Older Americans Act: Nutrition Services Program

Older Americans Act: Nutrition Services
Program
Carol O’Shaughnessy
Domestic Social Policy Division
Summary
The elderly nutrition services program, authorized under Title III of the Older
Americans Act, provides grants to state agencies on aging to support congregate and
home-delivered meals for people age 60 and older. The program is designed to address
problems of dietary inadequacy and social isolation among older people. It is the largest
Older Americans Act program, funded at $714.6 million in FY2006, accounting for 40%
of the Act’s total funding. In FY2005, 238 million meals were served to about 2.8
million people; 58% were served to frail older people living at home, and 42% were
served in congregate settings. The number of home-delivered meals served has outpaced
congregate meals, growing by almost 36% from FY1990 to FY2005; the number of
congregate meals served declined by 30%. The faster growth in home-delivered meals
is partially due to relatively higher growth in federal funding for home-delivered meals
over the period FY1990-FY2004, as well as state decisions to focus funds on frail older
people living at home.
Funding for the nutrition program has fluctuated slightly from FY2002-FY2006,
and actually declined by 0.2% over the entire period; the number of meals declined by
almost 5% FY2002-FY2005. Congress approved the Older Americans Act Amendments
of 2006 (P.L. 109-365) extending the act’s authorization of appropriations through
FY2011. This report will be updated periodically.
The elderly nutrition services program, authorized under Title III of the Older
Americans Act¹, provides grants to state agencies on aging to support congregate and
home-delivered meals to people age 60 and older. The program is the largest component
of the Act, accounting for 40% of the Act’s total FY2006 funding ($714.6 million out of
$1.783 billion). The program is designed to address problems of dietary inadequacy and
social isolation among older persons. It evolved from demonstration projects first funded
in 1968. In 1972, Congress authorized the program as a separate title of the Act and, in

¹ 42 U.S.C. 3021 et. Seq. Regulations are at 45 C.F.R. 1321.1.

1978, incorporated it into Title III. In 2006, Congress enacted P.L. 109-365 which
reauthorized all programs under the Act through FY2011.²
Purpose. P.L. 109-365 added a new purpose statement for the nutrition services
program emphasizing both its nutritional and socialization aspects and its importance in
promoting the health of older people. The purposes of the program as stipulated in the law
are: to reduce hunger and food insecurity and promote socialization of older individuals;
and to promote the health and well-being of older individuals by assisting them to access
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.
Administration and Funding. The Administration on Aging (AoA) in the
Department of Health and Human Services (DHHS) awards funds for congregate nutrition
services, home-delivered nutrition services, and nutrition services incentive grants to state
agencies on aging. State agencies award nutrition services funds to 655 area agencies on
aging that administer the program in their respective planning and service areas.
Congregate meals programs operate in a variety of sites, such as senior centers,
community centers, schools, and adult day care centers. Nutrition service providers offer
a variety of social services at meal sites, such as nutrition education and screening,
shopping assistance, and health promotion activities.
Funds for congregate and home-delivered nutrition services are allotted to states
according to a formula based on each state’s relative share of the population aged 60 and
over; however, the law stipulates that no state receive less than it received in FY2006.
P.L. 109-365 gradually eliminated a guaranteed growth factor in the formula, beginning
in FY2008.³ States are required to provide a matching share of 15% in order to receive
funds for congregate and home-delivered nutrition programs.
Funds for nutrition services incentive grants are allotted to states based on each
state’s share of total meals served by the nutrition services program in all states during
the prior year. These funds can be used to supplement funds for congregate and home-
delivered meals or to cover the costs of food commodities provided by the U.S.
Department of Agriculture (USDA). States may choose to receive their share of the
nutrition services incentive funds in cash or in commodities. However, most states choose
to receive their share of funds in cash, rather than commodities.⁴ There is no matching
requirement for these funds. (Through FY2002, funds for nutrition services incentive
grants were awarded to states by USDA; in FY2003, Congress transferred the program
to AoA.)
In FY2006, of the $714.6 million for the program, $385.1 million was for congregate
nutrition (54%); $181.8 million for home-delivered nutrition (25%); and $147.7 million

² For further information, see CRS Report RL31336, The Older Americans Act: Programs,
Funding, and 2006 Reauthorization (P.L. 109-365), by Carol O’Shaughnessy and Angela Napili.
³ For further information, see CRS Report RS22549, Older Americans Act: Funding Formulas
by Kirsten Colello.
⁴ In FY2006, 10 states chose to receive a portion of their share of the nutrition services incentive
funds in commodities: Connecticut, Delaware, Idaho, Iowa, Kansas, Massachusetts, Missouri,
Montana, Nevada, and Oklahoma.

for nutrition services incentive grants (21%) (Table 1). Funding for nutrition services
represents nearly 58% of FY2006 funding for Title III, which also funds a wide array of
social services, family caregiver support activities, and disease prevention and health
promotion services for older people.
In recent years, total funding for the nutrition program has fluctuated slightly, but
actually declined by 0.2% FY2002-FY2006. Funding for the congregate nutrition decreased
by 1.3%; the home-delivered nutrition program increased by 3%; and the nutrition services
incentive grant program decreased by 1.3%. This reduction has affected the number of
meals served, which declined by almost 5% FY2002-FY2005 (see Table 2).
Table 1. Older Americans Act Nutrition Services Funding,
FY1980 — FY2006
($ in millions)
Nutrition
servicesTotal
Fiscal Congregate Home-Delivered incent ive^a nut ri t i on
year meals meals grants services
1980 $270.0 $50.0 $74.2 $394.2
1985 $336.0 $67.9 $127.0 $530.9
1990 $351.9 $79.0 $143.5 $574.4
1995 $375.8 $94.1 $150.0 $619.9
1996 $364.5 $105.3 $150.0 $619.9
1997 $364.5 $105.3 $140.0 $609.9
1998 $374.4 $112.0 $140.0 $626.4
1999 $374.3 $112.0 $140.0 $626.3
2000 $374.3 $147.0 $140.0 $661.3
2001 $378.4 $152.0 $149.7 $680.1
2002 $390.0 $176.5 $149.7 $716.2
2003 $384.6 $181.0 $148.7 $714.3
2004 $386.4 $179.9 $148.2 $714.5
2005 $387.3 $182.8 $148.6 $718.7
2006 $385.1 $181.8 $147.7 $714.6
^Source:^A^o^A^/^{DHHS an}^d^USDA^ap^p^r^o^p^r^iatioⁿ^s^legⁱ^slatioⁿ^.
^{a. Fo}^r^m^er^ly^USDA^cash^o^r^cash^-ⁱⁿ^-^lieu^o^f^co^m^m^o^d^{ities p}^r^o^g^r^a^m^.
Although states receive separate allotments for congregate and home-delivered
nutrition services, and for supportive services, they are allowed to transfer allotted funds
among these three service categories (up to 40% of funds between congregate and home-
delivered nutrition services allotments with waivers for higher amounts if approved by
the Assistant Secretary for Aging; and up to 30% among supportive services and
congregate and home-delivered nutrition services allotments). (Nutrition services

incentive grants are exempt from the transfer provisions.) In recent years, state transfer
of funds has resulted in a decrease of funds available for congregate nutrition services. In
FY2004, states transferred $67.5 million out of their congregate nutrition services
allotments to either the home-delivered nutrition or supportive services allotments. These
funding transfers resulted in a decrease of 17.5% in funds that were originally allotted to
states for the congregate program. Funds available for home-delivered meals increased
by 17.6% as a result of funding transfers. Funds for the supportive services program
increased by 10%.⁵ State initiatives to respond to the demand for home-based services by
frail homebound older persons is an important factor in their decisions to transfer funds.
Eligibility and Service Delivery Requirements. People aged 60 or older and
their spouses of any age may participate. The following groups may also receive meals:
persons under age 60 with disabilities who reside in housing facilities occupied primarily
by the elderly where congregate meals are served; persons with disabilities who reside at
home with, and accompany, older persons to meals; and volunteers who provide services
during the meal hours. Services must be targeted at persons with the greatest social and
economic need, with particular attention to low income minority older persons, older
persons residing in rural areas and those at risk for institutionalization. Means tests for
program participation are prohibited, but older persons are encouraged to contribute
towards the costs of meals. They may not be denied services for failure to contribute.
Congregate and home-delivered nutrition services projects are required to offer at
least one meal per day, five or more days per week (except in rural areas where less
frequency is allowed). Meals provided must comply with the Dietary Guidelines for
Americans published by the Secretary of HHS and the Secretary of Agriculture. Projects
must provide meals that meet certain dietary requirements based on the number of meals
served by the project each day. Projects that serve one meal per day must provide to each
participant a minimum of one-third of the daily recommended dietary reference intakes
(DRIs) established by the Food and Nutrition Board of the Institute of Medicine. Projects
that serve two meals per day must provide a minimum of two-thirds of the DRIs, and
those that serve three meals per day must provide 100% of the DRIs. Providers must
provide meals that comply with state or local laws regarding safe and sanitary handling
of food, equipment, and supplies that are used to store, prepare and deliver meals, and
must carry out meal programs using the advice of dietitians and meal participants. The
law requires projects to provide for nutrition screening and education to participants, and
where appropriate, nutrition assessment and counseling. Providers are encouraged to
make arrangements with schools and other facilities serving meals to children in order to
promote intergenerational meals programs.
P.L. 109-365 noted that while diet is the preferred source of nutrition, evidence
suggests that the use of a single daily multivitamin-mineral supplement may be an
effective way to address poor nutrition among older people. Also, it noted that Title III
nutrition service providers should consider whether congregate and home-delivered
participants would benefit from a multivitamin-mineral supplement that is in compliance
with government quality standards and that provides at least two-thirds of essential

⁵ Administration on Aging, unpublished data.

vitamins and minerals at 100% of daily value levels as determined by the Commissioner
of Food and Drugs.⁶
Meals Served. In FY2005, 238 million meals were provided to older people.
(Table 2). In FY1990, home-delivered meals represented 42% of total meals served, but
by FY2005, the share had climbed to 58% of total meals. From 1990 to 2005, the number
of home-delivered meals served grew by almost 36%, while the number of congregate
meals served actually declined by 30%. A number of reasons account for this, including
the trend by states to transfer funds from their congregate services allotments to home-
delivered services; greater growth in federal funding for home-delivered services relative
to the congregate nutrition program funds; state initiatives to expand home care services
for frail older persons; and successful leveraging of non-federal funds for home delivered
services.
Table 2. Older Americans Act Nutrition Services,
Number of Meals Served, FY1990 — FY2005
(in millions)
Home-delivered
FiscalCongregateHome-deliveredmeals as a percent
yearmealsmealsTotal mealsof total meals

1990 142.4 101.8 244.2 42%

1995 123.4 119.0 242.4 49%

1996 118.6 119.0 237.6 52%

1997 116.5 123.5 240.0 51%

1998114.0130.0 244.053%

1999 112.8 134.6 247.4 54%

2000 115.9 143.5 259.4 55%

2001 112.1 143.5 255.6 56%

2002 108.3 142.0 250.3 57%

2003 105.7 142.6 248.3 57%

2004 105.6 143.1 248.7 58%

2005 99.6 138.2 237.8 58%

Source: Administration on Aging.
AoA data show that for FY2004, the U.S. average cost of congregate meals was
$5.81, ranging from $14.70 in Alaska to $1.60 in Puerto Rico. The average cost of home-
delivered meals was $4.68, ranging from $11.28 in Minnesota to $1.32 in Puerto Rico.⁷
Program Participation. AoA survey data show that in 2004, 62% of congregate
nutrition survey respondents were age 75 and older; 52% lived alone. Over one-quarter

⁶ Section 318 of P.L. 109-365.
⁷ Administration on Aging, unpublished data via personal communication. October 24, 2006.

had annual income of $10,000 or less; 56% reported that the congregate meals program
provided one-half or more of their daily food intake. Furthermore, many congregate
nutrition recipients said they participated in other activities at the meal site: 52% said they
took part in physical fitness activities when available; 59% used health screening services
at the nutrition sites; and 57% said that their social activities increased since they started
receiving congregate meals.⁸
This 2004 survey found that almost three-quarters of home-delivered respondents
were age 75 and over; 61% lived alone; 46% had annual income of $10,000 or less; 66%
said that the home-delivered meals program provided at least half their daily food intake.
According to the survey, home-delivered meals recipients are particularly impaired and
are at risk for institutionalization. Almost 40% of recipients reported needing assistance
with one or more activities of daily living (ADLs, such as bathing, dressing, eating, and
using the toilet). Almost 30% needed assistance with three or more ADLs. In addition,
69% reported needing assistance with one or more IADLs (instrumental activities of daily
living, such as shopping, telephoning, housework, and getting around inside the home).⁹
Program Evaluation. The last major national evaluation of the nutrition program
was completed in 1996. It showed that, compared to the total elderly population, nutrition
program participants were older and more likely to be poor, to live alone, and to be
members of minority groups. Almost half of home-delivered meal recipients and more
than one-third of congregate meal recipients had income below the federal poverty level,
compared to about 15% of the total U.S. population aged 60 and over (at the time of the
evaluation). Recipients were also more likely to have health and functional limitations
that place them at nutritional risk. The report found the program plays an important role
in participants’ overall nutrition and that meals consumed by participants are their primary
source of daily nutrients. The evaluation also found that the program leverages a fairly
significant amount of non-federal dollars: for every federal dollar spent, the program
leveraged (at that time) on average $1.70 for congregate meals, and $3.35 for home-
delivered meals from a variety of sources, including state, local, and private funds as well¹⁰
as participant contributions toward the cost of meals.
The 2006 reauthorization legislation stipulated that the Institute of Medicine (IOM)
conduct an evidence-based evaluation of the program. The evaluation is to include: (1)
an evaluation of the effect of nutrition projects on the health and nutrition status of
participants, prevention of hunger and food insecurity, and ability of participants to
remain living independently; (2) a cost-benefit analysis of nutrition projects, including
their potential to affect Medicaid costs; and (3) recommendations on how nutrition
projects may be modified to improve outcomes, and the nutritional quality of meals.

⁸ Administration on Aging, Highlights from the Pilot Study: Second National Survey of Older
Americans Act Title III Service Recipients (Additional Information site), at
[http://aoa.gov/about/results/Final-Highlights-2nd-natioinal-survey.pdf][sic], visited Feb. 7, 2007.
⁹ Ibid.
¹⁰ U.S. Department of Health and Human Services, Office of the Assistant Secretary for Aging,
Serving Elders at Risk: The Older Americans Act Nutrition Programs, National Evaluation of the
Elderly Nutrition Program, 1993-1995, June 1996. Available at
[http://www.aoa.dhhs.gov/prof/aoaprog/nutrition/program_eval/eval_report.asp], visited Feb. 5,

2007.