A CALL TO ACTION 

FOR THE AGING 

NETWORK

 URGENCY 

 FOR CHANGE

SPRING 2019 

Commissioned by: NRCNA 

Written by: Jean L. Lloyd, 

MS Nutrition Consultant 
 FOR

URGENCY 

CHANGE 

The National Resource Center 

on Nutrition and Aging 

(NRCNA) is hosted by Meals on 

Wheels America as part of a 

cooperative agreement with the 

Administration for Community 

Living.

 www.nutritionandaging.org

 @NRCNAeng_Aging 

A CALL TO ACTION 

FOR THE AGING 

NETWORK 
Table of Contents 

EXECUTIVE SUMMARY ................................... 1 

INTRODUCTION ........................................ 2 

DEMOGRAPHICS ........................................ 3 

GROWTH............................................... 3 

RACIAL/ETHNIC DIVERSITY ................................ 3 

INCREASE IN THOSE OVER 85 ............................. 3 

RATIOS OF WOMEN TO MEN .............................. 3 

LIVING ARRANGEMENTS.................................. 4 

INCOME DIVERSITY ...................................... 4 

DISABILITY AND HEALTH ................................. 4 

DISABLED POPULATION – ALL AGES ....................... 5 

SUMMARY OF DEMOGRAPHIC CHANGE AND IMPACT ........ 5 

COMPETITION.......................................... 6 

FOOD SERVICE COMPETITION............................. 6 

NEW BUSINESS MODELS ................................. 6 

SCIENCE, TECHNOLOGY AND MEDIA ...................... 7 

NUTRITION SCIENCE ..................................... 7 

HEALTH CARE AND SOCIAL SERVICES ...................... 8 

LONG-TERM SERVICES AND SUPPORTS .................... 9 

CONCLUSION .......................................... 10 

REFERENCES ........................................... 11 
Executive Summary 

To add value and to survive, senior nutrition programs need 

to modify and modernize. Senior nutrition program leaders 

will need to target services more sharply, and rethink how 

their business models can best mesh with existing systems. 

Both external and internal environmental changes are 

confronting nutrition programs. 

Urgent changes are needed in 

senior nutrition programs, who are 

now competing to provide the right 

services to the right people at the right 

time. 

In a fast-moving world, familiar 

services can vanish (goodbye pay 

phones), longtime stores can shrivel 

(think Sears), business models can 

change (hello Lyft, or electric cars), and 

individual needs evolve (more ondemand convenience). 

Senior nutrition programs are not 

immune to the tide of change. 

To add value and to survive, senior 

nutrition programs need to modify 

and modernize. Senior nutrition 

program leaders will need to target 

services more sharply, and rethink 

how their business models can best 

mesh with existing systems. Both 

external and internal environmental 

changes are confronting nutrition 

programs. 

Senior nutrition programs must 

change so they can: 

• Serve the demographics of a much

more diverse older population,

• Address compelling competition

from other private and public

service providers,

• Adjust to changes in science,

health, technology and media,

• Better integrate within the health

and social service systems and

• Become an essential component

of the long-term services and

supports (LTSS) system.

Other challenges include limited public 

funding, the need for innovation as 

food-service delivery mechanisms 

are changing, and the need for 

adaptation in serving the multiplicity 

of participants from the young old to 

the old old. 

Leaders of nutrition programs should 

be guiding discussions about how to 

incorporate quality and sustainability 

into their operations, and how to 

make services more individualized. 

The older population was more 

homogenous when the OAA Nutrition 

Program (OAA NP) began, but several 

decades have created significant 

demographic challenges. Changes 

include: the increasing number and 

percentage of older adults; increasing 

racial/ethnic diversity, especially 

population growth among Hispanics; 

increase in both healthy older adults 

and less healthy, less functional older 

adults; increase in those age 85-plus; 

increase in the percentage of older 

women; higher rates of poverty for 

some older adults; and increase 

in disabilities and chronic health 

conditions. 

Society has changed since 1972, when 

the OAA NP first was enacted. There 

was little competition for the new 

senior centers and congregate meal 

programs then. Personal technology 

barely existed, much less online 

ordering of personalized restaurant 

meals delivered to your door within 

the hour. 

Now, competition is everywhere, from 

soup and salad bars in supermarkets 

to food kits delivered to your home to 

make into meals. Private industry is 

serving and marketing to older adults. 

Commercial vendors now produce 

meals that meet the requirements 

of the OAA and also offer meals for 

special dietary needs and ones that 

meet regional/cultural preferences. 

Commercial vendors are competing 

with senior nutrition programs on 

both price and quality. 

Local senior nutrition programs need 

to improve the quality of their meals 

and services to help older adults 

actively choose their services. They 

also will need to better integrate 

within health and social service 

systems and ensure that they are an 

essential component of the emerging 

LTSS system. 

Such changes will help senior nutrition 

programs meet the demands of a 

larger, more diverse population—for 

both congregate and home-delivered 

meals—and ensure they can provide 

the right services to the right people at 

the right time. 

1 
Introduction 

“The times...they are changing” may 

be a cliché, but it is true. People 

change, things change, programs 

change, and systems change. 

The changing times affect how 

nutrition programs function every day 

and how well they can meet current 

and future needs. To be of value, 

nutrition programs need to invest in 

quality, efficient, effective, personcentered changes. 

Here are just a few examples of how 

programs have evolved over the 

past few decades. The Food Stamp 

Program was authorized in 1964 to 

improve the levels of nutrition in 

low-income households regardless 

of age. The Older Americans Act 

(OAA), passed in 1965, did not include 

any direct services. During the late 

1960s, it became apparent that older 

Americans continued to have food 

needs that were unmet by the Food 

Stamp Program. The Administration 

on Aging then funded pilot nutrition 

projects to meet these needs.1 

Based on these pilot projects, 

congregate meals were the first 

home- and community-based 

service1-2 authorized in the OAA in 

1972 (Administration for Community 

Living. 2019). Designed to meet social 

and nutrition needs of older adults, 

particularly those who were lowincome, the program also included 

social activities and connections 

to other needed services. Homedelivered meals were limited. Over 

the years, the program was reduced 

Both external and internal changes are sparking discussions 

about how to incorporate quality and sustainability into program 

operations—and how to do so more quickly. This document 

highlights the internal and external changes that are influencing 

implementation of the Older Americans Act Nutrition Program. 

within the aging services network to 

meal provision. 

In 2016, Congress reiterated the 

original broader purposes of the OAA 

Nutrition Program (OAA NP): 

1. To reduce hunger and food 

insecurity; 

2. To promote socialization of older 

individuals; and 

3. To promote the health and 

well-being of older individuals 

by assisting such individuals to 

gain access to nutrition and other 

disease prevention and health 

promotion services to delay the 

onset of adverse health conditions 

resulting from poor nutritional 

health or sedentary behavior. 

(Older Americans Act. 2016. 

Section 330.) 

OAA NP implementation has changed 

significantly from 1972. What has 

influenced this? Both external and 

internal environmental changes. 

Urgent external environmental 

changes include demographics, 

competition, science and technology, 

social services, health care, and 

integration of health and social 

services as a part of long-term services 

and supports systems (LTSS). 

Pressing internal environmental 

changes influence whether or not OAA 

NP can survive. They include limited 

public funding, limited innovation 

in service delivery as food-service 

delivery mechanisms are changing, 

less adaptation to serving the 

multiplicity of participants from the 

young old to the old old, and less 

focus on quality and changes in the 

business environment of OAA NP. 

Both external and internal changes 

are sparking discussions about how to 

incorporate quality and sustainability 

into program operations—and 

how to do so more quickly. This 

document highlights the internal and 

external changes that are influencing 

implementation of the OAA NP. 

2 
Demographics 

Our older population is growing overall, and especially among 

those over age 85. Its racial/ethnic, income, and health and 

functional diversity are increasing as well. This is causing an 

increase in the need for services, different kinds of services 

and different ways to finance them so that an older adult 

receives the right service at the right time in the right way. 

Growth 

The older population (defined as 65 

and older) is growing as a percentage 

of the U.S. population.3 Over the past 

10 years, the older population has 

increased 33% and will double to 98 

million by 2060. By 2035, the number 

of older adults will outnumber 

children, a situation that could 

stimulate competition for public and 

private funding and services. 

Nationally, about 15% of the U.S 

population is over 65, but the 

percentage is significantly higher in 

some places. Although California, 

Florida, Texas, New York and 

Pennsylvania have the largest number 

of older adults, Florida, Maine, Puerto 

Rico, West Virginia, Vermont and 

Montana have the highest percentage 

of older adults at 17% and over. Many 

rural states have a higher percentage 

than the national rate but also more 

limited public spending and social 

services. Between 2006 and 2016, 

Alaska (17.3%), Nevada (21.3%), 

Colorado (19.8%) and Arizona (23%) 

increased their age 65-plus population 

by 50%. 

Nationally about half of the older 

population is between the ages of 65 

and 74; about 29 percent is between 

75 to 84 or about double that of the 

age 85 and older population. 

States with an increased number 

and percentage of older adults face 

increased demands for services. 

However, the needs of these older 

adults may differ based on their age 

cohort and other characteristics. 

Racial/Ethnic 

Diversity 

The older population continues to be 

largely white. However, it is becoming 

more diverse. All minority race/ 

ethnicities (African American, Asian, 

American Indian/Alaska Natives, and 

Hispanic Americans) are increasing 

from 19% in 2006 to 23% of the older 

population by 2030, with the greatest 

increase for Hispanic Americans. 

Because racial/ethnic minorities 

will increase, some may expect 

more culturally appropriate meals, 

activities, and services as well as 

services in languages other than 

English. 

Increase in Those 

Over 85 

Although most older adults are under 

age 85, the age 85-plus population 

is expected to increase the fastest 

of the age cohorts, doubling by 2040 

and tripling by 2050. About 9% of this 

population lives in assisted living/ 

nursing homes, and 91% lives at 

home in the community. As the over 

age 85 population increases, there 

will be an increased demand for both 

home- and community-based services 

and facility-based services. 

Since most of the 85 and older 

population will continue to live at 

home in the community, they will 

need more in-home services and 

caregiver support services. 

Ratios of Women 

to Men 

Women continue to outnumber men, 

and most older men are married 

(70%) compared to older women 

(46%). Over half of older adults lived 

with a spouse or partner in 2017, but 

this percentage decreases with age, 

especially for women. About two times 

as many women who were 85-plus 

were widowed compared to men of 

the same age. In general, women are 

caregivers for men, who die sooner. 

The proportion of individuals living 

alone increases with age, with about 

45% of women age 75 and over living 

alone. 

Older women will be a significant 

portion of the population, possibly 

with increased social isolation or 

more caregiver burden, so services 

may need to adapt by focusing 

on more services or more intense 

services to keep them in the 

community. 3 
Living

Arrangements 

As people age, they are less likely to 

live in a family household.4 About 

81% of the U.S. population lived with 

a family in a household, while 67.6% 

of those age 65 and older did. By age 

85, about half of older adults lived in a 

family or non-family household, while 

about 39% lived alone. About 45% of 

women aged 75 and older lived alone 

compared to men, who were more 

likely to live in a family household. 

Living alone is a risk factor for 

social isolation as well as a risk 

factor for nursing home placement. 

Targeting services to those who live 

alone is not only required by the 

OAA, but also makes sense in terms 

of promoting health and delaying 

institutionalization. 

Income Diversity 

There is increased financial diversity—

more higher-income older adults and 

more poorer older adults. Although 

the median income of an older person 

in 2016 was $23,394, it was $31,618 

for males and $18,380 for women. For 

all older persons, 47% reported an 

income of $25,000 or more. 

The age cohorts provide more 

nuanced insights, however. Since 

about 49% of households between 

ages 65 to 74 had some earned 

income, many younger older adults 

are still in the work force and may 

not be ready to access services. This 

percentage declines with those age 

75-plus.

The poverty rate for the older 

population is lower than the general 

U.S. population. Using the U.S. Poverty 

Guidelines, about 9.3% of the older 

population is below the poverty level 

of $12,490 for a single person and 

another 4.9% are at 125% of poverty 

or “near poor.” About 14% reported an 

income below $10,000. 

Both ethnic/racial minorities and 

women have higher poverty rates. 

About 7.1% of Whites, 18.8 % of 

American Indian/Alaska Natives, 

18.7% of African Americans, 17.4% 

of Hispanics and 11.8% of Asian 

Americans are below the poverty 

level. Women (10.6%) have a higher 

poverty rate than men (7.6%) and 

Hispanic women who live alone have 

the highest rate (39.5%). Some states/ 

territories have the highest poverty 

rates, such as Puerto Rico (38.1%), 

District of Columbia (13.4%), Louisiana 

(13.0%), Mississippi (12.3%), New 

Mexico (11.5%), New York (11.4%) and 

Kentucky (11.1%). 

Those with higher incomes generally 

have better health, and are more able 

to access a wider array of health care 

and other supports/services from 

private sources. This higher-income 

group may also be able to voluntarily 

contribute more to the cost of publicly 

funded services that they do access. 

Those with lower incomes are more 

in need of diverse public services and 

have fewer options. 

Lower-income older adults and 

those in greater poverty have more 

food insecurity, poorer health, less 

functionality and more social isolation. 

Lower-income older women may be 

most in need. Needed services include 

meals, but also community-centered 

nutrition education, person-centered 

nutrition counseling and referral 

to other food assistance, economic 

security programs, HCBS services and 

health care options. 

Those with greater poverty are more 

in need of services due to associated 

issues such as food insecurity, poorer 

health, less functionality and more 

social isolation. Targeting services to 

these people helps fulfill the purposes 

of the OAA and keeps older adults at 

home in the community. 

Disability and

Health 

Based on its legislated purposes, the 

OAA NP is both a social service and 

health-related nutrition program. So 

knowledge of health and functionality 

is essential for appropriate targeting 

and tailoring of services to meet 

community and personal needs of 

older adults. 

Disabilities and poorer functionality 

increase with age. About 35% of 

the over-65 population has some 

disability. Although about 44% of 

those over 75 have some difficulty in 

physical functioning, about 56% do 

not. 

The most common disability among 

all older adult age cohorts is difficulty 

in walking and climbing stairs. About 

15% of those age 65 to 74 had these 

difficulties compared to about half 

of those age 85-plus. About 8% of 

those age 65 to 74 had difficulty with 

independent living, such as shopping 

or going to the doctor, compared to 

about 43% of those age 85-plus. As 

the population ages, the percentages 

rise of those with more than one type 

of disability (vision, hearing, cognition, 

ambulation, self-care and independent 

living). 

Health status also varies. Although 

most older adults assess their health 

as excellent or very good, most 

have at least one chronic condition 

and many have several. The top 

Lower income and poverty are risk factors 

for premature institutionalization. Those 

with greater poverty are more in need 

of services due to associated issues such 

as food insecurity, poorer health, less 

functionality and more social isolation. 

Targeting services to these people helps 

fulfill the purposes of the OAA and keeps 

older adults at home in the community. 

4 
chronic conditions are hypertension, 

hyperlipidemia, arthritis, heart disease 

and diabetes. About 31% of older 

adults are considered obese. Most of 

these conditions have nutrition and 

physical activity components to their 

management. Men and women and 

different racial/ethnic groups have 

differing rates of these conditions. 

Understandably, adults over age 75 

have more health care interactions 

than younger individuals, whether 

physician visits, hospitalizations or 

nursing home stays. 

Many older adults, including many 

over 75, are healthy, functional 

and socially active, so they will 

want healthy eating choices, 

physical activity programs to retain 

functionality, programs to reduce 

their risk of chronic disease, and social 

opportunities. For these people, the 

congregate programs will want to 

emphasize their healthy meal choices, 

health promotion activities, linkages 

to chronic disease management, and 

social activities that enhance social 

connectedness. 

Individuals with ambulatory 

difficulties will need assistance such 

as transportation to reach congregate 

services and other services that 

reduce social isolation. They may 

benefit from short-term in-home 

meals after hospitalization or nursing 

home rehabilitation, so that they can 

return to the congregate program. 

People who are 85-plus are often less 

healthy, more functionally-impaired, 

and poorer. At the same time nutrition 

programs are offering congregate 

programs to promote health, they 

need to provide programs to maintain 

the health and functionality of these 

high-risk older adults. 

For example, older adults with 

multiple chronic conditions may need 

meals and snacks at adult day care, 

home-delivered meals, medicallytailored special diet meals and 

supplements, specialized nutrition 

counseling, health coaching, in-home 

medication management programs 

and physical activity, in-home 

assistance for food programs, and 

other economic benefits and nutritionrelated caregiver support. 

Health and functionality status 

influence the different kinds of 

services that older adults need, 

as well as what they may expect. 

A challenge to the aging services 

network is to provide services that 

promote health, reduce the risk 

of chronic disease, and assist in 

managing chronic diseases and 

conditions, as well as help maintain 

health and functionality in 

populations that are compromised. 

The older population was more 

homogenous when the OAA 

NP program began and now is 

undergoing significant demographic 

challenges. To add value, nutrition 

programs will need to accelerate 

change, improve targeting of 

services, and tailor them to meet 

the more diverse needs of today’s 

heterogeneous population. 

Disabled 

Population – All

Ages 

Of all people with disabilities, about 

20% are 65 and older, 23% are under 

age 18 and 57% are between the 

ages of 18-64.5 The younger disabled 

population has different health, 

employment, food security, and 

services needs and challenges than 

older people do. The younger disabled 

population will continue to increase 

and may represent a new population 

to serve. Aging services providers 

will need to leverage traditional and 

non-traditional funding sources to 

serve this population as they age, 

anticipating that they may be a 

population that has differing needs 

than current OAA NP participants. 

Summary of

Demographic

Change and

Impact 

Urgent demographic factors 

all influence the services 

necessary to provide the 

right services to the right 

people at the right time. 

Demographic changes 

include the increasing 

number and population 

percentage of older adults; 

increasing racial/ethnic 

diversity; increase in both 

healthy functional older 

adults and less healthy, 

less functional older adults; 

increase in those age 85-plus; 

increase in the number and 

percentage of older women; 

higher rates of poverty for 

some older adults; and 

increase in disabilities and 

chronic health conditions as 

people age. 

The older population was 

more homogenous when 

the OAA NP program began, 

but several decades have 

created a new picture. The 

older population is now 

undergoing significant 

change. To add value, senior 

nutrition programs will need 

to adjust, modify, modernize 

and transform to meet the 

service needs of a diverse, 

heterogeneous population. 

5 
Competition

Significant demographic and societal 

shifts have occurred since the OAA 

was first enacted. Most women did not 

work outside the home then, families 

stayed in closer geographic proximity, 

and limited public services were 

targeted to older adults. 

Now, older adults’ incomes may be 

higher, their families more spread 

out. More women are working outside 

the home, in a greater variety of 

occupations. Regardless of their 

income level, older adults have higher 

expectations about accessing quality 

services. Individuals and public and 

private funders also expect quality 

services, with participant, patient 

or customer-focused care spurring 

competition. 

Food Service 

Competition 

In 1972, there was little competition 

for the new senior centers and new 

congregate meal programs, nor were 

there food products in groceries that 

only required limited preparation 

except “TV dinners.” 

Now competition is everywhere, and 

growing: restaurant early bird specials 

and senior discount meals; quality 

frozen food products; ready-to-eat 

meal components and soup and salad 

bars in supermarkets; on-demand 

restaurant deliveries in urban areas 

that go beyond pizza and Chinese 

carry-out; food kits delivered to the 

home to make into meals; and online 

ordering of frozen meats, meals and 

other food delivered to a consumer’s 

door. 

Besides physical activities at senior 

centers, there are health clubs, 

health insurance programs, and 

hospital and rehabilitation facilities 

that target special physical activities 

to older adults. Health insurance 

programs may offer discounts for 

health promotion/disease prevention 

programs, financial incentives and 

support groups. Many Medicare 

Advantage programs pay for Silver 

Sneakers memberships, which 

emphasize physical activity, health 

classes and social interactions.6 

Senior centers themselves have 

changed. For example, some senior 

centers offer different kinds of meals 

for different populations. They may 

offer the OAA NP meal to one group 

and the private pay, for-profit café 

meal to a more affluent group. These 

services may operate with different 

menus, may offer unique foods in 

varied locations in the same senior 

center at distinct times during the day 

- all targeting an array of clients with 

wide-ranging needs. Or a nutrition 

provider may operate a for-profit 

restaurant open to the general 

paying public, and offer OAA-financed 

congregate and home-delivered meals 

and private-pay home-delivered 

meals. 

Private industry is starting to serve 

and market to the older adult 

population. While many senior centers 

once self-produced congregate 

and home-delivered meals that 

catered to local tastes, they now 

have competition. Now, commercial 

vendors produce meals that meet the 

requirements of the OAA and also 

offer meals for special dietary needs 

and meals that meet regional/cultural 

preferences, including choices among 

entrees, sides and desserts. And 

because these meals may be delivered 

to the home and require reheating, 

older adults may choose when to eat, 

thus giving them more flexibility. 

Commercial vendors are competing 

with local programs on both price 

and quality to obtain contracts 

for congregate meals and homedelivered meals from both traditional 

funders and new HCBS managed-care 

organizations. 

New Business 

Models 

Since the 1970s, a variety of business 

social models have emerged that mix 

for-profit and not-for profit, private 

and public organizations, private 

industry and social entrepreneurial 

models. These models may include 

practices and concepts common to 

business, yet not-for-profit nutrition 

programs are now using them, too. 

Examples include partnerships of 

smaller programs to incorporate 

standards and service areas to appeal 

to health insurance companies, or 

not-for-profit nutrition programs 

that incorporate private for-profit 

businesses such as catering and cafes. 

To add value, local providers need to improve 

the quality of their meals and services to help 

older adults actively choose their services from 

the wider variety of competitive products. To 

provide the right services to the right people 

at the right time, providers must meet the 

demands of a larger, more diverse population, 

incorporate more social entrepreneurial 

efforts, enhance their business acumen, and

compete with private industry. 6 
Science, Technology 

and Media 

What other factors influence products 

and service diversity? Nutrition, health 

and food safety knowledge, behavioral 

science, health information targeted 

at professionals and consumers, 

and health literacy, to name a few. 

Changes in food, food technology, 

packaging, production and delivery 

mechanisms also influence product 

quality, safety and consumer 

satisfaction. Changes in computer 

technology, devices, software and 

interoperability also influence office 

operations, resource development, 

management and interactions with 

health care organizations, food 

assistance or other social services 

and service delivery. Media—whether 

print newspapers, radio and television, 

or social media such as YouTube, 

Facebook, Instagram or Twitter—affect 

consumers’ perceptions of services 

and products, as well. 

Nutrition Science 

The OAA requires that meals meet 

national nutrition standards, state and 

local food-service laws, be appealing, 

and if possible, meet special dietary 

needs of older adults. National 

nutrition standards include: 

• Dietary Guidelines for Americans7,

issued by the departments of

Health and Human Services and

Agriculture, which are based on

the most current science evidence

and updated every five years,

• Dietary Reference Intakes8,

published by the National

Academy of Sciences, and

• State, tribal and local foodservice laws that are based on

the model Food Code (2017),

published by the Food and Drug

Administration and periodically

modified to safeguard public

health and ensure food is safe and

unadulterated.

Evidence-based and evidenceinformed behavioral science, health 

information and health literacy shape 

health promotion/disease prevention 

programs (whether disease and 

medication management programs or 

caregiver support), nutrition education 

and individual, person-centered 

nutrition counseling. Improved food 

technology is transforming food 

products and delivery processes.9 

Computer technology is influencing all 

operations. And media can make or 

break a program. 

None of these factors are on as 

predictable a schedule as the 

nutrition and food safety science. As 

a result, nutrition programs need to 

incorporate considered changes as 

soon as economically possible and 

feasible. Organizations also need 

to respond quickly to advances 

in science, technology and media 

to ensure quality, sustainable 

programs. 

7 
Health care and 

Social Services 

According to the Centers for Medicare 

and Medicaid Services (CMS), health 

spending will grow from $3.6 trillion in 

2018 to $6.0 trillion in 2027, primarily 

due to the increase in the older 

population. Increases are expected 

in Medicare; Medicaid; out-of-pocket 

costs; prescription drugs; and hospital, 

physician and clinical services.10-12 

CMS has been experimenting 

with ways to support innovative 

approaches to improving quality, 

accessibility and affordability, while 

finding the best ways to use innovative 

technology to support patientcentered care. The CMS Innovation 

Center is focused on new payment 

and service delivery models, including 

quality and effectiveness. These 

innovation programs may affect 

local delivery systems and the 

partnership opportunities available 

to local programs. 

Public health affects community health 

care. The Community Guide explores 

what works to promote health for 

communities, emphasizing integrated 

community efforts for all ages (The 

Guide to Community Preventive 

Services. 2019). These efforts are 

in part funded by the Department 

of Health and Human Services, 

Agency for Health care Research and 

Quality, and offer opportunities for 

integrating evidence-informed service 

approaches. 

Social determinants of health (SDOHs) 

are defined as conditions in the 

environments in which people live, 

learn, work, play, worship, and age 

that affect a wide range of health, 

functioning, and quality-of-life 

outcomes and risks. Factors like 

food insecurity, economic instability, 

housing transportation, public safety, 

social cohesion, access to health care, 

language and literacy and access to 

emerging mass media are examples 

of these SDOHs.14 To better address 

SDOH, the social service systems 

and health care and public health 

systems are attempting to better 

integrate. For example, Medicare 

spends more on socially isolated older 

adults; being socially connected helps 

people age better.15 A purpose of the 

OAA NP is to promote socialization 

for both congregate and homedelivered program participants and to 

coordinate with the HCBS under OAA 

Title III-B to address some of these 

essential SDOH. OAA Title-III B funds 

programs providing in-home and 

community-based 

long-term care services, including 

supportive services such as 

transportation, information & 

assistance, outreach, case 

management, homemaker or chore 

services, legal 

service, and adult day centers. 

To add value, senior nutrition 

programs need to better integrate 

the health, public health and social 

service aspects of the program, 

integrating with health care and 

collaborating with other agencies 

that are addressing aspects of 

SDOH. This might mean the provision 

of meals after hospital discharge; 

referrals from clinics and physicians 

for congregate or home-delivered 

services; provision of culturally 

appropriate congregate and homedelivered meals for racial/ethnic 

minorities; collaboration with food 

assistance programs funded by the 

U.S. Department of Agriculture; 

collaboration with transportation 

services to bring people to a senior 

center; ensuring access to volunteer 

activities, enhancing civic engagement; 

referrals for heating assistance; 

enhancement of friendly visiting 

through volunteer programs; and 

partnering with the public health 

department to ensure flu vaccinations 

or referrals for appropriate oral health 

care. All of these activities address 

aspects of SDOH and ways to help 

older adults remain at home, and in 

the community. 

Collaborating 

with Other 

Agencies 

Health 

Public 

Health 

Social 

Service 

Health 

Care 

8 
Long-Term Services 

and Supports (LTSS) 

Systems change. The OAA ushered 

in the development of HCBS such 

as senior centers, congregate and 

home-delivered meals, transportation, 

home-modification, chore support, 

case management, prevention of elder 

abuse, and caregiver support, long 

before the concept of LTSS. The U.S. 

does not have a consistent state-bystate, formal LTSS system, but does 

have a variable system including 

private- and public-funded community 

and facility-based services. 

LTSS include a range of medical 

and personal care assistance to 

help people of any age function 

more easily in daily life. These 

services can be provided informally 

by family members or formally by 

paid providers. Meals in congregate 

sites and home-delivered meals are 

essential components of this system. 

Congregate meals provide the 

foundation service connecting 

people with health promotion/ 

disease prevention services, social 

opportunities and community services. 

Home-delivered meals bridge health 

care and community care. Although 

many local nutrition programs 

may not consider themselves part 

of a broader system, the LTSS will 

increasingly influence the provision of 

services, quality and funding. 

Over the past 20 years, care has 

shifted from facility-based services 

to HCBS. This shift is due to many 

factors such as personal and family 

preference, the Supreme Court’s 

Olmstead decision, and the high cost 

of institutional care. Institutional care 

costs exceed HCBS service costs.16 

A 2016 study based on the 2004 

National Long-Term Care Survey 

(NLTCS) found a modest association 

between the use of paid HCBS and 

the reduced use of long-stay nursing 

home care among older adults 

aged 65 and older. Although the 

amount of nursing home reduction 

was not enough to offset the HCBS 

costs, older adults and their families 

overwhelmingly prefer HCBS and 

many states are promoting HCBS in 

place of nursing home care.17 Studies 

have also found that state-funded 

HCBS programs that are not Medicaidfunded do help low-income adults 

with care needs to live at home.18 

In addition, states that invest more 

in delivering meals to older adults’ 

homes have lower rates of “low-care” 

seniors (defined as residents who 

have the functional capacity to live in a 

less care-intensive environment) living 

in nursing homes, after adjusting for 

several other factors. For every $25 

per year per older adult that states 

spend on home-delivered meals, they 

reduce their percentage of low-care 

nursing home residents compared to 

the national average by 1 percentage 

point.19 

Although LTSS relies on HCBS services 

provided by a variety of private and 

public sources, these services have 

not kept pace with increasing need. 

Funding for the OAA NP has remained 

relatively flat20; there is a shortage 

of home health workers; assisted 

living and residential care facilities for 

those who can pay remain limited; 

and the nursing home population 

continues to decline. All these factors 

place increasing pressure on family 

caregivers and publicly funded 

programs such as the OAA NP.21 

A recent analysis of the National 

Health and Aging Trends Study found 

that two-thirds of older Medicare 

beneficiaries living in the community 

rely on some level of LTSS, but many 

of these beneficiaries had an unmet 

need for LTSS, especially those who 

were lower-income and eligible for 

both Medicare and Medicaid.22 

LTSS is financed by both public and 

private funding with the majority 

covered by public sources such as 

Medicaid. Historically within the 

Medicaid program, there has been 

a bias toward institutional care. 

However, in the past two decades 

there has been significant progress 

toward rebalancing institutional care 

in favor of HCBS. Nutrition services 

(primarily as home-delivered meals 

but also nutrition counseling, nutrition 

support and nutrition supplements) 

are a part of many Medicaid HCBS 

targeted to older adults. As the 

multiple efforts funded through CMS 

to identify, develop and evaluate 

HCBS quality measures22 come into 

common practice, senior nutrition 

programs that are highly variable may 

be affected.

As the demand for HCBS increases 

and there are limited LTSS options 

outside of Medicaid and little 

financial support for most older 

adults needing services, the 

reform of LTSS policy and financial 

incentives to care organizations, 

etc. will need to be considered to 

support functional independence 

and enhance quality of life for most 

older Americans. To keep being of 

value in a changing, competitive 

system, senior nutrition programs 

will need to ensure that they 

provide quality, effective, efficient 

and sustainable services within this 

emerging system. 

9 
Senior nutrition programs must provide quality 

and sustainable nutrition services if they are to 

survive in a rapidly changing environment. It is 

urgent to change so they can: 

• Meet the exploding demographics of a

diverse older population,

• Address the compelling competition from

other private and public service providers,

• Adjust to the changes in science, health,

technology and media,

• Better integrate within health and

social service systems, and

• Ensure they are an essential

component of the emerging

LTSS system.

Conclusion 

10 
References 

14. United States Department of Health and Human Services,

2010. Office of Disease Prevention and Health Promotion. 

Healthy People 2020. Social Determinants of Health. Available 

at: https://www.healthypeople.gov/2020/topics-objectives/ 

topic/social-determinants-of-health. Retrieved February 26, 

2019. 

15. Flowers L, Houser A, Nobel-Miller C, Shaw J, Bhattacharya

1. Administration for Community Living, 2019. Historical

Evolution of Programs for Older Americans. Available

at: https://acl.gov/about-acl/authorizing-statutes/olderamericans-act. Retrieved February 26, 2019.

2. Administration for Community Living, 2018. 2017 Profile

of Older Americans. Available at: https://acl.gov/sites/

default/files/Aging%20and%20Disability%20in%20

America/2017OlderAmericansProfile.pdf. Retrieved February J, Shoemaker L, Farid M, 2017. Medicare Spends More on

26, 2019. Socially Isolated Older Adults. AARP Public Policy Institute.

3. United States Census Bureau, 2018. The Population 65 Years Available at: https://www.aarp.org/content/dam/aarp/

and Older in the United States: 2016. American Community ppi/2017/10/medicare-spends-more-on-socially-isolatedSurvey Reports. Available at: https://www.census.gov/content/ older-adults.pdf. Retrieved February 26, 2019.

dam/Census/library/publications/2018/acs/ACS-38.pdf. 16. 1Reaves E.L., Musumeci M, 2015. Medicaid and Long-Term

Retrieved April 8, 2019. Services and Supports: A Primer. Kaiser Family Foundation.

4. Federal Interagency Forum on Aging-Related Statistics, 2016. Available at: https://www.kff.org/medicaid/report/medicaidOlder Americans: Key Indicators of Well-Being. Available at: and-long-term-services-and-supports-a-primer/. Retrieved

https://agingstats.gov/docs/LatestReport/Older-Americans- February 26, 2019. 

2016-Key-Indicators-of-WellBeing.pdf. Retrieved February 26, 17. Spillman B, 2016. Does Home Care Prevent or Defer Nursing

2019. Home Use? Office of the Assistant Secretary for Planning

5. United States Census Bureau, 2018. Americans with and Evaluation. Department of Health and Human Services.

Disabilities: 2014. Current Population Reports. Available at: Available at: https://aspe.hhs.gov/basic-report/does-homehttps://www.census.gov/library/publications/2018/demo/p70- care-prevent-or-defer-nursing-home-use. Retrieved February

152.html. Retrieved February 26, 2019. 26, 2019. 

6. Silver Sneakers, 2019. Available at: https://www. 18. O’Brien, E. Fox-Grage, W. Ujvari, K, 2019. Home and

silversneakers.com/. Retrieved February 26, 2019. Community-Based Services Beyond Medicaid: How State7. United States Department of Health and Human Services, funded Programs Help Low-Income Adults with Care Needs

2015. Office of Disease Prevention and Health Promotion. Live at Home. Available at: https://www.aarp.org/content/

Dietary Guidelines for Americans: 2015-2020. Available dam/aarp/ppi/2019/02/home-and-community-based-servicesat: https://health.gov/dietaryguidelines/2015/guidelines/. beyond-medicaid.pdf. Retrieved February 26, 2019.

Retrieved February 26, 2019. 19. Thomas K, Mor V, 2012. The Relationship between Older

8. Dietary Reference Intakes: The essential Guide to Nutrient Americans Act Title III State Expenditures & Prevalence

Intakes, 2006. Institute of Medicine. Available at: https:// of Low-Care Nursing Home Residents. Health Services

www.nap.edu/catalog/11537/dietary-reference-intakes-the- Research. 12.3.12. Available at: http://onlinelibrary.wiley.com/

essential-guide-to-nutrient-requirements. Retrieved February doi/10.1111/1475-6773.12015/abstract

26, 2019. 20. Napili A, Colello K, 2013. Funding for the Older Americans Act

9. Food and Drug Administration. 2017. Food Code 2017. and Other Aging Service Programs. RL33880. Congressional

Available at: https://www.fda.gov/Food/GuidanceRegulation/ Research Service. Available at: www.crs.gov Retrieved

RetailFoodProtection/FoodCode/ucm595139.htm. Retrieved February 26, 2019.

February 26, 2019. 21. Houser, A. Fox-Grage, W. Ujvari, K. 2018. Across the States:

10. Centers for Medicare and Medicaid Services, 2019. Office Profiles of Long-Term Services and Supports. AARP Public

of the Actuary. National Health Expenditure Projections. Policy Institute. Available at: https://www.aarp.org/content/

Available at: https://www.cms.gov/Research-Statistics- dam/aarp/ppi/2018/08/across-the-states-profiles-of-longData-and-Systems/Statistics-Trends-and-Reports/ term-services-and-supports-full-report.pdf. Retrieved

NationalHealthExpendData/NationalHealthAccountsProjected. February 26, 2019. 

html. Retrieved February 26, 2019. 22. Willink A, Kasper J, Skeha M.E., Wolff J.L., Mulchany J., Davis L,

11. Centers for Medicare and Medicaid Services, 2019. Innovation 2019. Are Older Americans Getting the Long-Term Services

Center. Available at: https://innovation.cms.gov/initiatives/ and Supports They Need? Commonwealth Fund. Available

Medicare-Health-Care-Quality/. Retrieved February 26, 2019. at: https://www.commonwealthfund.org/sites/default/

12. Centers for Medicare and Medicaid Services, 2019. The CMS files/2019-01/Willink_are_older_americans_getting_LTSS_

Innovation Center. Available at: https://innovation.cms.gov/ . ib.pdf. Retrieved February 26, 2019. Older Americans Act.

Retrieved February 26, 2019. 2016. Available at: https://legcounsel.house.gov/Comps/

13. The Community Guide, 2019. Available at: https://www. Older%20Americans%20Act%20Of%201965.pdf. Retrieved

thecommunityguide.org/. Retrieved February 26, 2019. February 26, 2019. 

11