 percent 

have a plan for long-term emergencies (Table III.23). Ninety percent of AAAs have an 

emergency plan that includes nutrition services. Of these, 89 percent have a plan for short-term 

emergencies, and 15 percent have a plan for long-term emergencies. Eighty-six percent of LSPs 

have an emergency plan that includes nutrition services. All of these have a plan for short-term 

emergencies, and 17 percent have a plan for long-term emergencies.

Components of emergency preparedness plans. For SUAs with emergency plans, 68 

percent indicated that their emergency preparedness plan for nutrition services includes provision 

of food and water and a strategy to identify and address the health and wellness needs of 

nutrition clients (Table III.23). Seventy-nine percent of SUAs with emergency plans indicated 

that their plans include arrangements for communications between organizations as well as with 

clients.

37
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Partner organizations during emergencies. SUAs reported requiring the help of partner 

organizations to continue providing services during an emergency. Ninety-three percent of SUAs 

indicated that they rely on local organizations, 86 percent stated that they rely on the Red Cross, 

and 66 percent cited FEMA Citizen Corps as providing important operational support during an 

emergency (Table III.23).

Table III.22. Referrals to other programs

 

AAA 

Congregate 

meal 

programs

AAA 

Homedelivered 

meal 

programs

LSP 

Congregate 

meal 

programs

LSP 

Homedelivered 

meal 

programs

Participants in the NSP are actively assisted in 

accessing the following programs:a 

 

Medicaid waiver programs 47 67* 36 40* 

Medicaid (non-waiver) 46 53 24 23

Medicare Parts A or B 59 59 51* 43* 

Medicare Part D 67* 65* 54* 41* 

Housing programs 51 52 30 33

Transportation services 77* 68* 66* 58* 

Low-Income Home Energy Assistance Program 58 61 47* 40* 

Supplemental Security Income 42 47 26 25

Other supportive services 56 68* 36 39

SNAP 62* 62 38 33

Commodity Supplemental Food Program NA NA 29 27

Other food or nutrition services 44 49 35 39

Veterans Affairs services 64* 68* 24 23

Adult Protective Services 75* 53 30 34

Evidence-based health promotion and disease 

prevention programs 44 49 54* 29

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions. 

 Estimates with * represent the top five most common referrals in each column.

aMultiple answers allowed.

NA = not applicable because the response option was not included in the AAA survey. 

38
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.23. Emergency nutrition services (percentages)

 SUA AAA LSP 

Have an emergency preparedness plan that includes nutrition services:a 

Any plan 68 90 86

Plan for short-term emergencies 68 89 86

Plan for long-term emergencies 25 15 17

Have polices that required AAA contracts or grants to LSPs to include how nutrition 

services are to be provided during local emergencies 87 NA NA

Components in the emergency preparedness plan for nutrition servicesa,b

Plan for communications between organizations as well as with clients 79 NA NA

Plan for the provision of food and water 68 NA NA

Plan for identifying and addressing the health and wellness needs of nutrition clients 68 NA NA

Entities that help meet the needs of the NSP clients during emergenciesa . . . 

County or local organizations 93 NA NA

Red Cross 86 NA NA

FEMA Citizen Corps 66 NA NA

VOAD or their members 48 NA NA

Private-sector entities involved in disasters 50 NA NA

Organizations that experienced a disaster in the past three years NA NA 34

Initiated an emergency plan during that disaster, among organizations that experienced a 

disaster in the past three years NA NA 95

Sources: SUA survey, AAA survey, and LSP survey (AAA and LSP survey data are weighted).

Note: Tabulations are based on an unweighted sample sizes of 56 SUAs, 333 AAAs and 199 LSPs. Individual 

estimates within the table may have slightly fewer observations due to item nonresponse to individual 

questions.

VOAD = National Voluntary Organizations Active in Disasters

aMultiple answers allowed.

bPercentages estimated out of the SUAs (or AAAs, LSPs) that have an emergency preparedness plan.

NA = not applicable because the response option was not included in the respective survey. 

C. Training and technical assistance, data collection and reporting, and 

interactions with other agencies and programs 

For the NSP to deliver nutrition services to participants successfully, the agencies within the 

administrative hierarchy must understand and successfully execute their programmatic 

responsibilities. The first aspect of this process is for agencies within the network to both provide 

and receive information in the form of technical assistance and training. The second important 

element is for agencies to monitor and assess the performance of subordinate agencies in the 

program hierarchy. Finally, service provision must be carefully coordinated with other agencies 

providing assistance to older adults. This section explores each of these issues. Subsection 1 

examines training and technical assistance among the agencies. Subsection 2 examines data 

systems and reporting. Finally, Subsection 3 explores collaboration with other agencies relevant 

to the NSP program. 

1. Training and technical assistance 

Types of training provided by SUAs. In the past two years, 70 percent of SUAs held 

general trainings on a range of programs and services, and 60 percent have held trainings that 

focus on the NSP and related topics (Table III.24). About 60 percent of SUAs have provided 

training on nutrition quality, food safety, and food service to AAAs or LSPs. 

39
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.24. Training and technical assistance provided by SUAs

 Percentage 

of SUAs

SUAs have provided the following training and technical assistance to AAAs or LSPs for the NSP in 

the past two years:a 

Held specific trainings that focus on the NSP and related topics 60

Held general trainings that cover a range of programs and services, including the NSP and 

related topics 70

Held trainings on the NSP and related topics in conjunction with other state or local agencies or 

organizations 40

SUAs have provided training on the following topics to AAAs or LSPs:a . 

Nutrition quality 56

Food safety 63

Food service 56

Nutrition education 53

Nutrition counseling 35

Program evaluation or outcome measurement 42

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

2. Data systems and reporting 

SUA data systems and reporting. SUAs require AAAs to report nutrition program data 

regularly through, for example, nutrition program service reports, program performance data, 

quality assurance findings, and fiscal management reports. All AAAs report at least some NSP 

data to SUAs electronically (using software or a computer system),9

 and 65 percent of AAAs are 

required to provide data at least monthly (Table III.25). Seventy percent of SUAs require all 

AAAs to report data beyond those required for the AoA state program report. For SUAs that 

require additional data, 77 percent require AAAs to provide additional program performance 

data, and 77 percent require the provision of additional fiscal management report data. 

9 Ninety-one percent of SUAs require all AAAs in the state to use the same software for reporting.

40

 
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.25. SUA data systems and reporting

 Percentage of 

SUAs

SUAs receive NSP data from AAAs by:a 

Software/computer system 100

Email 16

Telephone 5 

Mail 5 

SUAs require all AAAs in the state to use the same software for reporting 91

SUAs require all AAAs to report NSP data beyond those required in the AoA state program report 70

Data being collected beyond those required for the state program reporta,b 

Nutrition program service reports/program performance data 77

Quality assurance findings 47

Fiscal management reports 77

SUAs have established NSP performance measures at the AAA level. 49 

SUAs share NSP performance data with the public. 65 

Frequency with which AAAs are required to report NSP data to the SUA 

Continuously 14 

Monthly 51 

Quarterly 26

Semiannually 2 

Annually 2 

Other 5 

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

bPercentage of SUAs requiring all AAAs to report NSP data beyond those required in the AoA state program report.

AAA data systems and reporting. More than half of AAAs use electronic program 

participant tracking or referral systems (Table III.26). Forty-eight percent of AAAs reported 

using electronic financial systems for billing or service payments, and 27 percent use a costcentered accounting system. More than one-third of AAAs carry out computer-assisted menu 

planning and analysis, and about one-third also reported using electronic systems for recording 

that meals were received. Moreover, a high percentage of AAAs collect program performance 

data: 88 percent collect nutrition program service reports and program performance data, 70 

percent collect quality assurance findings, 83 percent collect fiscal management reports, and 88 

percent collect client assessments of service.

LSP data systems and reporting. Forty-two percent of LSPs use electronic program 

participant tracking or referral systems (Table III.26). Thirty percent reported using electronic 

financial systems for billing or making payments for service, and 20 percent use a cost-centered 

accounting system. Thirty-one percent of LSPs carry out computer-assisted menu planning and 

analysis, and 24 percent reported using electronic systems to record that meals were received. 

Whereas 10 percent of AAAs indicated that they have no automated systems, 30 percent of LSPs 

reported that they do not use any automated systems. 

41
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.26. AAA and LSP data systems and reporting

 Percentage of AAAs Percentage of LSPs

Data systems currently useda 

Computer-assisted menu planning and analysis 38 31

Software to track inventory or order food 14 14

Delivery systems for home-delivered nutrition 24 14

Program participant tracking or referral systems 53 42

Electronic client ID card 11 11

Electronic system for recording that service (the meal) 

was received 35 24

Financial systems for billing and/or making payments for 

services 48 30

Cost-centered accounting system 27 20

Geographic Information Systems 6 3 

No automated systems 10 30

Types of program performance data currently collected:a . 

Nutrition program service reports/program performance 

data 88 NA

Quality assurance findings 70 NA

Fiscal management reports 83 NA

Client assessments of service 88 NA

None 1 NA

NSP performance data are used:a . . 

To justify funding requests 63 NA

To manage the NSP 84 NA

To administer vendor contracts 50 NA

To provide information to stakeholders 84 NA

For program planning 83 NA

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

NA = not applicable because the response option was not included in the LSP survey.

3. Collaboration, integration, and partnerships with other programs 

Many SUAs partner with organizations or groups to engage in advocacy, strategic planning, 

public education, senior activities, service delivery, outreach, fundraising, and other activities to 

meet the nutrition and health needs of NSP participants. Therefore, agencies were asked to 

provide information about the organizations with which they partner. 

Most important partners for the NSP. The ADRC and other OAA programs were cited as 

the most important partners or collaborators for the NSP at the SUA level. Eighty-four percent of 

SUAs selected these organizations as one of the top five most important partners (Table III.27). 

Elder abuse prevention programs (or Adult Protective Services) and state public health 

departments or agencies also were important partners. 

42
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.27. Most important partners or collaborators for the NSP

 Percentage of SUAs

Percentage of SUAs indicating the following as one of the five most important partners 

or collaborators for the NSP: 

ADRC program 84

Other OAA programs 84

Elder abuse prevention programs or Adult Protective Services 79

State public health departments or agencies 77

SNAP (including SNAP Education) 73

State Medicaid agency/unit (including Medicaid waiver) 70

College or university 68

Senior Farmers Market Nutrition Program 66

State association of AAAs 61

Churches, synagogues, mosques, faith-based organizations 59

Volunteer organizations 59

Non-OAA-funded home-delivered nutrition programs (for example, Meals on Wheels) 54

Other state human services agencies or programs 52

Energy assistance 45

Commodity Supplemental Food Program 38

Veterans Affairs (state or federal) 38

State transportation department or agency 36

Private industry 34

State public housing department or agency 32

Child and Adult Care Food Program 21

Emergency Food Assistance Program 20

Food Distribution Program on Indian Reservations 13

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

SUA collaboration with other food and nutrition programs. Most SUAs reported that 

they collaborate (very much or somewhat) with SNAP (56 percent) and the Senior Farmers 

Market Nutrition Program (SFMDP) (62 percent; Table III.28). There is minimal collaboration 

with the Commodity Supplemental Food Program (CSFP), Child and Adult Care Food Program 

(CACFP), and the Temporary Emergency Food Assistance Program (TEFAP); 59 percent of 

SUAs reported little or no collaboration with CSFP, and 77 percent reported little or no 

collaboration with CACFP and TEFAP. 

43
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.28. Collaboration with other food and nutrition programs 

(percentages of SUAs)

 SNAP SFMNP CSFP CACFP TEFAP

SUAs collaborate: 

Very much 18 48 13 4 0 

Somewhat 38 14 13 4 4 

A little 23 9 27 25 20

Not at all 16 20 32 52 57

Not applicable 5 9 16 16 20

SUA NSP staff have collaborated in the following ways:a,b 

Participate in review or development of policies or 

procedures 21 41 14 7 0 

Promote older-adult access to the program 68 59 34 13 13

Participate in training and technical assistance 32 41 13 5 0 

Participate in committees and workshops 55 45 14 11 4 

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of SUAs reporting that they collaborated with the other food and nutrition program.

SUA integration with nonfood and nutrition programs. For case management, 

information and referrals, and ADRC services, SUA staff have been involved in (1) review or 

development of policies, guidance, or regulations for the inclusion of nutrition services; (2) 

development or review of screening protocols; and (3) development or review of assessment 

tools (Table III.29). SUA staff have also been involved with evidence-based health promotion 

and disease prevention programs. Seventy percent of SUAs indicated that they had advocated for 

including nutrition program clients as participants in these programs, and more than 60 percent 

of SUAs have participated in outreach activities. 

44
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.29. Integration with nonfood and nutrition programs

 Percentage of SUAs

NSP staff have been involved with case management, information and 

referral/assistance, or ADRC services in the following ways:a 

Review or development of polices, guidance, or regulations regarding the inclusions 

of nutrition services 43

Development or review of screening protocols 43

Implementation of screening protocols 29

Development or review of assessment tools 43

Development or review of referral/assistance process 36

Implementation of referral/assistance process 23

Provision of training 34

Receipt of training from nonfood and nutrition program 18

NSP staff have been involved with evidence-based health promotion and disease 

prevention programs in the following ways:a . 

Management of evidence-based health promotion and disease prevention grants 55

Promotion of inclusion of nutrition program clients as participants 70

Participation in outreach activities 61

Coordination with state health department evidence-based grantees 54

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

SUA coordination and collaboration with Title VI programs. Forty-nine percent of 

SUAs reported having one or more OAA Title VI Nutrition Supportive Services for Native 

American, Alaska Native, and Native Hawaiian Programs grant programs operating in their state 

(Table III.30). Of these SUAs, 56 percent collaborate to share resources, 44 percent collaborate 

on service delivery, and 41 percent collaborate on advocacy and public education. 

Table III.30. SUA coordination and collaboration with Title VI programs

 Percentage of SUAs

SUAs have one or more OAA Title VI nutrition and supportive services for Native 

American, Alaska Native, and Native Hawaiian programs grants 49

SUA currently collaborates with Title VI programs in the following areas:a,b . 

Shared resources 56

Advocacy 41

Strategic planning 26

Public education 41

Development of policies, guidance, or regulations 15

Service delivery 44

Shared outreach 22

Targeting special populations 33

Development of consumer materials 11

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of SUAs with one or more OAA Title VI programs.

45
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

D. Quality of nutrition-related program services provided

The ability to meet client dietary needs is perhaps the most important aspect of the NSP. 

Accordingly, the study examined several indicators of nutrition program quality. This section 

examines three important components of quality: nutrition program quality at the SUA level, 

nutrition program quality at the AAA and LSP levels, and food safety policy and practices used 

in preparing and serving meals.

1. Nutrition program quality at SUAs 

Dietary Reference Intakes (DRIs) are nutrition recommendations from the Institute of 

Medicine of the National Academies. The extent to which DRIs are followed in the planning of 

program meals is an indicator of program quality. Seventy-four percent of SUAs have full 

implementation of DRIs throughout the state, and 18 percent have partial implementation 

throughout the state (Table III.31). Six percent of SUAs reported having very little 

implementation throughout the state.

Table III.31. Nutrition program quality at SUAs

Characteristic Percentage of SUAs

Implementation status of Dietary Reference Intakes (DRIs) 

Full implementation throughout the state 74

Full implementation in portions of the state 2 

Partial implementation throughout the state 18

Very little implementation throughout the state 6 

Implementation status of Dietary Guidelines for Americans . 

Full implementation throughout the state 77

Full implementation in portions of the state 2 

Partial implementation throughout the state 17

Very little implementation throughout the state 4 

SUA has a formal policy for the implementation of the following: . 

DRIs only 9 

Dietary Guidelines only 13

Both DRIs and Dietary Guidelines 66

Neither DRIs nor Dietary Guidelines 13

Year the implementation policy of the DRIs or Dietary Guidelines was last updated . 

Before 2001 0 

2001–2010 32

Since 2011 68

Frequency of updates for the implementation policy of the DRIs or Dietary Guidelines . 

Yearly 6 

After every reauthorization of the Older Americans Act 0 

After changes are made to the DRIs, Dietary Guidelines, or food service codes 52

Every 1 to 5 years 13

Other 9 

No schedule is used 20

SUA has established a formal policy for the NSP regarding the implementation of state 

and local food service codes. 75

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

46
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Dietary Guidelines for Americans are jointly issued and updated every five years by the 

U.S. Department of Agriculture (USDA) and DHHS and provide authoritative dietary and 

wellness recommendations for Americans ages 2 and older. Seventy-seven percent of SUAs have 

full implementation of the Dietary Guidelines throughout the state, and 17 percent have partial 

implementation throughout the state (Table III.31). Four percent reported having very little 

implementation throughout the state.

Policies for Dietary Reference Intakes and Dietary Guidelines. Sixty-six percent of SUAs 

have a formal policy for the implementation of both DRIs and Dietary Guidelines (Table III.31). 

Only 13 percent of SUAs have no formal policy for the implementation of DRIs and Dietary 

Guidelines. 

Updates to implementation policy. Sixty-eight percent of SUAs have updated the 

implementation policy for DRIs and Dietary Guidelines since 2011, and the remaining 32 

percent have updated the policy since 2001 (Table III.31). Six percent of SUAs indicated that 

they update their implementation policy every year, and 13 percent indicated that they make 

updates every one to five years. Fifty-two percent of SUAs indicated that they update their 

implementation policy whenever changes are made to the DRIs, Dietary Guidelines, or food 

service codes.

2. Nutrition program quality at AAAs and LSPs 

Staff, programs, and materials that contribute to the quality of nutrition education. 

AAAs and LSPs use a variety of methods to ensure the quality of nutrition education. Most 

AAAs and LSPs use credentialed nutrition professionals to conduct education (58 and 64 

percent, respectively; Table III.32). AAAs also report employing surveys to measure program 

participant needs (45 percent), and using evidence-based education programs (45 percent), 

cooperative extension materials (58 percent), and curricula from a reliable, science-based 

organization (68 percent). 

47
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.32. Nutrition program quality at AAAs and LSPs

 

Percentage of 

AAAs

Percentage of 

LSPs 

To contribute to the quality of nutrition education, the following 

are required:a 

Credentialed nutrition professional to conduct education 58 64

Survey of program participant needs 45 39

Evidence-based education programs 45 29

Cooperative extension materials 58 51

Curricula from a reliable, science-based organization 68 42

To contribute to the quality of nutrition counseling, the following 

are required:a . . 

Credentialed nutrition professional to conduct education 76 52

Protocols approved by a respected source 39 38

Credentialed non-nutrition professionals (such as nurses or 

diabetes educators) to conduct counseling 15 20

The following are used to contribute to the nutrient quality of 

meals:a . . 

Computer-assisted menu analysis 49 20

Meal patterns 41 29

Dietitian or other state-credentialed nutrition professional 84 65

SUA guidance 65 64

OAA guidance 57 15

The following contribute to the overall food service quality 

provided at the program:a . . 

Food service license/safety inspections 88 83

Training of staff 88 92

Survey of program participants 87 77

Program participant feedback mechanism 77 78

Regularly scheduled site visits to production location and/or 

service location 85 48

Visits to home of home-delivered nutrition clients 71 56

Program participant advisory or menu committees 45 23

Food quality specifications 56 40

Use of dietitian or state-credentialed nutrition professional 85 65

AAA guidance 76

SUA guidance 73 22

OAA guidance 65 26

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

Staff, programs, and materials that contribute to the quality of nutrition counseling.

For nutrition counseling, AAAs and LSPs also use credentialed nutrition professionals to 

conduct counseling (76 and 52 percent, respectively), use protocols that have been approved by a 

respected source (39 and 38 percent, respectively), and rely on credentialed non-nutrition 

professionals (such as nurses or diabetes educators) to conduct counseling (15 and 20 percent, 

respectively; Table III.32).

Staff, programs, and materials that contribute to the nutrient quality of meals. AAAs 

and LSPs reported using the following resources to contribute to the nutrient quality of meals: 49 

percent of AAAs and 20 percent of LSP use computer-assisted menu analysis; 41 percent of 

48
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

AAAs and 29 percent of LSPs use meal patterns; 84 percent of AAAs and 65 percent of LSPs 

use the services of a dietitian or state-credentialed nutrition professional; 65 percent of AAAs 

and 64 percent of LSPs rely on guidance from the SUAs; and 57 percent of AAAs and 15 percent 

of LSPs rely on guidance from the OAA (Table III.32). 

3. Food safety policies and practices in NSPs 

Food safety is a critical indicator of the quality of program services offered. Ninety-six

percent of AAAs and 96 percent of LSPs require their service personnel to have food safety and 

sanitation training (Table III.33).

Table III.33. Food safety policies and practices in the NSP

 Percentage of 

SUAs

Percentage 

of AAAs

Percentage 

of LSPs

Food service production facilities required to have a food 

service license NA 88 90

Food service personnel for the NSP required to have food 

safety and sanitation training NA 96 96

Individual service providers are required to report incidents of 

food-borne illness in the NSP to:a . . . 

AAA NA 74 56

SUA NA 39 18

State or local department of health NA 80 72

Other NA 4 4 

Not required to report food-borne illnesses NA 2 6 

Follows polices for reporting food-borne illnesses and food 

recallsb NA 97 NA

Mean number of times in the past three years that the food 

served in the congregate nutrition program was associated 

with an outbreak of food-borne illness <1 0 0 

Mean number of congregate nutrition program participants 

who got sick in the past three years 6 3 0 

Mean number of times in the past three years that the food 

served in the home-delivered nutrition program was 

associated with an outbreak of food-borne illness <1 0 0 

Mean number of home-delivered nutrition program 

participants who got sick in the past three years 3 <1 0 

Sources: SUA survey, AAA survey, and LSP survey.

Note: Tabulations are based on an unweighted sample sizes of 56 SUAs, 333 AAAs and 199 LSPs. Individual 

estimates within the table may have slightly fewer observations due to item nonresponse to individual 

questions.

aMultiple answers allowed.

bQuestion not asked in the LSP survey.

NA = not applicable because the question was not included in the SUA or LSP survey.

Food-borne illness policies. Sixty-nine percent of SUAs have formal policies, guidance, or 

regulations for managing food-borne illnesses in the NSP (Table III.34). These policies were 

developed by several stakeholder organizations. Fifty-two percent of AAAs, 34 percent of SUAs, 

83 percent of state or local departments of health, and 10 percent of state departments of 

agriculture were involved in developing the current food-borne illness policies (Table III.34). 

49
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.34. Food safety policies and practices in SUAs

 Percentage of 

SUAs

Percentage of SUAs with formal policies, guidance, or regulations for managing food-borne 

illnesses in the NSP 69 

Entities involved in the development of the SUA’s current food-borne illness policy for the NSPa . 

AAAs 52 

SUAs 34 

State or local department of health 83 

State department of agriculture 10 

None of the above 3 

Percentage of SUAs with formal policies, guidance, or regulations for managing food recalls 32 

Entities involved in the development of the SUA’s current food recalls policy for the NSPa . 

AAAs 38

SUAs 31 

State or local department of health 85 

State department of agriculture 23 

None of the above 0 

Percentage of SUAs that require LSPs to report incidents of food-borne illness that occur in the 

NSP to each of the following entities: . 

AAA 56

SUA 49 

State or local department of health 76 

Source: SUA survey. 

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

Food recall policies. Thirty-two percent of SUAs have formal policies, guidance, or 

regulations for managing food recalls (Table III.34). Like the food-borne illness policies, the 

food recall policies were developed by several stakeholder organizations. Thirty-eight percent of 

AAAs, 31 percent of SUAs, 85 percent of state or local departments of health, and 23 percent of 

state departments of agriculture were involved in developing the current food recall policies 

(Table III.34).

Incidence of food-borne illness. The major outcome of interest regarding food handling is 

whether participants become sick because of the food served by the meal programs. Although 

there have been instances of food-borne illness associated with the NSP, the reported incidence 

of such outbreaks is relatively low (Table III.33). For example, at the AAA level, the mean 

number of times in the past three years that the food served in congregate settings was associated 

with an outbreak of food-borne illness was less than one (only five incidents of illness associated 

with the NSP food were reported in the past three years across the 333 AAAs surveyed). The 

mean number of participants who got sick in the past three years was reported to equal between 

three and four participants. The figures for home-delivered meal participants were lower.10

10 Note that it is believed that the actual incidence of food-borne illness is much higher throughout the food service 

industry than the incidence reported; therefore, it is likely that the reported incidence of food-borne illness in the 

NSP is probably less than the actual incidence.

50

 
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

E. Program resources

The degree to which SUA program staff can effectively monitor income and expenditures, 

track funding sources, manage budgetary concerns, and distribute resources across their service 

area has a direct impact on AAA and LSP operations. This section examines four important 

components of program resources: budgetary and fiscal guidelines, and procedures for budget 

monitoring and analysis; facilities and equipment provided by SUAs; strategies AAAs and LSPs 

use to address increasing service costs; and LSP resources. 

1. SUA budget and fiscal year guidelines

SUA budget and fiscal activities and guidelines. Many agencies in the program hierarchy 

involve staff in budget-related activities, including monitoring budgets and fiscal performance. 

Seventy-four percent of SUAs monitor expenditures per meal at the SUA or AAA level, 74 

percent monitor program income, and 70 percent monitor funding sources (Table III.35). Fiftysix percent of SUAs have staff that prepare or review budget justification materials, and 44 

percent have staff that provide research or analysis on the implications of budget options (Table 

III.35). However, only 21 percent of SUAs rely on NSP staff to determine budget allocations.

Table III.35. SUA budget and fiscal activities

 Percentage of SUAs

NSP staff participate in the following budget-related activities:a 

Providing research or analysis on the implications of budget options 44

Preparing or reviewing budget justification materials 56

Determining budget request amounts 30

Determining budget allocation 21

NSP staff currently monitor the following at SUA or AAA level:a . 

Expenditures per meal 74

Expenditures per client 51

Contract costs 67

Program income 74

Funding sources 70

Percentage of SUAs that have policy, guidance, or regulations related to AAA and LSP 

offering private pay/fee-for-service nutrition services 51

Level of encouragement or discouragement SUAs provide to AAAs or service 

providers to operate pay/fee-for-service nutrition services. SUAs: . 

Strongly encourage 12

Encourage 20

Allow private pay but neither encourage or discourage the activity 61

Discourage 2 

Prohibit 5 

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs.

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

51
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Unit rate for nutrition services programs. Sixteen percent of SUAs use a statewide unit 

rate for reimbursement of nutrition services provided through their congregate nutrition 

programs (Table III.36). Twenty-one percent of SUAs use a statewide unit rate for homedelivered nutrition programs, and 46 percent of SUAs use a statewide unit rate for Medicaid 

waiver nutrition programs. About 20 percent of these programs involved NSP staff in the setting 

of the unit rate. 

Table III.36. Statewide unit rate for nutrition services programs

 Congregate 

nutrition program

Home-delivered 

nutrition program

Medicaid waiver 

nutrition 

services

Percentage of SUAs with a statewide unit rate 16 21 46

Percentage of SUAs that involved NSP staff in 

setting the unit rate 21 20 20

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

2. Program resources

Facilities and equipment provided by the SUA. Thirty-six percent of SUAs provide 

equipment for the home-delivered or congregate nutrition programs, either directly to the site or 

through designated funding (Table III.37). Twenty percent of SUAs provide facilities (again, 

either directly or through designated funding) for the home-delivered or congregate nutrition 

programs. 

Table III.37. Facilities and equipment provided by the SUA

 Percentage of SUAs

SUAs provide equipment, either directly or through designated funding, for use by the 

NSP (home-delivered or congregate nutrition programs). 36

SUAs provide any facilities, either directly or through designated funding, for use by the 

NSP (home-delivered or congregate nutrition programs). 20

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

AAA and service providers’ response to increased costs. Ninety percent of AAAs took 

actions to respond to increased costs such as labor, fuel, or food costs for the NSP (Table III.38). 

Just 10 percent made no changes in response to increases in costs. The most frequently selected 

responses indicate that AAAs modify the program menu, reduce program services, or implement 

more economical service delivery approaches to offset these costs, or look for efficiencies 

without reducing services. Many agencies reported reducing staff or staff hours (47 percent), 

reducing the number of days of service per week at congregate locations (34 percent), reducing 

the number of congregate nutrition sites (33 percent), and reducing the frequency of homedelivered meals (32 percent). However, many agencies also reported modifying menus or, in the 

home-delivered nutrition program, increasing the use of frozen meals (49 and 39 percent, 

respectively).

52
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.38. AAA response to increased service costs

 Percentage of AAAs

Ways in which AAAs respond to increased service costs such as labor, fuel, or food costs 

for the NSP:a 

Modification of menu 49

Reductions in staff or staff hours 47

Increased use of frozen meals in the home-delivered nutrition program 39

Reductions in the number of days of service per week at congregate locations 34

Reductions in the number of congregate nutrition sites 33

Group purchasing 32

Reductions in frequency of home-delivered nutrition deliveries 32

Changes in catering or service provider contract requirements/specifics to reduce cost 30

Shared resources 26

Reductions in the number of home-delivered nutrition participants served 23

Reductions in the number of people served at congregate locations 16

Reductions in home-delivered nutrition service area 14

Reductions in the number of home-delivered meals provided per participant 13

Additional restrictions in program eligibility criteria 10

Reduced or eliminated compensation to volunteers 10

No changes in response to increased cost 10

Source: AAA survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

LSP program resources. LSP program needs are often met using a mix of owned, rented, 

and donated resources. Table III.39 presents the percentage of LSP that use rented, owned, or 

donated resources. A greater percentage of LSPs own, rather than rent, kitchens, delivery 

vehicles, garages and parking facilities, and congregates sites. Using donated or free resources is 

less common for all resources compared using owned resources.

Table III.39. LSP program resources

Resource

Rented

(Percentage of LSPs)

Owned

(Percentage of 

LSPs) 

Donated/free use

(Percentage of 

LSPs) 

Kitchen 38 53 19

Off-site storage 12 11 5 

Delivery vehicles 5 53 11

Vehicle garage/parking facility 16 24 10

Congregate site 39 47 28

Source: LSP survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

53
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

F. Program contributions, private pay, and waivers

Participant contributions to the NSP, the extent to which private pay services are offered, 

and the use of Medicaid waivers are important because they affect service delivery, as well as 

participants’ experiences with the program. This section discusses the policies and standards 

related to each of these issues.

1. Participant contributions

Participants are not charged for meals, but they are encouraged to make a voluntary 

contribution toward the meal costs. However, participants cannot be denied meals or other 

services because of an inability to contribute or an unwillingness to do so. 

Policies related to participant contributions. Nearly all SUAs have policies related to the 

collection and management of voluntary participant contributions (98 percent; Table III.40). 

Most SUAs also have policies for the distribution and spending of participant contributions (81 

and 93 percent, respectively). Fifty-one percent of AAAs and LSPs are required by their SUA to 

spend participant contributions first and then use other funds. 

Table III.40. Participant contributions

 Percentage of SUAs

SUAs have a policy regarding: 

Collection and/or management of participant contributions for NSP 98

Distribution of participant contributions for the NSP 81 

Spending of participant contributions for the NSP 93

SUAs have specific policies on the noncoercion of participants with regard to 

participant contributions 95

Ways in which the SUA determines whether participant contributions to the NSP are 

used to expand services:a . 

AAAs and LSPs are required to spend participant contributions first and then other 

funds. 51 

AAAs and LSPs are required to report data on services delivered using participant 

contributions. 44 

The SUA monitors program data in relation to participant contributions reported. 65

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 43 SUAs that do not also function as AAAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

LSP-recommended participant contributions. The distribution of recommended 

contributions is provided in Table III.41. Ninety-three percent of LSPs recommend that 

congregate meal participants contribute $4.50 or less for a single meal. The mean recommended 

contribution for congregate meals is $2.88. Ninety-two percent of LSPs recommend that homedelivered meal participants contribute $4.50 or less for a single meal. The mean recommended 

contribution for home-delivered meals is $3.00. 

54
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.41. LSP recommended participant contributions

 Percentage of LSPs

Recommended contribution for congregate meal participants for a single meal 

$0.00 to $1.50 30

$1.51 to $3.00 39

$3.01 to $4.50 24

$4.51 to $6.00 4 

$6.01 to $7.50 0 

$7.51 or more 2 

Recommended contribution for home-delivered meal participants . 

$0.00 to $1.50 22

$1.51 to $3.00 39

$3.01 to $4.50 31

$4.51 to $6.00 5 

$6.01 to $7.50 3 

$7.51 or more 0 

Source: LSP survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

2. Private pay

AAA private pay and fee-for-service operations. Providers may offer “private pay” or 

“fee-for-service” programs in which specific services are offered for a fee. Forty percent of 

AAAs have specific policies to permit, encourage, or prohibit the operations of private or feefor-service nutrition programs for older adults (Table III.42). However, the level of 

encouragement or discouragement varies. Of those AAAs with specific policies, 30 percent of 

AAAs encourage service providers to operate fee-for-service nutrition programs for older adults, 

61 percent of AAAs neither encourage nor discourage such programs, and 10 percent discourage 

or prohibit the operation of fee-for-service programs.

Table III.42. AAA private pay and fee-for-service operations

 

Percentage 

of AAAs

AAAs have policies that permit, encourage, or prohibit the operations of private pay/fee-for-service 

nutrition programs for older adults 40

Level of encouragement or discouragement AAAs provide to service providers to operate private 

pay/fee-for-service nutrition programs for older adults. SUAs: 

Strongly encourage 8 

Encourage 22

Allow private pay but neither encourage or discourage the activity 61

Discourage 3 

Prohibit 7 

Sources: AAA survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 333 AAAs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

55
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

LSP private pay and fee-for-service operations, congregate meals. Twenty-two percent 

of LSPs have a private pay or fee-for-service meal program in addition to their NSP congregate 

nutrition program (Table III.43). The method used to calculate fees for these programs varies, 

but these LSPs favor cost-reimbursement over fair market value reimbursements (37 percent use 

cost-reimbursement versus 5 percent that use fair market value). Most LSPs that offer fee-forservice congregate meals offer the same meals to private pay clients and NSP clients (95 percent) 

and meals are served at the same site (93 percent). On average, the price of a fee-for-service 

lunch in the congregate nutrition program is $5.27. 

Table III.43. LSP private pay and fee-for-service operations

 . 

Percentage of LSPs that have a private pay/fee-for-service meal program in addition to 

the NSP congregate nutrition program. 22

Percentage of LSPs that calculate the selling price for the private pay/fee-for-service 

programs meal by:b . 

Cost-reimbursement 37

Fair market value 5 

Mean price (in dollars) of the private pay/fee-for-service lunch meal congregate meals b 5.27

Percentage of LSPs that offer OAA clients in the congregate nutrition programs the same 

meals as the private pay/fee-for-service customersb 95

Percentage of LSPs that offer the private pay/fee-for-service meal at the same site as the 

NSP congregate mealb 93

Percentage of LSPs that have a private pay/fee-for-service meal program for homedelivered meals 31

Percentage of LSPs that calculate the price of private pay/fee-for-service home-delivered 

meals by:c . 

Cost-reimbursement 57

Fair market value 5 

Mean price of the private pay/fee-for-service home-delivered lunch meal c 5.62

Percentage of LSPs that offer OAA clients in the home-delivered nutrition programs the 

same meals as the private pay/fee-for-service customers.

c 90

Sources: LSP survey, weighted data. 

Note: Tabulations are based on an unweighted sample sizes of 199 LSPs. Individual estimates within the table 

may have slightly fewer observations due to item nonresponse to individual questions.

bPercentage estimated out of the LSPs that offer private pay/fee-for-service meal program in addition to their NSP 

congregate nutrition program.

cPercentage estimated out of the LSPs that offer private pay/fee-for-service meal program in addition to their NSP 

home-delivered nutrition program.

LSP private pay and fee-for-service operations, home-delivered meals. Thirty-one 

percent of LSPs have a private pay or fee-for-service meal program for home-delivered meals 

(Table III.43). Fifty-seven percent of these LSPs use the cost-reimbursement method to calculate 

fees for the program, and only 5 percent use fair market values to calculate fees. Ninety percent 

of these LSPs offer fee-for-service clients the same home-delivered meals offered to participants 

in the OAA home-delivered meal program. On average, the price of a home-delivered fee-forservice lunch is $5.62. 

56
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

3. Medicaid waivers

Medicaid waiver program for older adults. As part of a coordinated system of services for 

Medicaid participants at risk of institutionalization, a state can obtain a Medicaid waiver that 

allows Medicaid funds to be used to pay for the costs of providing services to these adults, 

including meals. Fifty percent of SUAs administer a Medicaid waiver program for older adults

(Table III.44). Of these SUAs, 85 percent offer home-delivered meals under this program, 41 

percent offer nutrition assessments, and 30 percent offer nutritional supplements. Nutrition 

standards and food safety standards are consistent across the Medicaid waiver program and NSP 

for 69 and 75 percent of LSPs, respectively, and nutrition counseling services are the same for 31 

percent of LSPs.

Table III.44. Medicaid waivers

. 

Percentage of SUAs 

or LSPs

SUAs administer a Medicaid waiver program for the elderly. 50

SUAs provide the following services under the state Medicaid waiver program for the 

elderly:a, b . 

Nutrition assessment 41

Nutrition counseling 22

Nutrition risk reduction 19

Home-delivered meals 85

Medical nutrition therapy 15

Dietitian services 15

Nutritional supplements 30

SUA ENSP staff were involved with the state Medicaid waivers for the elderly by:b . 

Reviewing policies related to nutrition services 27

Providing input regarding the use of nutritional supplements in the waiver programs 14

The following are consistent across Medicaid waiver and the ENSPs:b . 

Nutrition standards 69

Food safety standards 75

Nutrition counseling services 31

Cost or rates for nutrition services 25

LSPs provide Medicaid nutrition services to the elderly:a . 

Provide Medicaid waiver nutrition services to the elderly 39

Provide nonwaiver Medicaid nutrition services to the elderly 9 

Do not provide Medicaid waiver or nonwaiver nutrition services to the elderly 42

Sources: SUA and LSP surveys.

Note: Tabulations are based on an unweighted sample sizes of 56 SUAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

bPercentages of SUAs with Medicaid waiver program.

To administer this program effectively, NSP staff must coordinate with home- and 

community-based long-term care. To this end, 27 percent of SUA staff reviewed state Medicaid 

waiver policies related to nutrition services, and 14 percent of SUAs provided input regarding 

the use of nutritional supplements in the waiver (Table III.44). 

57
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

G. Prioritization of services, access to services, and waiting lists 

Although adults ages 60 and older are eligible to participate in the NSP, the OAA requires 

programs to target individuals who have the highest social and economic needs. This section 

explores the prioritization of services, discussing which organizations are involved in 

establishing prioritization policies and the criteria used as a basis for deciding whom to serve. It 

also discusses the eligibility criteria used to determine who may receive services regardless of 

program resource limitations, as well as the use of waiting lists.

1. SUAs’ prioritization of services 

SUAs were asked to specify who sets their prioritization policy. Sixty-two percent of SUAs 

set their own prioritization policies, although more than half of those SUAs (39 percent of the 62 

percent) also seek input from AAAs (Table III.45). Twenty percent of SUAs reported that AAAs 

set the prioritization policy, 7 percent reported that LSPs set the policy, and 11 percent have no 

policy. For SUAs that have a prioritization policy, 55 percent apply the same prioritization 

criteria throughout the state, 33 percent use AAA-specific criteria, and 13 percent use LSPspecific criteria.

Table III.45. SUAs’ prioritization of services

 Percentage of 

SUAs

Prioritization policy of SUA is set for the NSP by: 

SUA 23

SUA with input from AAAs 39

AAAs with input from SUA 11

AAAs 9 

LSPs 7 

No prioritization policy exists 11

Prioritization criteria are:a 

Statewide 55

AAA-specific 33

LSP-specific 13

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 42 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aPercentage of SUAs with prioritization policy. 

For congregate meal programs, the top five most frequently reported prioritization criteria 

were based on low income (43 percent), racial or ethnic minority status (38 percent), nutrition 

risk assessments (36 percent), geographic isolation (34 percent), and food insecurity status (34 

percent; Table III.46). For home-delivered meal programs, SUAs prioritize service for those 

older adults who are homebound (66 percent), meet the ADL or IADL impairments minimums 

(59 percent), are geographically isolated (52 percent), low income (50 percent), socially isolated 

(50 percent), and for those lacking informal or family support (50 percent). 

58
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.46. SUA policy criteria to determine NSP prioritya 

Criteria

Congregate meal 

prioritization

Home-delivered meal 

prioritization

ADL and/or IADL impairment minimum 20 59

Lack of informal or family support 27 50

Geographic isolation 34 52

Social isolation 32 50

Chronic health condition 21 36

Poor housing or lack of kitchen access 23 36

Homebound 13 66

Racial/ethnic minority 38 41

Advanced age 20 30

Low income 43 50

Limited English proficiency 32 34

Dementia or cognitive impairment 20 45

Food insecurity or hunger 34 39

Nutrition risk assessment 36 45

Adult day care participation 11 11

Long-term care need for service 13 30

Short-term care need for service 16 30

No prioritization criteria 13 11

Criteria are not set by the SUA 23 20

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

2. Access to services 

AAAs and LSPs were asked about prioritization of services.11 Sixty-eight percent of AAAs 

and 55 percent of LSPs indicated that they are responsible for prioritizing clients for NSP 

services. Most of those AAAs reported that they had specific criteria for doing so; roughly half 

of the LSPs that are responsible for prioritizing their services reported that they had specific 

criteria for prioritizing clients (Table III.47).

Fifty-four percent of AAAs reported that they were responsible for setting prioritization 

criteria,12 55 percent indicated that they had a lot of influence on the prioritization criteria, and 

only 11 percent indicated that they had no influence on the prioritization criteria (Table III.47).

11 Some of their responses regarding who set prioritization policy appear to contradict the information reported at 

the SUA level. However, responses provided at each level are not mutually exclusive. It is possible for SUAs and 

AAAs to state that they are responsible for prioritizing client services because there is a hierarchy of responsibilities 

that resembles the hierarchy of organizations. In other words, each respondent is defining their responsibilities in 

different ways.

12 This corroborates the information reported by SUAs in Table III.45, which indicates that 39 percent of SUAs seek 

input from AAAs on prioritization criteria and that 21 percent of AAAs have primary responsibility for setting 

prioritization policy.

59

 
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.47. Access to services

 Percentage of AAAs Percentage of LSPs

AAA/LSP is responsible for prioritizing clients for the NSP

services. 68 55

AAA/LSP has specific prioritization criteria for NSP services.

a 67 52

Prioritization criteria is established by:a . 

AAA 54 NA

SUA 29 NA

Other 17 NA

Amount of influence the AAA had on prioritization criteriaa . 

A lot 55 NA

Some 28 NA

A little 6 NA

None 11 NA

Sources: AAA survey and LSP survey, weighted data. 

Note: Tabulations are based on an unweighted sample sizes of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aPercentage of AAAs (LSPs) who report being responsible for prioritizing clients for NSP services. 

NA = not applicable because the question was not included in the LSP survey.

For congregate meals, AAAs and LSPs both prioritize service based on household income 

(32 and 38 percent), social isolation (27 and 26 percent), and food security status (23 and 31 

percent; Table III.48). AAAs also use nutrition risk assessments (36 percent) and prioritize 

services for racial/ethnic minorities (20 percent).

For home-delivered meals, AAAs and LSPs both prioritize service based on homebound 

status (87 and 88 percent, respectively), nutrition risk assessments (73 and 59 percent), lack 

informal or family support (69 and 60 percent), household income (67 and 63 percent), chronic 

health conditions (60 and 62 percent), and food security status (54 and 53 percent, Table III.48). 

60
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.48. Access to servicesa

 

AAA 

Congregate 

meal 

programs

AAA 

Homedelivered 

meal 

programs

LSP 

Congregate 

meal 

programs

LSP Homedelivered meal 

programs

Criteria used for prioritization: 

ADL cutoff 9 54 6 37

IADL cutoff 8 49 6 38

Homebound 3 87 4 88

Food insecurity or hunger 23 54 31 53

Nutrition risk assessment 36 73 28 59

Poor housing or lack of kitchen access 12 37 19 42

Low income 32 67 38 63

Lack of informal or family support 18 69 18 60

Racial/ethnic minority 20 31 19 30

Geographic isolation 17 47 17 41

Social isolation 27 45 26 35

Chronic health condition 16 60 22 62

Advanced age 12 43 32 51

Dementia or cognitive impairment 11 46 4 38

Limited English proficiency 9 16 4 8 

Adult day care participation 3 4 1 12

Long-term need for service 5 24 1 22

Living alone NA NA 40 72

Lack of ability to stand and cook NA NA 29 69

Sources: AAA survey and LSP survey, weighted data. 

Note: Tabulations are based on an unweighted sample size of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

NA = not applicable.

3. Waiting list policies

Many SUAs have policies or regulations pertaining to the creation and maintenance of 

waiting lists. Forty-one percent of SUAs indicated that they have such policies for congregate 

meal program waiting lists, and 57 percent of SUAs have regulations for home-delivered meal 

program waiting lists (Table III.49). A substantial number of SUAs either maintain or have direct 

access to waiting lists for home-delivered nutrition services (71 percent), congregate nutrition 

services (50 percent), and other OAA services (48 percent). The waiting lists typically contain 

only applicants who are determined to be eligible, and applicants on the waiting list are usually 

prioritized on a first-come, first-served basis (Table III.50). Relatively few sites maintain waiting 

lists that contain adults who have not been screened for eligibility (Table III.50). At the AAA 

level, an average of 51 people are on the PSA waiting list for congregate meal programs, and an 

average of 143 are on the waiting list for home-delivered meals (Table III.50). At the LSP level, 

an average of 19 people are on the PSA waiting list for congregate meal programs, and an 

average of 28 are on the waiting list for home-delivered meals (Table III.50).

61
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.49. SUA waiting list policies for the NSP

Criteria Percentage of SUAs

SUAs have policies, guidance, or regulations pertaining to the creation and 

management of waiting list for the following NSP services:a 

Home-delivered nutrition services 57

Congregate nutrition services 41

SUAs maintain or have access to information on waiting lists for the following 

services:a 

Home-delivered nutrition services 71

Congregate nutrition services 50

Other OAA services 48

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 56 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aMultiple answers allowed.

62
III. TITLE III-C NSP PROGRAM ADMINISTRATION AND SERVICE DELIVERY MATHEMATICA POLICY RESEARCH

Table III.50. Waiting list policies

 

AAA 

Congregate 

nutrition 

programs

AAA Homedelivered 

nutrition 

programs

LSP 

Congregate 

nutrition 

programs

LSP Homedelivered 

nutrition 

programs

Waiting lists are maintained by: 

SUA 11 16 NA NA

AAA 20 38 NA NA

LSP 27 39 29 51

Current waiting list policy in the PSA: . . . 

Waiting list contains everyone who 

requested service without screening for 

service eligibility or need, ordered by date of 

request. 13 9 9 7 

Waiting list contains everyone who is 

screened eligible for services on a firstcome, first-served basis. 23 15 19 4 

The waiting list contains everyone who is 

screened eligible and in priority order (by 

priority criterion). 37 64 30 47

Policy varies across the PSA. 8 8 NA NA

There is no waiting list policy. 13 2 0 0 

Mean number of people on the PSA waiting 

list 51 143 19 28

Waiting list is updated and checked for 

duplication and those no longer eligible or in 

need: . . . 

Weekly 13 17 4 30

Monthly 24 31 54 32

Quarterly 18 21 21 15

Semiannually 8 9 14 14

Yearly 7 9 0 5 

Never 7 1 0 0 

Sources: AAA survey and LSP survey, weighted data.

Note: Tabulations are based on an unweighted sample size of 333 AAAs and 199 LSPs. Individual estimates 

within the table may have slightly fewer observations due to item nonresponse to individual questions.

NA = not applicable. 

63
This page has been left blank for double-sided copying.
IV. CONCLUSION

Following are key findings of the evaluation. Where appropriate, the findings are compared 

to those in the last NSP evaluation conducted between 1993 and 1995, here referred to as the 

1995 evaluation (Ponza et al. 1996). 

Organizational structure of the National Aging Network

SUAs, AAAs, and LSPs comprise core components of the National Aging Network. SUAs 

oversee an average of 12 AAAs (one more than in 1995), although this number varies 

considerably from state to state with a low of 1 and a high of 59. AAAs are more likely to be 

public organizations than private nonprofit organizations (62 and 38 percent, respectively), while 

LSPs are more likely to be private nonprofit organizations than public organizations (61 and 36 

percent, respectively). These percentages are similar to those in 1995. 

Program characteristics

LSPs provide a variety of nutrition and non-nutrition services. The most common service 

that LSPs provide is congregate meals, provided by nearly all (93 percent) of LSPs. Most (87 

percent) also provide home-delivered meals. In the 1995 evaluation, these percentages were 95 

and 81 percent, respectively. Thus, LSPs’ congregate meal provision has decreased slightly, and 

home-delivered meal provision has increased.

All NSP congregate programs serve lunch. In addition, about 11 percent of Title III-C 

congregate programs serve breakfast, up from only 4 percent in 1995. Similarly, 11 percent of 

programs serve dinner, up from 1 percent in 1995. Most congregate sites operate only on 

weekdays; however, about 15 percent of sites also serve weekend meals. This is sizably higher 

than in the 1995 evaluation, when only 4 percent of sites served weekend meals. 

Sixty-three percent of congregate meal sites make “modified” meals available (such as those 

that are low in fat or sodium), and 79 percent of home-delivered providers offer these meal types. 

This prevalence is noticeably higher than in 1995 (49 and 63 percent, respectively). 

Many programs prepare home-delivered meals on-site at congregate meal sites (40 percent), 

where they are packaged and then distributed. However, more than half (52 percent) of LSPs 

with home-delivered meal programs contract for these meals with outside vendors or caterers, 

and 44 percent prepare home-delivered meals at a project-affiliated central kitchen. The 

preparation of meals at a central kitchen has increased greatly from 1995, when only 17 percent 

of LSPs used them. 

LSPs provide other nutrition-related services in addition to meals, including nutrition 

education (77 percent of LSPs), nutrition screening and assessment (52 percent), and nutrition 

counseling (28 percent). Non-nutrition services are also common, including social activities; 

health promotion and disease prevention activities; and transportation to and from meal sites.

65
IV. CONCLUSION MATHEMATICA POLICY RESEARCH

Clients’ needs assessments

NSP agencies strive to understand the needs of program participants by seeking information 

on how clients learn about program services and how nutrition programs help meet the nonnutritional needs of clients by making it easier for them to access other programs. 

AAAs reported that clients are typically referred to the congregate and home-delivered meal 

programs through family and friends. For congregate meal programs, it is also common for 

clients to be referred through the Aging Network information and assistance system, which helps 

older adults access social and health services across the country. For home-delivered meal 

programs, it is also common for clients to be referred through hospitals, health care facilities, and 

discharge planners. 

AAAs and LSPs help many participants in the NSP access other programs. AAAs and LSPs 

reported that they most often provide assistance accessing transportation services, Adult 

Protective Services, Medicare Part D, Medicaid waiver programs, Veterans Affairs services, and 

evidence-based health promotion and disease prevention programs. 

Collaboration, integration, and partnerships with other programs 

Many SUAs partner with organizations or groups to engage in such activities as advocacy, 

strategic planning, public education, senior activities, service delivery, fundraising, and outreach. 

The ADRC was cited as the most important partner or collaborator for the NSP at the SUA level. 

Eighty-four percent of SUAs selected these organizations as one of the top five most important 

partners. Elder abuse prevention programs (or Adult Protective Services) and state public health 

departments or agencies were also important partners. Most SUAs reported that they also 

collaborate with the Supplemental Nutrition Assistance Program and the Senior Farmers’ Market 

Nutrition Program as well. 

Quality of program services provided 

AAAs and LSPs use a variety of methods to ensure the quality of nutrition education and the 

nutrient quality of meals. Most AAAs and LSPs use credentialed nutrition professionals to 

conduct education (58 and 64 percent, respectively). Many AAAs also report employing surveys 

to measure program participant needs and using evidence-based education programs and 

curricula from a reliable, science-based organization. LSPs contribute to the nutrient quality of 

meals by using computer-assisted menu analysis, meal patterns, or the services of a dietitian or 

state-credentialed nutrition professional, and by relying on guidance from the SUAs.

Food safety is also a critical indicator of the quality of program services offered, with nearly 

all AAAs and LSPs (96 percent) require their service personnel to have food safety and 

sanitation training. Reported instances of such illness do occur, but they are rare. 

Program resources

The degree to which SUA program staff can effectively monitor income and expenditures, 

track funding sources, manage budgetary concerns, and distribute resources across their service 

area has a direct impact on AAA and LSP operations. Seventy-four percent of SUAs monitor 

expenditures per meal at the SUA or AAA level, 74 percent monitor program income, and 70 

percent monitor funding sources. Thirty-six percent of SUAs provide equipment for the home66
IV. CONCLUSION MATHEMATICA POLICY RESEARCH

delivered or congregate nutrition programs, either directly to the site or through designated 

funding. A smaller, though still sizable, percentage of SUAs (20 percent) provide facilities for 

the programs. 

Program contributions

Policies related to participant contributions to the NSP are important because they can affect 

service delivery as well as participants’ experiences with the program. Nearly all SUAs (98 

percent) have policies related to the collection, management, and spending of participant 

contributions. Almost two-thirds (65 percent) of SUAs monitor program data such as service 

units and people served in relation to participant contributions reported. Fifty-one percent of 

SUAs require AAAs and LSPs to spend participant contributions first and then use other funds. 

LSPs vary in their recommended participant contribution for a single congregate meal. 

Thirty percent of LSPs recommend less than $1.50, and 93 percent recommend less than $4.50. 

For home-delivered meals, 22 percent recommend less than $1.50, and 92 percent recommend 

less than $4.50. 

Prioritization of services and waiting lists 

Although all people ages 60 and older are eligible to participate in the NSP, the program 

must sometimes decide to serve some adults before others when resources are limited. Although 

required by law, only 89 percent of SUAs report having a prioritization policy. For congregate 

meal programs, prioritization criteria are most commonly based on racial or ethnic minority 

status, nutrition risk assessments, economic need, and geographic isolation. For home-delivered 

meal programs, prioritization criteria are most commonly based on whether a person is 

homebound, meets the Activities of Daily Living impairments minimums, is geographically 

isolated, or has low income.

About one-half (51 percent) of the LSPs that arrange or provide home-delivered meals 

report having a waiting list for potential participants, compared to 41 percent in the 1995 

evaluation. For LSPs that maintain waiting lists, the mean number of people on the lists is 28. 

This is substantially lower than in 1995, when it was 85 people. Therefore, waitlists are slightly 

more common now, but they contain many fewer people than in 1995. 

Waiting lists are much less common for congregate meal programs. Twenty-nine percent of 

LSPs arranging or providing congregate meals report having waiting lists. For LSPs that 

maintain waiting lists, the mean number of people on the lists is 19, less than half as many as in 

the 1995 evaluation, when an average of 52 people were on a waiting list. 

Conclusion

Findings from the process study demonstrate an elaborate National Aging Network of 

SUAs, AAAs, and LSPs that interact to provide older people with congregate and homedelivered meals and services to help meet their health and nutrition needs. Although comparisons 

with the 1995 evaluation findings are limited due to differences in survey modules and content, 

several findings revealed key changes to program administration and service delivery: 

67
IV. CONCLUSION MATHEMATICA POLICY RESEARCH

• There has been robust expansion in meal provision since 1995. Eighty-seven percent of 

LSPs now provide home-delivered meals, up from 81 percent in 1995. Although the 

percentage of LSP providing congregate meal programs decreased slightly (from 95 to 93 

percent), there was a substantial increase in the percentage of congregate meal programs that 

offer breakfast and dinner (all programs served lunch both in 1995 and in the current study). 

The percentage of LSPs that offered breakfast is about 3 times larger than it was in 1995, 

and the percentage of LSPs that offer dinner is more than 10 times larger than it was in 

1995. Similarly, the percentage of LSPs that offer congregate meals on weekends is almost 

four times larger than in 1995. 

• Meal offerings and preparation have changed. “Modified” meals that are low in fat, 

sodium, or calories are offered by many more LSPs than in 1995. There has also been a shift 

toward preparing home-delivered meals at a central kitchen. 

• Waiting lists for home-delivered meals are slightly more common than in 1995. About 

one-half (51 percent) of LSPs have waiting lists, compared to 41 percent in 1995. However, 

the waiting lists contain far fewer people, on average, than in 1995 (28 versus 85 people). 

The waiting lists for congregate meals also contain less than half as many people (19 versus 

52 people). These findings generally suggest an increase in program access across both 

program types. 

In addition to these changes, the National Aging Network continues to try to meet client 

dietary needs through ensuring nutrition program quality. AAAs and LSPs use many methods to 

improve the quality of nutrition services (such as using credentialed nutrition professionals, 

assessing needs through surveys, and using evidence-based curricula from reliable, science-based 

organizations). Agencies also continue to partner and collaborate with organizations (most 

notably, SNAP and SFMNP) to engage in advocacy, strategic planning, and service delivery. 

The data suggest that assessment of clients’ needs is one area for further exploration and 

improvement. Twenty percent of SUAs have conducted a statewide community needs 

assessment in the past five years, and more than a third (40 percent) of SUAs have not conducted 

at least one local community needs assessment during that time. Furthermore, many AAAs and 

LSPs do not have a formal process for assessing nutrition needs of NSP congregate meal and 

home-delivered meal participants, and even fewer have a formal process for assessing nonnutrition needs. Finally, nearly 20 percent of AAAs and LSPs have no policy to define how 

frequently participants’ service needs should be reassessed. 

Examining the program administration and service delivery data collected in this evaluation 

in conjunction with the evaluation’s cost and client outcomes data will shed additional light on 

how (1) program efficiency varies by core administrative and service-oriented components (such 

as program size, meal preparation method, and other program characteristics); and (2) program 

effectiveness varies by programs’ policies and practices related to ensuring the nutritional quality 

of program meals. Studying these data will help identify the best ways to use available resources 

to make sure that older people participating in the NSP receive adequate services to meet their 

health and nutrition needs.

68
REFERENCES
This page has been left blank for double-sided copying.
REFERENCES

Administration for Community Living. “FY 2015 ACL Budget Table: Administration for 

Community Living, FY 2015 President’s Budget.” Washington, DC: U.S. Department of 

Health and Human Services, ACL, 2014. Available at: 

http://www.acl.gov/About_ACL/Budget/ACL-FY2015-budget-table.aspx. Accessed June 

24, 2015. 

Administration for Community Living. “Aging Integrated Database.” Washington, DC: U.S. 

Department of Health and Human Services, ACL, 2015. Available at 

http://www.agid.acl.gov/. Accessed June 24, 2015. 

Ponza, Michael, James C. Ohls, Barbara E. Millen, Audrey M. McCool, Karen E. Needels, Linda 

Rosenberg, Dexter Chu, Catherine Daly, Paula A. Quatromoni. “Serving Elders at Risk: The 

Older Americans Act Nutrition Programs, National Evaluation of the OAA Nutrition 

Services , 1993-1995,” Volumes I, II, and III. U.S. Department of Health and Human 

Services, Administration on Aging, 1996. 

Ziegler, Jessica, Nicholas Redel, Linda Rosenberg and Barbara Carlson. “Older Americans Act 

Nutrition Programs Evaluation: Meal Cost Analysis.” U.S. Department of Health and 

Human Services, Administration for Community Living. September 30, 2015. 

71
This page has been left blank for double-sided copying.
APPENDIX A:

PROCESS STUDY SURVEY METHODOLOGY
This page has been left blank for double-sided copying.
APPENDIX A MATHEMATICA POLICY RESEARCH

Survey Methodology

Overview

The OAA Title III-C NSP process evaluation was designed to examine the strategies, 

activities, and resources of the program at each level of the aging network: SUA, AAA, and LSP. 

The following describes the survey of all 56 SUAs, a sample of 360 AAAs, and a sample of 230 

LSPs, using web surveys and self-administered questionnaires. 

Instrumentation

We created the SUA, AAA, and LSP survey instruments to respond to current 

Administration for Community Living/Administration on Aging (ACL/AoA) priorities and 

interests, basing them on instruments from the prior national evaluation of the OAA Nutrition 

Services . Mathematica completed pretests with 3 SUA directors. The purpose of the pretest was 

to determine the amount of time needed to complete the survey and identify any issues with 

respondents’ understanding of the questions. The SUA directors also participated in a debriefing 

with Mathematica staff to provide feedback on the survey instruments. The instruments were 

revised based on this feedback. 

Based on feedback from NASUAD that the SUAs were familiar with completing surveys 

online, we decided to field the SUA survey as an editable PDF instrument, as this was more costeffective than a web survey given the small sample size.

We asked the AAAs and LSPs sampled for the study to each complete a web survey and a 

fax-back form. The web survey contained questions about program processes (for example, 

partnerships with other organizations) that respondents would likely be able to answer without 

referring to other sources. The fax-back form contained questions that would likely require 

referring to other data sources (for example, program costs). The concern was that if both types 

of questions were included in a web survey, respondents might stop at a question that required 

looking up the data elsewhere, possibly leading to more incomplete web surveys. Therefore, we 

decided to separate the two types of questions into two instruments. We pretested the two 

instruments with respondents from three AAAs and three LSPs that were not sampled for the 

AAA and LSP surveys, respectively, to determine the amount of time needed to complete the 

surveys and identify any issues with respondents’ understanding of the questions. 

As discussed in Section III.A of the evaluation report, some AAAs had a dual function as 

both an AAA and an LSP. To limit response burden on these agencies, we incorporated a “direct 

services module” in the AAA web survey that included questions about functions as an LSP. 

Data collection procedures

SUA survey 

In December 2013, Mathematica sent letters to the SUAs to inform them that they would be 

receiving the SUA survey via email in January. The letter instructed SUA directors to send an 

email to the NSP study inbox if they wanted to designate someone else within their SUA to 

receive and complete the survey. The mailing also included a brochure that provided an 

overview of the evaluation.

A.3 
APPENDIX A MATHEMATICA POLICY RESEARCH

We sent an email to SUA directors or their designee in January 2014, asking them to 

complete and return the attached SUA survey. The SUA survey was in an editable PDF format, 

which allowed respondents to enter data in the form electronically without altering the 

formatting of the questionnaire. We trained four survey liaisons to provide technical assistance to 

SUAs and to ensure that all surveys were returned and accurately completed. 

These liaisons began calling the survey respondent the day after the SUA survey was 

emailed to make sure they received the survey and were able to open it and enter data in the 

editable PDF format. The liaison also answered any questions the respondent had about the 

survey or the evaluation. Those who did not respond to the survey request received one reminder 

email, as well as follow-up calls from a survey liaison until the questionnaire was completed. 

AAA web survey and fax-back form

Before launching the AAA survey, we asked SUAs for the contact information of the AAA 

directors selected for the study. In early April 2014, we sent email invitations to the 360 AAAs 

selected to participate in the evaluation. The email contained a link to the web survey and had the 

fax-back form attached as a PDF file.13 Over a period of seven weeks, nonrespondents received 

up to three additional reminder emails to complete the survey and fax-back form. Survey liaisons 

also periodically contacted nonrespondents by phone and email to encourage participation. In 

early May, the ACL project officer sent an email to those who did not respond to encourage 

participation. Data collection for both the web survey and fax-back form closed at the end of 

May 2014. 

LSP web survey (Part A) and fax-back form (Part B) 

For the AAA data collection, we sent respondents an email with a link to the web survey and 

attached a PDF version of the fax-back form to the email. Some respondents did not understand 

that these were two different data collection instruments and that both needed to be completed. 

Because the LSP survey also has a web survey component and a fax-back form component, we 

planned to send respondents an email with a link to the web survey only. When the respondent 

completed all questions in the web survey, the final screen would thank them for completing 

“Part A” (that is, the web survey) and instruct them to download and complete “Part B” (that is, 

the fax-back form in editable PDF format). 

We contacted the 115 AAAs that had provided lists for LSP sampling to inform them of 

which LSPs had been selected. At the same time, we requested contact information for each LSP 

(a primary contact and an alternate contact, if available) so that we could send them an email 

invitation to complete the web survey. Slightly more than three-quarters of the 115 AAAs 

provided some contact information for their selected LSPs, but we were missing email addresses 

for 60 of the 230 sampled LSPs at the time of the survey launch. 

13 During data collection, we found that some AAA respondents were confused by the request to complete both a 

web survey and a fax-back form, thinking that they needed to complete only one or the other. As a result of their 

feedback, and internal usability testing, we changed how we presented the fax-back form to LSPs so respondents 

would be asked to only complete one instrument at a time.

A.4 

 
APPENDIX A MATHEMATICA POLICY RESEARCH

In mid-November 2014, the sampled LSPs that had an email address on file received an 

invitation email. After the launch of the survey, liaisons attempted to reach all LSPs by 

telephone, starting with those that did not receive the invitation email because we did not have 

their email address. The liaisons tried to identify a respondent from these LSPs and obtain an 

email address. The liaisons also called LSPs for which we did have an email address to confirm 

that the LSP contact had received the survey invitation and that the LSP contact was the 

appropriate survey respondent. 

Through a combination of liaison calls to LSPs and emails from the ACL project officer 

encouraging AAAs to provide contact information, we eventually obtained contact information 

for the 60 LSPs originally missing email addresses. As we received this information, we sent the 

web survey invitation to them (on a rolling basis). In December 2014 and January 2015, we sent 

four rounds of reminder emails to nonrespondents asking them to complete the Part A web 

survey. In December and January, we also sent five rounds of reminders to LSPs that had 

completed Part A but did not respond to Part B. 

The 28 AAA/LSP combination agencies that had already completed the AAA survey with 

the direct services module were not asked to complete the LSP survey, which included most of 

the same questions they had already answered. Instead, we asked them by telephone a short set 

of questions from the LSP web survey that were not in the AAA survey and requested that they 

all complete Part B. 

Response Rates

We used the American Association of Public Opinion Research’s Standard Definitions for 

establishment surveys to calculate response rates.14 The response rate was defined as 

response rate = I / ( I + P + R + NC + O ) where

I = Complete interviews

P= Partial Interviews

R = Refusal and break off

NC = Non Contact 

O = Other

14 American Association of Public Opinion Research, Standard Definitions: Final Dispositions of Case Codes and 

Outcome Rates for Surveys, revised April 2015. 

http://www.aapor.org/AAPORKentico/AAPOR_Main/media/publications/StandardDefinitions2015_8theditionwithchanges_April2015_logo.pdf 

A.5 

 
APPENDIX A MATHEMATICA POLICY RESEARCH

Table A.1. Shows the final disposition and response rate for each survey 

instrument.

. Initial 

sample Ineligible Refusal Complete Partial 

Response 

rate

SUA survey 0 0 0 56 0 100%

AAA survey 360 1a 3 328 (web)

292c (fax back)

5 (web)

0 (fax back)

92%

81%

LSP survey 230 4b 0 (web)

2 (fax back)

193 (web)d

140 (fax back)

6 (web)

0 (fax back)

85%

62%

aOne AAA lost its designation and was therefore ineligible.

bOne LSP only contracted for cash-in-lieu funds to help with their resident nutrition program. During the fielding, three 

LSPs were found to be duplicates of other LSPs in the sample.

cAAAs were expected to complete the web survey before the fax-back form. However, 6 completed the fax-back form 

but not the web survey (that is, 298 fax back completes total). AAAs that completed the fax-back form without the 

web survey were assigned a weight of 0 in the analysis. 

dThe total of LSP completed surveys includes the 28 AAA/LSP combinations that completed the AAA survey with 

direct services module.

Tables A.2 and A.3 show the number of completed web surveys (Part A) and fax-back forms 

(Part B) among the stand-alone LSPs and AAA/LSP combination agencies, respectively. 

Table A.2. LSP Web (Part A) and Fax-Back (Part B) Survey Completes Among 

Stand-Alone LSPs

Status Number of stand-alone LSPs

Part A and Part B complete 121

Part A complete, Part B untouched 42

Part A complete, Part B refusal 2 

Part A partial 6 

Part A untouched 27

Ineligible 4 

Total 202

Table A.3. LSP Fax-Back (Part B) Survey Completes Among AAA/LSP 

Combinations

Status Number of AAA/LSP combinations

Part B complete 19

Part B untouched 9 

Total 28

Quality assurance procedures

We reviewed all responses on the SUA survey, the AAA fax-back form, and Part B of the 

LSP survey, as these instruments were fielded as an editable PDF file or hard copy and did not 

have validations and logical checks built into them. Survey liaisons contacted the respondents to 

clarify inconsistencies and obtain missing data.

A.6 
This page has been left blank for double-sided copying.
APPENDIX B:

SAMPLE DESIGN FOR THE SURVEYS OF AAAS AND LSP
This page has been left blank for double-sided copying.
APPENDIX B MATHEMATICA POLICY RESEARCH

Sample Design for the Surveys of AAAs and LSPs

Surveys were conducted for SUAs, AAAs, and LSPs. All SUAs were included in the study, 

but probability samples were selected for the AAA and LSP surveys. 

AAA Sample. With the help of the National Association of States United on Aging and 

Disabilities (NASUAD), we obtained from each SUA an unduplicated number of people who 

received congregate nutrition services and home-delivered nutrition services for older adults 

during their most recently completed fiscal year in each of their AAAs. Using these client 

counts, we constructed a composite size measure. For the study, eligible AAAs included only 

those located in the continental 48 states and the District of Columbia (616 AAAs). Six AAAs 

with the largest values for the composite size measure were included in the sample with 

certainty. Of the remaining 610 AAAs, we selected a random sample of 354, using equal 

probability sequential sampling, and implicitly stratifying by the ranking of each AAA’s state in 

terms of (a) the square miles of service area per AAA and (b) the AAA’s composite size 

measure. Of these 354 selected AAAs, we randomly selected 60 AAAs to serve as a backup 

sample using a systematic sample, but with the same implicit stratification variables used for the 

initial sample. All 60 backup AAAs were eventually released into the sample, for a total of 360 

AAAs for which web and then faxback surveys were attempted. 

LSP Sample. To select a sample of LSPs to survey we first needed lists of LSPs from the 

sampled and participating AAAs. For reasons of efficiency, we subsampled 120 AAAs from 

which we would attempt to get these lists: 100 from the main sample of 300 AAAs and 20 from 

the 60 backup sample of AAAs. The original 6 certainty selections were automatically included 

in this subsample. Before subsampling the remaining 114 AAAs, we excluded 20 AAAs that had 

refused to participate in the study. We then selected two probability-proportional-to-size (PPS) 

sequential samples, one from the main AAA sample and one from the backup AAA sample. 

When selecting these subsamples, we used the AAA’s composite size measure, and implicitly 

stratified by groupings of AAAs that were similar in terms of their size and their geographic 

region. Among these 114 selections, 30 additional AAAs were selected with certainty due to the 

large value of their composite size measure. All 20 backup AAAs were eventually released for 

LSP survey, for a total of 120 AAAs. Ultimately, 115 AAAs provided lists of their LSPs. 

In total, the 115 participating AAAs provided a list of 1,169 eligible LSPs. The basic 

strategy was to select an average of 2 LSPs per AAA for a total of 230 LSPs. Of the 115 AAAs, 

40 AAAs only had 1 or 2 LSPs, and we selected all their LSPs (a total of 51 LSPs). Among the 

remaining 75 AAAs with 3 or more LSPs, we randomly selected 47 AAAs from which to sample 

2 LSPs each, 27 from which to sample 3 LSPs each, and 1 from which to sample 4 LSPs to get to 

the target number of 230. These LSP samples were selected within AAA using sequential 

sampling with probability proportional to size with the measure of size being another composite 

measure of size incorporating both congregate and home-delivered meals at the LSP level, and 

implicitly stratifying by provider type (whether they provided congregate meals, home-delivered 

meals, or both). Of the 230 LSPs in the sample, 88 were selected with certainty – 51 because 

there were only 1 or 2 LSPs in the AAA and 37 because of their size relative to other LSPs in the 

AAA. Web and then faxback surveys were attempted for all 230 sampled LSPs. 

B.3 
This page has been left blank for double-sided copying.
APPENDIX C:

ANALYSIS WEIGHTS FOR THE SURVEYS OF AAAS AND LSPS
This page has been left blank for double-sided copying.
APPENDIX C MATHEMATICA POLICY RESEARCH

The purpose of analysis weights is to allow for the computation of unbiased estimates based 

on sample survey responses from the study population. Weights take into account both the 

probability of selection into the sample and the differential response patterns that may exist in 

the respondent sample. All SUAs were included in the sample, and all responded to the survey, 

so no analysis weights were needed for the analysis of data from the SUAs. Weights were 

constructed for the samples of AAAs and LSPs (for the web and faxback surveys) as these 

samples involved both sampling and nonresponse. 

AAA Surveys. We attempted a web survey and then a separate faxback survey for a 

probability sample of 360 AAAs. The sampling weight for AAAs, accounting for their selection 

probabilities, was 1 for the sample selected with certainty (the six largest AAAs), and was 1.723 

for each of the 354 AAAs selected from the remaining 610. Among the 360 in the sample, 333 

responded to the web survey, 3 were refusals, 23 were nonrespondents with no contact, and 1 

was ineligible. We first adjusted for the 23 nonrespondents with no contact using response 

propensity models. We entered the following set of variables into a chi-square interaction 

detection (CHAID) software as well as a stepwise logistic regression model to determine which 

main effects and two-order interactions were significant predictors of making contact with the 

sample member: census region, size of area served, rank of size of state’s area served per AAA, 

number of congregate meals served, and number of home delivered meals served. Each of these 

was broken into four categories, using quartiles for the continuous variables. The final model, 

run using a normalized sampling weight, had only two significantly predictive variables: number 

of congregate meals (whether between about 1500 and 3000 meal or not) and home delivered 

meals (whether greater than about 1800 meals). We multiplied the inverse of the resulting 

propensity score and the sampling weight for the 337 for whom contact was made. For the 336 

eligible AAAs, only 3 were nonrespondents, and we applied a simple ratio adjustment of 1.009 

to the 333 respondents to get the final AAA web survey weight, which ranged from 1.03 to 1.97 

and sums to 614.1 – an estimate of the number of eligible AAAs in the population, and a design 

effect due to unequal weighting of 1.005. 

Among the 333 web survey respondents, 292 responded to the faxback survey. Using the 

same process and same candidate variables as used for the web survey response propensity 

logistic regression model, the final model found the following variables to be predictive of 

response: 

• Midwest census region or not, 

• State’s average size of area served by its AAAs (whether between about 960 and 3750 

square miles or not), and 

• The interaction between the average size of its service area (previous bullet) and whether the 

AAA served more than about 1,800 home delivered meals or not. 

We multiplied the inverse of the resulting propensity score and the AAA web survey weight 

for the 292 faxback survey respondents to obtain the final AAA faxback survey analysis weight, 

which ranged from 1.06 to 2.94, and also summed to 614.1, with a design effect of 1.011. No 

large outlier weights were identified for either AAA survey weight. 

C.3 
APPENDIX C MATHEMATICA POLICY RESEARCH

LSP Surveys. For a probability sample of 230 LSPs, we attempted a web survey and then a 

separate faxback survey. The sampling weight for 142 of the sampled LSPs accounted for their 

probability-proportional-to-size selection probability, and 88 LSPs had a sampling weight of 1 

due to their being selected with certainty. The sampling weights, conditional on the selected 

AAAs, ranged from 1 to 89, and summed to 1225 (with an unequal weighting design effect of 

4.533). Four of the 230 LSPs were classified as ineligible. We then compensated for the 27 web 

survey nonrespondents among the 226 remaining LSPs in the sample using procedures similar to 

those described above for the AAA web survey. The variables available as predictors for the 

LSPs were limited to census region, number of congregate meals served by the LSP, and number 

of home delivered meals served by the LSP. The final logistic regression response propensity 

model for the LSP web survey included census region and number of home-delivered meals. We 

multiplied the inverse of the resulting propensity score and the LSP sampling weight for the 199 

web survey respondents. This final weight summed to 1,212, the sum of the sampling weights for 

the 226 eligible LSPs (with a design effect of 3.482). We then trimmed three outlier weights 

resulting from the nonresponse adjustments. 

Among the 199 web survey respondents, 140 responded to the faxback survey. Using the 

same process and same candidate variables as used for the LSP web survey logistic regression 

response propensity model, the final model found the following variables to be predictive of 

response to the LSP faxback survey: number of congregate meals served (whether between about 

170 and 560 meals) and number of home-delivered meals served (whethxc ffer between 135 and 

410 meals). We multiplied the inverse of the resulting propensity score and the web survey 

weight for the 140 faxback survey respondents to get the analysis weight. We applied a ratio 

adjustment of 1.03 so that the final LSP faxback survey weight also summed to 1,212 with an 

unequal weighting design effect of 3.297. We then trimmed 2 outlier weights resulting from the 

nonresponse adjustments. 

But these LSP survey weights do not yet account for the selection and response probabilities 

for the AAAs that provided the list of LSPs from which the sample of 230 was selected. As 

described in the sampling section, we subsampled 120 AAAs from 340 sampled and 

participating AAAs. After adjusting the initial AAA sampling weight for the 20 AAAs that 

refused to participate in this part of the study (using logistic regression response propensity 

modeling), we applied the inverse of the subsampling probability of the 120 AAAs to this 

refusal-adjusted weight. We then further adjusted for the 5 subsampled AAAs who never 

provided their lists of LSPs using yet another propensity model. This cumulative AAA weight 

summed to 606. After applying this cumulative AAA weight to the LSP web survey weight, the 

final cumulative LSP web weight summed to 3,755.11 and ranged from 1.07 to 225.12 

(weighting design effect of 2.962). After applying the cumulative AAA weight to the LSP 

faxback survey weight, we applied a ratio adjustment of 0.979 to ensure the final cumulative 

LSP faxback weight also summed to 3,755.11. The range of this weight was 1.60 to 258.73, with 

a design effect of 2.621. 

C.4 
APPENDIX D:

ADDITIONAL TABLES FOR SUAS THAT OPERATE AS AAAS
This page has been left blank for double-sided copying.
APPENDIX D MATHEMATICA POLICY RESEARCH

Table D.1. SUA data systems and reporting

. Percentage 

of SUAs

SUAs that function as AAAs receive NSP data from LSPs by:a . 

Software/computer system 92

Email 54

Telephone 31

Mail 38

SUAs that function as AAAs require all LSPs in the state to use the same software for reporting. 75

SUAs that function as AAAs require all LSPs to report NSP data beyond those required in the 

AoA state program report. 77

Data being collected beyond those required for the state program reporta,b . 

Nutrition program service reports/program performance data 50

Quality assurance findings 40

Fiscal management reports 60

SUAs that function as AAAs have established NSP performance measures at the LSP level. 62

SUAs share NSP performance data with the public. 58

Frequency with which LSPs are required to report NSP data to the SUA that function as AAA . 

Continuously 8 

Monthly 58

Quarterly 17

Semiannually 0 

Annually 17

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 13 SUAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

bPercentage of SUAs requiring all AAAs to report NSP data beyond those required in the AoA state program report.

D-3 
APPENDIX D MATHEMATICA POLICY RESEARCH

Table D.2. Food safety policies and practices in SUAs

. Percentage of SUAs

Percentage of SUAs with formal policies, guidance, or regulations for managing foodborne illnesses in the NSP 67

Entities involved in the development of the SUA’s current food-borne illness policy for the 

NSPa . 

LSPs 38

State or local department of health 100

State department of agriculture 0 

None of the above 0 

Percentage of SUAs with formal policies, guidance, or regulations for managing food 

recalls 33

Entities involved in the development of the SUA’s current food recalls policy for the NSPa . 

LSPs 50

State or local department of health 50

State department of agriculture 0 

None of the above 25 

Percentage of SUAs that require LSPs to report incidents of food-borne illness that occur 

in the NSP to each of the following entities: . 

SUA 45

State or local department of health 67

Source: SUA survey. 

Note: Tabulations are based on an unweighted sample size of 13 SUAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

D-4 
APPENDIX D MATHEMATICA POLICY RESEARCH

Table D.3. Participant contributions

. Percentage of SUAs

SUAs have a policy regarding: . 

Collection and/or management of participant contributions for NSP 92

Distribution of participant contributions for the NSP 92

Spending of participant contributions for the NSP 75

SUAs have specific policies on the noncoercion of participants with regard to 

participant contributions 83

Ways in which the SUA determines whether participant contributions to the NSP are 

used to expand services:a . 

LSPs are required to spend participant contributions first and then other funds. 38

LSPs are required to report data on services delivered using participant 

contributions. 38

The SUA monitors program data in relation to participant contributions reported. 54

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 13 SUAs. 

Individual estimates within the table may have slightly fewer observations due to item nonresponse to 

individual questions.

aMultiple answers allowed.

D-5 
APPENDIX D MATHEMATICA POLICY RESEARCH

Table D.4. SUAs’ prioritization of services

. Percentage of 

SUAs

Prioritization policy of SUA is set for the NSP by: . 

SUA 45

SUA with input from LSPs 9 

LSPs with input from SUA 18

LSPs 0 

No prioritization policy exists 27

Prioritization criteria area . 

Statewide 82

LSP-specific 18

Source: SUA survey.

Note: Tabulations are based on an unweighted sample size of 13 SUAs. Individual estimates within the table may 

have slightly fewer observations due to item nonresponse to individual questions.

aPercentage of SUAs with prioritization policy. 

D-6 
www.mathematica-mpr.com

Improving public well-being by conducting high quality, 

objective research and data collection

PRINCETON, NJ ■ ANN ARBOR, MI ■ CAMBRIDGE, MA ■ CHICAGO, IL ■ OAKLAND, CA ■ WASHINGTON, D

Mathematica® is a registered trademark 

of Mathematica Policy Research, Inc.