• The Health and Aging Chartbook, 1999 provides important data on the population, health status and health care access and utilization from national data sources. The Chartbook supports the importance of nutrition and health promotion services and addresses many risk factors that contribute to nutritional concerns.
  

• The Institute of Medicine (IOM) report, The Role of Nutrition in Maintaining Health in the Nation's Elderly: Evaluating Coverage of Nutrition Services for the Medicare Population (1), examined the nutrition services that older adults receive along the continuum of care, the role of nutrition therapy in the management of diseases, and the expertise neededto provide appropriate nutrition therapy. The following recommendations pertain to home and community based care:
  
  Recommendation 1: Nutrition therapy, upon referral by a physician, be a reimbursable benefit for Medicare beneficiaries. This is based on the high prevalence of individuals with conditions for which nutrition therapy was found to be of benefit. Eighty-six percent of Medicare beneficiaries over 65 years of age have diabetes, hypertension, and/or dyslipidemia alone.

  Recommendation 2: Registered dietitians be directly reimbursed as providers of nutrition therapy. In addition, a registered dietitian should be involved in educating other members of the health care team regarding nutrition interventions and practical aspects of nutrition. This is of particular importance in the areas of home care, ambulatory care, and care given in skilled nursing and long-term care facilities, where basic nutrition advice or reinforcement of nutrition plans will likely be provided by other health professionals.

  Recommendation 4: The Centers for Medicare and Medicaid Services (formally the Health Care Financing Administration) as well as accreditation and licensing groups should reevaluate existing reimbursement systems and regulations for nutrition services along the continuum of care to determine the adequacy of care delineated by such standards. The committee found numerous inconsistencies with regard to regulations and reimbursement systems related to the provision of nutrition services across the continuum of care.

  Recommendation 4.2: The availability of nutrition services be improved in the home health care setting. Both types of nutrition services are needed in this setting: nutrition education and nutrition therapy. A registered dietitian should be available to serve as a consultant to health professionals providing basic nutrition education and follow-up, as well as to provide nutrition therapy, when indicated, directly to Medicare beneficiaries being cared for in a home setting.

  In summary, the IOM committee found that expanded coverage for nutrition therapy would be economically beneficial to participants and Medicare. Nutrition therapy in the context of multidisciplinary care has potential short term cost savings for populations with hypertension, dyslipidemia, and diabetes. In addition to decreased mortality and morbidity, nutrition therapy can have impact quality of life in less tangible ways that cannot be measured quantitatively. Meals provide the social context for many experiences across the course of life, including holidays. Because food is central to an individual's social attachment and role, dietary problems that require significant behavior change or interfere with long-established social relationships can have a significant impact on well-being independent of their impact on mortality or morbidity. Nutrition therapy translates the care plan into daily life skills such as grocery shopping, food preparation, and menu selection. Nutrition therapy that assists homebound individuals to participate in family meals may have a greater impact on subjective well being than many other interventions that have an equal impact on physical health (1).

• Healthy People 2010 is a set of disease prevention and health promotion objectives
  for the Nation to achieve during the first decade of the new century. The national health objectives are designed to identify the most significant preventable threats to health and to establish national goals to reduce these threats. Healthy People 2010 has two goals:
  1) Increase quality and years of healthy life, and
  2) Eliminate health disparities.
  
  

  Focus Areas of Healthy People 2010
  1. Access to Quality Health Services	15. Injury and Violence Prevention
  2. Arthritis, Osteoporosis, & Chronic Back Conditions	16. Maternal, Infant, and Child Health
  3. Cancer	17. Medical Product Safety
  4. Chronic Kidney Disease	18. Mental Health and Mental Disorders
  5. Diabetes	19. Nutrition and Overweight
  6. Disability and Secondary Conditions	20. Occupational Safety and Health
  7. Educational & Community-Based Programs	21. Oral Health
  8. Environmental Health	22. Physical Activity and Fitness
  9. Family Planning	23. Public Health Infrastructure
  10. Food Safety	24. Respiratory Diseases
  11. Health Communication	25. Sexually Transmitted Diseases
  12. Heart Disease and Stroke	26. Substance Abuse
  13. HIV	27. Tobacco Use
  14. Immunization and Infectious Diseases	28. Vision and Hearing

  
  
  

  Leading Health Indicators of Healthy People 2010
  1. Physical Activity	6. Mental Health
  2. Overweight and Obesity	7. Injury and Violence
  3. Tobacco Use	8. Environmental Quality
  4. Substance Abuse	9. Immunization
  5. Responsible Sexual Behavior	10. Access to Health Care

  Each health indicatorhas one or more objectives in Healthy People 2010 associated with it. Of the 467 objectives in Healthy People 2010, 76 specifically related to older adults can be found at: http://www.healthypeople.gov/hpscripts/KeywordResult.asp?n270=270&Submit=Submit
  

  Healthy People 2010 can be used as a framework to guide nutrition and health promotion activities. By using the national objectives, OAA Nutrition Programs can develop appropriate nutrition and health promotion programs to help improve health and prevent disease in older adults. OAA Nutrition Programs are encouraged to integrate Healthy People 2010 into their current community programs, special events and publications.

• The USDA Food and Nutrition Service (FNS) developed Promoting Healthy Eating: An Investment in the Future—A Report to Congress. It focused on issues that require congressional action and concludes that the Nation must enhance the investment in nutrition education in order to promote food security, avoid preventable deaths, eliminate nutrition-related health disparities, and address the obesity epidemic. The needed changes can only be achieved through a sustained, integrated, long-term nutrition education effort.
  

B. HOME and COMMUNITY BASED CARE

Home and community-based care (HCBC) refers to a variety of services and settings available to older and disabled people living in their own homes or in residential care settings. Basic community services available through an HCBC system include:

• Information and assistance
• Personal care, homemaker and chore services
• Congregate and home-delivered meals
• Adult day care
• Rehabilitative care
• Transportation assistance
• Home health care
• Caregivers' support, assistance and respite care
• Housing options, including assisted-living arrangements
• Consumer protection and advocacy.

Frequently older and disabled persons often have multiple and changing health and social service needs. Therefore, effective HCBC programs facilitate services at a consolidated location for comprehensive assessment, care planning or case management, pre-nursing home admission screening, and/or referrals to medical care providers.

The network of SUAs and AAAs are in position to provide a full range of HCBC services and administrative systems to meet the needs of the older adults and their caregivers. Many AAAs, through state allocations of Older Americans Act funds, state and local revenues, Social Services Block Grant funds, and other resources, fund local service providers to deliver basic HCBC services.

A caregiver is a person who provides assistance to someone else who experiences limitations in activities of daily living (ADLs) and/or instrumental activities of daily living (IADLs). Informal and/or family caregivers are unpaid individuals such as family members, friends, neighbors and volunteers who provide help or arrange for help. They may be primary or secondary caregivers, full time or part time, and may or may not live with the person recipient. Caregivers may assist with household chores, finances, or with personal or medical needs (5). Family caregivers provide ongoing assistance to allow loved ones to remain in the comfort of their own home and community. Caregivers require respite and such assistance should be available. Respite care services provide temporary relief to family caregivers and include in-home respite, adult day care, and overnight respite (6).

The 2000 amendments to the OAA established the National Family Caregiver Support Program (NFCSP). Funded at $125 million in fiscal year 2001, approximately $113 million was allocated to states to work in partnership with AAAs and local providers. The NFCSP is a significant addition to the OAA because it enables the aging network to develop caregiver support programs. It provides an opportunity for the aging network to develop services and programs to respond to the needs of our Nation’s caregivers. The basic services for family caregivers are:

1. Information to caregivers about available services,
2. Assistance to caregivers in gaining access to supportive services,
3. Individual counseling, organization of support groups, and caregiver training to caregivers to assist the caregivers in making decisions and solving problems relating to their caregiving roles,
4. Respite care to enable caregivers to be temporarily relieved from their caregiving responsibilities, and
5. Supplemental services, on a limited basis, to complement the care provided by caregivers.
   

The following link to AoA provides helpful information, resources and tools on implementing caregiver services: http://www.aoa.gov/carenetwork/

A number of states that provide innovative services and programs for caregivers are described in the following reports:

Survey of Fifteen States' Caregiver Support Programs: http://www.caregiver.org/issues/execsum9910.html

Helping the Helpers: State Supported Services for Family Caregivers: http://research.aarp.org/health/2000_07_help.pdf

Building Multifaceted Systems for Caregivers: A Variety of State Efforts http://www.aoa.dhhs.gov/carenetwork/NFCSPConf01-Papers/state-efforts.html

SEC 321
PART B-SUPPORTIVE SERVICES AND SENIOR CENTERS PROGRAM AUTHORIZED
(5) services designed to assist older individuals in avoiding institutionalization and to assist individuals in long-term care institutions who are able to return to their communities, including--
(A) client assessment, case management services, and development and coordination of community services;
(B) supportive activities to meet the special needs of caregivers, including caretakers who provide in-home services to frail older individuals; and
(C) in-home services and other community services, including home health, homemaker, shopping, escort, reader, and letter writing services, to assist older individuals to live independently in a home environment.

Part E--National Family Caregiver Support Program
Sections 371, 372, 373, and 374 of the Older Americans Act of 1965, as Amended (P.L. 106-501), Grants for State and Community Programs on Aging

SECTION 373 PROGRAM AUTHORIZED
(a) IN GENERAL- The Assistant Secretary shall carry out a program for making grants to States with State plans approved under section 307, to pay for the Federal share of the cost of carrying out State programs, to enable area agencies on aging, or entities that such area agencies on aging contract with, to provide multifaceted systems of support services--

(1) for family caregivers; and
(2) for grandparents or older individuals who are relative caregivers.

(b) SUPPORT SERVICES- The services provided, in a State program under subsection (a), by an area agency on aging, or entity that such agency has
contracted with, shall include--

(1) information to caregivers about available services;
(2) assistance to caregivers in gaining access to the services;
(3) individual counseling, organization of support groups, and caregiver training to caregivers to assist the caregivers in making decisions and solving problems relating to their caregiving roles;
(4) respite care to enable caregivers to be temporarily relieved from their caregiving responsibilities; and
(5) supplemental services, on a limited basis, to complement the care provided by caregivers.

(c) POPULATION SERVED; PRIORITY-

(1) POPULATION SERVED- Services under a State program under this subpart shall be provided to family caregivers, and grandparents and older individuals who are relative caregivers, and who--

(A) are described in paragraph (1) or (2) of subsection (a); and
(B) with regard to the services specified in paragraphs (4) and (5) of subsection (b), in the case of a caregiver described in paragraph (1), is
providing care to an older individual who meets the condition specified in subparagraph (A)(i) or (B) of section 102(28).

(2) PRIORITY- In providing services under this subpart, the State shall give priority for services to older individuals with greatest social and economic
need, (with particular attention to low-income older individuals) and older individuals providing care and support to persons with mental retardation and
related developmental disabilities (as defined in section 102 of the Developmental Disabilities Assistance and Bill of Rights Act (42 U.S.C. 6001))
(referred to in this subpart as `developmental disabilities').

(d) COORDINATION WITH SERVICE PROVIDERS- In carrying out this subpart, each area agency on aging shall coordinate the activities of the agency, or entity that such agency has contracted with, with the activities of other community agencies and voluntary organizations providing the types of services described in subsection (b).

C. NUTRITION SCREENING and ASSESSMENT

Nutrition screening is a first step in identifying individuals at nutritional risk or with malnutrition. Screening tools, such as the Nutrition Screening Initiative (NSI) and the "Mini Nutritional Assessment" (MNA) have been used in different settings to screen older adults for nutrition risk. The NSI Checklist was designed to increase older adults' awareness about nutrition and health. The Mini Nutrition Assessment (MNA®) was designed to identify older adults (>65 years) at risk of malnutrition. Both help differentiate among adequate nutritional status, malnutrition risk, and malnutrition.

Title III, Section 339 of the OAA requires that nutrition projects provided nutrition screening. The AoA as part of its reporting requirements in the State Performance Report requires that states report on nutrition risk status of individuals who receive home-delivered and congregate meals, nutrition counseling, and/or case management. The NSI Checklist, was initially developed as a public awareness tool. AoA does not require that the NSI Checklist be used verbatum. States can organize the questions in their own client assessment instruments or add to the 10 checklist questions. However, AoA requests that States report, through NAPIS, the 10 questions and the related score for consistency from state to state.

Under ideal circumstances when an older adult is identified as being at nutritional risk, it is recommended that a referral be made to a dietitian. A dietitian then conducts a nutrition assessment to obtain more specific information regarding the individual's anthropometric, biochemical, clinical, dietary, psychosocial, economic, functional, mental health, and oral health status. Nutrition screenings and/or assessments may be administered at a individual's home, congregate dining center, health fair, doctor's office, etc. Such information is necessary to develop a care plan that will best meet the needs of the individual and his/her situation. Care plans include interventions, expected outcomes, and monitoring strategies.

Although there are nutrition programs that refer to the dietitians they employ, many nutrition programs do not have dietitians and thus have to refer to a dietitian in their local communities. These referals may be made to dietitians in outpatient clinics, hospitals, health clinics, home health agencies or dietitians in private practice.

The National Evaluation of the Older Americans Nutrition Program 1993-95 (7) found that only 25% of Title III congregate dining sites offered nutrition screening and that a registered dietitian administered the screening at about half of those sites. The National Evaluation found 64% of congregate and 88% of homebound participants at moderate to high nutrition risk, using an approximation of the NSI Checklist. About 66% were either under- or overweight, placing them at increased risk for nutritional and health problems. Over 50% of participants usually ate alone and about 25% ate fewer than 3 meals per day. One in 3 had an illness/condition that required a special diet. Forty-one percent of the homebound clients could not prepare meals. About 25% of congregate participants and more than 75% of the homebound clients had difficulty doing everyday tasks (7).

Today, nutrition screening of congregate and homebound participants is routine at most OAA Nutrition Programs. The National Aging Program Information System (NAPIS) reporting requirements are being revised. Once the revision is complete, this section will be updated. It is anticipated that nutrition screening will be included in the revision.

Title III and Title VII State Program Reports Definitions

Questions and Answers About the National Aging Program Information System (State Performance Reports)

The AoA continues to develope and field-test a core set of performance measures for state and community OAA programs. Called the Performance Outcomes Measures Project (POMP), this project will help SUAs and AAAs address their own planning and reporting requirements, while assisting AoA to meet the accountability provisions of the Government Performance and Results Act (GPRA). POMP developed measures for 8 client-service domains. The nutritional risk performance measure can be used to determine whether a nutritional service, such as home delivered meals or congregate meals, helps to sustain or improve the nutritional status of clients over time. The Nutrition Performance Indicator and other performance indicators are available at: http://www.gpra.net/main.htm

SECTION 339 Nutrition
(2) ensure that the project ---
(J) provide for nutrition screening and, where appropriate, for nutrition education and counseling.

Utah
The State developed a screening system using the NSI DETERMINE Checklist as part of a complete process to identify needs and make appropriate referrals (link to this document).

Delaware

• At least once a year, all homebound clients will complete a nutrition screening checklist provided by the Delaware Division of Services for Aging and Adults with Physical Disabilities. Appropriate counseling, nutrition information and/or referrals will be offered to all high-risk clients. Clients designated as high-risk will be contacted within six months of the screening.
• All congregate clients will be offered the opportunity to complete a nutrition screening checklist provided by the Delaware Division of Services for Aging and Adults with Physical Disabilities (DSAAPD). At least once a year, clients will complete the checklist and be provided with appropriate counseling, information or other interventions. Those designated as high-risk will be contacted within six months of the nutrition screening.

Nutrition Screening Tasks

Homebound Clients

• Provide copies of a DSAAPD-approved checklist to all homebound clients at least once. All new clients should complete a checklist as well as all current clients, on an annual basis.
• Checklists will be scored and separated according to risk status
• All high-risk clients will be provided with appropriate nutrition education materials, dietary counseling or other interventions) as deemed necessary.
• Those clients identified as high-risk must be contacted within six months to re-evaluate their status and provide necessary counseling/referrals.
• All clients receiving nutritional supplements must be visited at least once a year to assess their, status. If possible, weight should be determined.
• Clients receiving nutritional supplements must be contacted by telephone at least every four months. A home visit may substitute for this phone contact.
• Printed nutrition education topics should be developed, based on responses to the checklist.
• Accurate records of screening activities will be maintained.
• Quarterly reports of screening activities will be prepared and sent to the Delaware Nutrition Screening Program (DNSP) Coordinator. Information will be forwarded to the DSAAPD Nutritionist.

Congregate Clients

• Provide copies of a DSAAPD-approved checklist to all congregate clients at least once a year.
• Contact high-risk clients within six months of screening to reevaluate nutritional status.
• Score checklists and separate according to risk status.
• Provide all high-risk clients with appropriate nutrition education materials, dietary counseling or other intervention as deemed necessary.
• Contact clients receiving adult nutritional supplements every four months.
• Develop group nutrition education topics based on responses from the nutrition screening checklists.
• Provide on-going support groups for diabetes and other relevant topics.
• Maintain accurate records of activities.
• Prepare quarterly report of screening activities and send to the Delaware Nutrition Screening Program (DNSP) Coordinator. Information will be forwarded to the DSAAPD Nutritionist.

Documentation of Nutrition Screening Activities

• Completed and scored checklists will be kept on file at the agency.
• Educational materials mailed and/or nutritional counseling provided will be noted on the client's checklist.
• Where possible, contacts related to nutrition screening will be noted in the client's chart.
• Number of total and high-risk clients will be calculated.
• Contacts made with non-risk and high-risk clients will be documented.
• Attendance at support groups and nutrition programs must be maintained.
• Quarterly reports must be submitted to the DNSP Coordinator

North Dakota
All congregate and home-delivered meals clients must be screened for nutritional risk using the Nutrition Screening Checklist, which is part of the Adult Services Intake Form.

• The screenings should be conducted a minimum of one time during the contract agreement.
• Data on the number of clients screened 'at high nutritional risk' will be reported on the Adult Services Intake Form.

D. NUTRITION COUNSELING/MEDICAL NUTRITION THERAPY

"Eighty-seven percent of older Americans have either diabetes, hypertension, dyslipidemia, or , or a combination of these chronic diseases" (1). These can be successfully managed with appropriate nutrition interventions that will improve health and quality of life outcomes. Nutrition counseling or medical nutrition therapy (MNT) is the provision of individualized comprehensive guidance to persons who are at nutritional risk because of their health or nutritional history, dietary intake, medications use, or chronic illnesses. It takes into consideration the client's desires, health, cultural, socioeconomic, functional, and psychological factors, as well as home and caregiver resources. Nutrition counseling is provided in accordance with state law and policy. It provides individuals with options and methods for improving their nutritional status. The Institute of Medicine recommended that MNT be provided by registered dietitians as part of the health-care team (1). In 2000, Medicare coverage was expanded by Congress to include registered dietitians providing MNT to diabetes and rental disease patients.

The availability of nutrition services under Medicare, Medicaid, and private insurers is expanding. Increasing health care and consumer demand for MNT provides dietitians an opportunity to expand nutrition counselingservices. Understanding funding sources for nutrition services by Medicare, Medicaid, managed care organizations (MCOs), and in alternate care settings is essential. Obtaining payment from these insurers involves learning the language of reimbursement, including coding systems and billing essentials. Selected reimbursement resources are highlighted in a reimbursement bibliography. Each affiliate and several Dietetic Practice Groups (DPGs) have a reimbursement representative. For the name of your state's affiliate/DPG reimbursement representative, contact the affiliate/DPG directly or e-mail reimburse@eatright.org for the name and for answers to specific reimbursement questions.

A number of States require nutrition education and/or counseling (MNT) to be provided by or under the direction of a registered and/or licensed dietitian/nutritionist. Registered dietitians (RDs) are food and nutrition experts who have completed a minimum of a bachelor's degree at a US regionally accredited university or college and course work approved by the Commission on Accreditation for Dietetics Education (CADE) of the American Dietetic Association (ADA), completed a CADE-accredited or -approved supervised practice program at a healthcare facility, community agency, or a foodservice corporation, or combined with undergraduate or graduate studies, passed a national examination administered by the Commission on Dietetic Registration (CDR), and complete continuing professional educational requirements to maintain registration (8). Medicaid and Medicare nutrition services often require the use of a registered and/or licensed dietitian/nutritionist. The ADA provides a number of resources concerning State Professional Regulation (9).

The ADA defines licensing as statutes that include an explicitly defined scope of practice. Performance of the profession is illegal without first obtaining a license from the state. Statutory certification limits the use of particular titles to persons meeting predetermined requirements, while persons not certified could still practice the occupation or profession. Registration is the least restrictive form of state regulation. As with certification, unregistered persons may be permitted to practice the profession if they do not use the state-recognized title. Typically, exams are not given and enforcement of the registration requirement is minimal (9).

SECTION 339 Nutrition
(2) ensure that the project ---
(J) provide for nutrition screening and, where appropriate, for nutrition education and counseling.

Kansas
Provision of individualized advice and guidance to individuals who are at nutritional risk because of their health or nutritional history, dietary intake, medications use or chronic illnesses, about options and methods for improving their nutritional status, performed by a health professional in accordance with state law and policy.

Nebraska

• A more specialized activity which may be included as a component of the nutrition education program is dietary screening and counseling.
• Dietary screening and counseling is the process of providing individualized and group professional guidance to assist people in adjusting their daily food consumption to meet their health needs. The objective is modification of behavior. This objective is accomplished when individuals understand how to make wise food choices.
• Dietary screening and counseling is a component of a nutritional care program in which a Registered Dietitian gives professional guidance to an individual, working with the individual's physician as appropriate. The service includes:
  • Assessing present food habits, eating practices and related factors.
  • Developing a written plan for appropriate dietary screening and counseling. Translating the written plan into a daily meal plan with the individual.
  • Planning follow-up care and evaluating achievement of objectives.

Florida
Individuals to receive counseling may be identified through a screening/intake process, self-referred, or referred by a caregiver or other concerned party. A licensed dietitian/nutritionist (LD/N) or a Registered Diet Technician (RDT) under the supervision of a LD/N evaluates the participants nutritional needs, conducts a comprehensive nutrition assessment, and develops a nutrition care plan in accordance with Chapter 64B8-43, Florida Administrative Code. Based on the individual's needs and with appropriate contact with the individual's physician and caregiver, the LD/N develops and implements or supervises the development and implementation of the nutrition care plan.

Nutrition counseling shall be provided by a Licensed Dietitian (LD/N) (Chapter 468 Part X, Florida Statues, Dietetics and Nutrition Practice, Chapter 468.504, Florida Statues) who is covered by liability insurance. A Registered Dietetic Technician may assist the LD/N in the screening and assessment process.

Licensed Dietitians/Nutritionists shall keep applicable written participant records that shall include the nutrition assessment, the nutrition counseling plan, dietary orders, nutrition advice, progress notes, and recommendations related to the participant's health or the participant's food or supplement intake, and any participant examination or test results, in accordance with Chapter 64B8-44, Florida Administrative Code.

E. NUTRITION EDUCATION

Nutrition education helps promote health and prevent disease. Research confirms that well-designed, behavior-focused interventions can effectively improve diets and nutrition-related behaviors. OAA Nutrition Programs provide unique opportunities to deliver nutrition and healthy lifestyle messages to older adults. Nutrition education is essential for helping older adults achieve and maintain optimal nutrition status. Older adults are eager for health information and tend to be active in community health promotion programs. Therefore, nutrition education activities are well received by older adults especially if these activities are developed according to their needs, behaviors, motivations, and desires.

Nutrition education, by a dietitian (or individual of comparable expertise), provides accurate and culturally sensitive nutrition, physical fitness, and health (as it relates to nutrition) information and instruction to participants and/or their caregivers in groups or individually. (See Chapter II: Definitions). Nutrition education programs must go beyond providing information alone. To be effective, programs must incorporate methods for creating behavior change (10). To do so, nutrition education must be provided on a continuous basis to OAA Nutrition Program participants. As the OAA does not specify the frequency of providing nutrition education, the SUAs may specify this in their policies and procedures.

Although nutrition education is a fundamental OANP component, there are few nutrition education tools for older participants and there has been minimal assessment of their effectiveness. Older adults are willing to change their eating habits when they understand the benefits. They are more receptive to the positive messages of health promotion and disease prevention through better nutrition (11-13). Many older adults are in the pre-contemplation stage of change for losing weight and exercising (14). Nutrition education based on appropriate behavior change and adult learning theories is more likely to be effective. It is recommended that resources be allocated to develop and evaluate nutrition materials and methods. OAA Nutrition Programs can take the lead in demonstrating how to effectively reach older adults in congregate sites and homes with important nutrition information that helps maintain independence and quality of life. Topics could include eating healthy to prevent or treat disease(s), interpreting nutrition messages in the media (15), hydration (16,17), avoiding unintended weight loss, changing nutrient needs with age, drug/nutrient interactions, keeping caregivers nutritionally healthy, etc.

The 1995 Journal of Nutrition Education Special Issue included a chapter on the effectiveness of nutrition education in older adults (18). The extensive search revealed only 14 nutrition education intervention studies that had acceptable evaluation criteria and measured behavioral outcomes. The authors attributed this lack of evaluation "partly due to the fact that, although nutrition education is mandated as part of some federal food programs for older adults, evaluations of such efforts are not required." The lack of clarity and ambiguity regarding the goals for nutrition education for older adults was also noted. Consortiums in several states, such as Kansas (19), Ohio (20), and Georgia (21), have recently developed nutrition education programs for older adults and there is interest in evaluating their effectiveness. Many more are needed, especially those that are culturally and ethnically diverse.

There are a variety of theoretical framework models (see below) that can be used to develop nutrition education strategies to achieve a change in nutrition-related behaviors (22). These include:

• Knowledge-attitude-behavior model: A gain in new knowledge leads to changes in attitude, which, in turn, result in improved dietary behavior or practices. The knowledge provided must be motivational for changing attitudes and behaviors.
• Health belief model: Emphasizes perceived threat as a motivating force and perceived benefits as providing a preferred path to action.
• Social learning theory: Emphasizes the interactive nature of the effects of cognitive and other personal factors and environmental events on behavior.
• Marketing model: An aggregate of functions involved in moving goods from the producer to the consumer.
• Social marketing model: The use of marketing concepts and tools to increase the acceptability of social ideas or practices.
• Social action model: Uses conflicting and advocacy approaches to change powerful interests and defend victims (22).

Nutrition education needs to be culturally appropriate. The Ask the Experts Cultural Diversity as Part of Nutrition Education and Counseling helps guide to individuals providing nutrition services to ethnic and cultural groups. A "one size fits all" program is not usually effective. To target diverse participant groups, use print and broadcast media, nutrition contests, table tents in the dining room, group nutrition education classes, clinic based programs, food taste testing sessions, nutritious potluck dinners, etc. Other innovative approaches include nutrition-through-gardening and computerized programs. Many ideas and suggestions could be successfully implemented with various groups, including home-delivered and congregate meal participants. Refer to the American Dietetic Association, Cooperative Extension Services including the University of Nebraska Cooperative Extension and Nutrition for Older Adults Health (NOAHnet from the University of Georgia) for nutrition education resources as well as those on the Center's Resources section online.

Measuring the Success of Nutrition Education and Promotion in Food Assistance Programs: http://www.usda.gov/cnpp/FENR%20V11N3/fenrv11n3p68.PDF

SEC. 214. NUTRITION EDUCATION.
The Assistant Secretary and the Secretary of Agriculture may provide technical assistance and appropriate material to agencies carrying out nutrition education programs in accordance with section 339(2)(J).

Florida
Nutrition and related client and health instruction or information is provided by or under the direction of a licensed dietitian at each congregate site and distributed to each home-delivered meal participant a minimum of two times per year, with at least 3 months between each session.

Congregate Nutrition Education is a formal program of regularly scheduled health promotion presentations on culturally sensitive nutrition, or physical fitness, or health as they relate to nutrition information and instruction to participants in a group setting.

Home Delivered Nutrition Education is a formal program of regularly scheduled individual distribution of health promotion information on culturally sensitive nutrition, or physical fitness or health as they relate to nutrition topics.

Nutrition education shall be planned and directed by a licensed dietitian/nutritionist (LD/N) (Chapter 468.504, Florida Statues) who is covered by liability insurance. Under the direction of the dietitian, individuals with comparable expertise or special training, e.g., Cooperative Extension agents or trained Meal Site Coordinators, may provide such education activities. An individual with comparable expertise is defined as a person who has a Bachelor's or Master's degree in Home Economics, Family and Consumer Sciences, or Human Sciences with an emphasis in Nutrition and Dietetics.

An annual nutrition education plan/schedule is developed. Participants' needs, comments and requests are considered when planning programs. Teaching methods and instructional materials must accommodate the older adult learner, e.g., large print handouts, demonstrations. Other resources are used to enhance programming as appropriate, e.g., Dairy Council, Cooperative Extension.

Kansas
A program to promote better health by providing accurate and culturally sensitive nutrition, physical fitness, or health (as it relates to nutrition) information and instruction to participants or participants and caregivers in a group or individual setting overseen by a dietitian or individual of comparable expertise.

Nevada

• Nutrition education services shall be provided no less than semi-annually to congregate and home-delivered meal participants
• The goal of nutrition education is to provide older persons with information that will promote improved food selection, eating habits and health related practices.
• Documentation shall include:
  • date of presentation or distribution of materials
  • name and title of presenter or title of materials distributed
  • topic discussed (if applicable)
  • number of persons in attendance
• If materials are delivered to homebound participants, documentation shall include date of distribution, copy of distributed material, and number of participants receiving the information.

Nebraska

• Nutrition education is the process by which individuals gain the understanding, skills, and motivation necessary to promote and protect their nutritional well-being through their food choices.
• Each congregate and home-delivered meal nutrition project shall provide nutrition education a minimum of twice each year as an important and integral part of providing nutrition services to older individuals.
• It is recommended that nutrition education be provided quarterly to congregate and home-delivered meal participants.
• Nutrition education services shall be planned for congregate and home-delivered participants in accordance with AAA nutrition policy.
• All nutrition education plans, activities, and materials shall be approved by the nutrition coordinator and/or dietitian prior to presentation.
• Nutrition education services shall be provided by a dietitian or by someone of comparable expertise.

Nutrition Education Goals:

• To create positive attitudes toward good nutrition and provide motivation for improved dietary practices conducive to promoting and maintaining the best attainable level of wellness for an individual.
• To provide adequate knowledge and skills necessary for critical thinking regarding diet and health so the individual can make appropriate food choices from an increasingly complex food supply.
• To assist the individual to identify resources for continuing access to sound food and nutrition information.

Nutrition Education Content

• Food, including the kinds and amounts of food that are required to meet one's daily nutritional needs.
• Nutrition, including how it relates to successful aging.
• Behavioral practices, including the factors which influence one's eating and food preparation habits.
• Consumer issues, including eating alone, cooking for one, and how to eat well on a limited income.
• Diet and disease relationships including risks for high blood pressure, heart disease, stroke, certain cancers, and diabetes.
• Examples of nutrition education activities include: cooking classes, food preparation demonstrations, field trips, plays, lectures, panel discussions, planning and/or evaluating menus, debates, food tasting sessions, question and answer sessions, gardening, physical fitness programs, motion pictures, film strips, slide shows and food and/or nutrition experiences.
  

F. CARE MANAGEMENT/CASE MANAGEMENT

Care management is often referred to as "case" management, but the more socially acceptable phrase is care management. Care management provides an important framework for assessing participant needs and arranging for the delivery of services. For this reason, care management often transcends the boundaries of OAA services and assist participants in accessing other programs and services such as housing assistance, the Low Income Home Energy Assistance Program (LIHEAP), Medicaid, Social Security Income (SSI), and the Food Stamp Program.

Care management in the community setting aims to incorporate the range of medical, social, nursing, psychological and supportive services to maintain older adults in their homes and communities, ie, to avoid both acute and long-term institutionalization (23). Through care management, the needs of each individual are assessed, a plan of services to meet those needs are developed, the delivery of services are arranged and monitored, and the effectiveness and need for continuation of services are evaluated.

Care managers work with clients to ensure that a care plan matches needs, values, and preferences. It is preferred that care managers refer older individuals at nutritional risk to a dietitian/nutritionist. This is a comprehensive way of providing nutrition assessment and appropriate interventions rather than simply refering for meal services. Nutrition care management identifies the specific nutritional needs of participants and arranges for nutrition interventions, such as home-delivered meals, nutrition education, diet modification, adaptive eating devices, and medical nutrition therapy.

Nutrition care management of an older person helps prevent or delay chronic diseases and their complications, maintain or improve immune function and resistance to infection, shorten hospital stay, decrease surgical risk and postoperative complications, speed wound healing and recovery, and ultimately decrease health care utilization and costs (23).

SEC 321
PART B-SUPPORTIVE SERVICES AND SENIOR CENTERS PROGRAM AUTHORIZED
(5) services designed to assist older individuals in avoiding institutionalization and to assist individuals in long-term care institutions who are able to return to their communities, including--
(A) client assessment, case management services, and development and coordination of community services;
(B) supportive activities to meet the special needs of caregivers, including caretakers who provide in-home services to frail older individuals; and
(C) in-home services and other community services, including home health, homemaker, shopping, escort, reader, and letter writing services, to assist older individuals to live independently in a home environment.

PART E-NATIONAL FAMILY CAREGIVER SUPPORT PROGRAM
SEC 373 Program Authorized
(b) SUPPORT SERVICES- The services provided, in a State program under subsection (a), by an area agency on aging, or entity that such agency has contracted with, shall include-
(3) individual counseling, organization of support groups, and caregiver training to caregivers to assist the caregivers in making decisions and solving problems relating to their caregiving roles.

SEC 373 (b) SUPPORT SERVICES- The services provided, in a State program under subsection (a), by an area agency on aging, or entity that such agency has contracted with, shall include-(5) supplemental services, on a limited basis, to compliment the care provided by caregivers.

Tennessee
A service designed to help older individuals to assess the needs, and to arrange, coordinate, and monitor an optimum package of services to meet the needs of the older individual.

The program must individualize the situation of persons being served by such means as case assessment or diagnosis, periodic reassessment and, sometimes, counseling or, at least, effective communicative relationships between a worker and a client. The program should provide continuity and comprehensiveness of service to special subgroups of multi-problem clients through such activities as assigning a case manager or service team, maintaining a client-oriented tracking system, or arranging case conferences. While such case coordination also needs to occur within a single agency with multiple services to offer, this definition is restricted to those case coordination efforts which must involve other agencies in providing services on a client-by-client basis in a harmonious way by referral, purchase of service, written agreements, case advocacy, or appeals.

SERVICE ACTIVITIES: (REQUIRED)
Comprehensive assessment of the older individual - Administering structured assessment instruments) which has been approved by the state agency to gather information about a participant to determine need and/or eligibility for services. Information collected must include health and nutritional status, financial status, activities of daily living status, physical environment, and social support system.

Development and implementation of a service plan with the older individual to mobilize the formal and informal resources and services identified in the assessment to meet the needs of the older individual, including coordination of the services and resources. Includes technical review and analysis of facts concerning an individual's social, psychological and physical health problems for the purpose of determining the types of services needed and resulting in a written plan for services and assistance. Purchasing services and/or arranging services with formal and informal service providers, including family, friends, and volunteers to perform services needed by the participant is also included.

Coordination and monitoring of formal and informal service delivery including activities to ensure that services specified in the plan are being provided.
Periodic reassessment and revision of the plan based on changes in the status of the individual or his/her circumstances. Consists of evaluating the appropriateness and/or effectiveness of service in meeting individual participant needs, includes the convening of case conferences and the joint review of care plans, when necessary.

Intake Screening
Each case management program must have uniform intake procedures and maintain consistent records. Intake may be conducted over the telephone. Intake records for each participant must include at a minimum:
Individual's name, address, and telephone number;
Individual's age or birthday;
Physician's name, address, and telephone number;
Name, address, and phone number of person, other than spouse or relative with whom individual resides, to contact in case of emergency;
Handicaps, as defined by Section 504 of the Rehabilitation Act of 1973, or ether diagnosed medical problems;
Perceived supportive service needs as expressed by individual or his/her representatives;
Race;
Sex;
Whether or not the individual has an income at or below the poverty level for intake and reporting purposes.
If intake indicates that needs can be met by a single service, the individual should be provided Information and Referral Services. When intake suggests multiple service needs, a comprehensive individual assessment of need must be performed within ten (10) working days of intake.

Assessments
All assessments and reassessments must be conducted in person. Each assessment should provide as much of the following information as is possible to determine:

(Note: Caseworkers must attempt to acquire each item of information listed, but must also recognize and accept the client's right to refuse to provide requested items)

Basic Information

• Individual's name, address, and telephone number;
• Age, date, and place of birth;
• Gender
• Marital status;
• Minority status (African American, Hispanic, American Indian/Alaskan, Asian/Pacific Islanders, Non-minority).
• Living arrangements; (living alone or with others)
• Condition of environment;
• Income and other financial resources, by source (including SSI);
• Expenses; and,
• Religious affiliation, if applicable.

Functional Status

• ADL/IADL Status -- number and type of limitations in activities in daily living and instrumental activities of daily living;
• Cognitive impairment;
• Vision;
• Hearing;
• Speech;
• Oral status (condition of teeth, gums, mouth, and tongue).;
• Prostheses;
• Psychosocial functioning;
• History of chronic and acute illness;
• Nutrition Screening risk status and diet restrictions, if any; and,
• Prescriptions, medications, and other physician orders.

Supporting Resources

• Physician's name, address, and telephone number;
• Pharmacist's name, address, and telephone number;
• Services currently receiving or received in past (including identification of those funded through Medicaid);
• Extent of family and/or informal support network;
• Hospitalization history;
• Medical/health insurance available; and,
• Clergy name, address and telephone number, if applicable.

Need Identification

• Participant/family perceived;
• Assessor perceived and/or identified from referral source/professional community; and,
• Each participant is to be reassessed every six months, or as needed, to determine the results of implementation of the care plan. If reassessment determines the participant's identified needs have been adequately addressed, the case should be closed.

Care Plan
A written care plan must be developed for each person determined in need of and eligible for case management. The care plan must be developed in cooperation with and be approved by the participant (or participant's guardian or designated representative, if applicable). The care plan must contain at a minimum:

• statement of the participant's problems, needs, strengths, and resources;
• Statement of the goals and objectives for meeting identified needs;
• Description of methods and/or approaches to be used in addressing needs;
• Identification of services to be provided by other agencies and the service schedules;
• Treatment orders of qualified health professional, when applicable.
• Participants with unmet health needs (physical or mental) are to be referred to appropriate health care provider(s).
• Each program must have a written policy/procedure to govern the development, implementation, and management of care plans.

Record Keeping
Each program must maintain comprehensive and complete case files which include at a minimum:

• Details of participant's referral to case management program;
• Intake records;
• Comprehensive individual assessment and reassessment;
• Care Plan (with notation of any revisions);
• Listing of all contacts (dates) with participants (including units of service per participant);
• Case notes in response to all participant or family contacts (telephone or personal);
• Listing of all contacts with service providers on behalf of participant;
• Comments verifying participant's receipt of services from other providers and whether service adequately addressed participant need; and,
• Record of release of any personal information about the participant and copy of signed release of information form.
• In order to maintain confidentiality, all case files must be stored in controlled-access files. Each program must use a standardized release of information form, which is time limited and specific as to the information being released.
  

G. HEALTH PROMOTION/DISEASE PREVENTION and WELLNESS ACTIVITIES

Health promotion and disease prevention programs are key to helping improve the health of Americans. National programs such as the President's Healthier US Initiative, USA on the Move: Steps to Healthy Aging and Healthy People 2010 recognize the importance of activities that promote health and address the relationship between nutrition, physical activity, and chronic disease (1). Health promotion and disease prevention programs help minimize health-related risk factors associated with aging. The programs can help older adults understand the factors associated with optimal psychosocial and physical well-being and provide resources to help them cope with the psychological and physical changes of aging (24).

Health promotion programs for older adults focus on increasing control over and improving their health in a variety of areas; for example, nutrition, physical activity, mental health, alcohol and substance reduction, tobacco use. Wellness programs--a type of health promotion program--involve all aspects of the individual: mental, physical, and spiritual. Both types of programs provide structured opportunities to increase knowledge and skills in specific areas, such as stress management, or environmental sensitivity. The supportive environment nurtures the emotional and intellectual aspects of participants, and helps them become increasingly responsive to their health needs and quality of life (7). These programs are usually short-term and educational rather than therapeutic in nature.

A sedentary lifestyle, due to age, depression, obesity, arthritis, stroke or respiratory diseases, is a major risk factor for disability in older adults (25-28). Research supports the importance of physical activity in reducing the risk of these debilitating conditions (26-32). The well documented benefits of physical activity include increased appetite, increased mobility and flexibility, and improved muscle strength and aerobic capacity (33). Active participants have better dietary intakes, improved functional capacity to perform activities of daily living, reduced risk for falls, improved bone health, and improved responses to coronary heart disease, hypertension, diabetes, and osteoarthritis than their non-active counterparts (26-31).

According to National Evaluation, 80% of nutrition sites that provided recreation and social activities (or 67% of all congregate sites) offered these activities at least twice per week (7). Physical activity programs were included in this category but were not listed as a separate activity. The Surgeon General, supported by American Association of Retired Persons (AARP), the American College of Sports Medicine, the American Geriatrics Society, the National Institute on Aging, the Center for Disease Control and Prevention, and the Office of the Assistant Secretary for Planning and Evaluation in the US Department of Health and Human Services, recommend community-based physical activity programs or community activities that include physical activity opportunities to achieve health benefits in older adults (31,34,35). Some congregate nutrition programs offer resistance training (eg, strength training via free-weights or machines), endurance training (eg, aerobics, walking, swimming), flexibility training (eg, stretching, yoga), and balance training (eg, Tai-chi). These help older adults in their pursuit of a healthy lifestyle (33,36).

The 2000 Dietary Guidelines for Americans (DGs) is an essential health promotion/disease prevention document that focuses on the relationship between nutrition, food, health, and physical activity. The Dietary Guidelines provide consumers and professionals good information about nutrition and physical activity. Because the OAA requires compliance with the Dietary Guidelines, this document can assist states, AAAs, and local providers to address nutrition and physical activity in their programs.

A National Survey of Health and Supportive Services in the Aging Network, by the National Council on the Aging (Summer 2001) describes the impact of organizations in improving health outcomes and supporting older people in their homes (37). It shows the vitality and diversity of agencies and services in the aging network. It illuminates the range of innovative services in diverse settings and geographic areas. For example, these programs operate in clinics, churches, community centers and in residences of the homebound in inner cities, urban, suburban and rural areas. It identifies the resourcefulness of agencies in recruiting and employing certified professionals and engaging well-trained volunteers. The study reports successes in measuring program outcomes via positive changes in health status, health practices, and quality of life. These high quality programs i make extensive use of partnerships to leverage funding and meet participant needs. More than 50% partner with health care providers. Others partner with universities, public agencies, and local businesses. Cost sharing is common with 67% reporting fees and donations as important funding sources.

Steps to Healthy Aging: Eating Better and Moving More is a two-part program designed to improve nutrition and physical activity in older adults. It is sponsored by AoA and the National Policy and Resource Center on Nutrition and Aging. Simple, modest increases in daily activities can improve overall health, prevent disease and disability, and reduce health care costs for our nation. The Steps to Healthy Aging: Eating Better and Moving More Guidebook will be available in late 2003.

The Ask the Experts Wellness Activities for Older Adults has examples from a wide variety of organizations and agencies. It summarizes objectives and activities of specific programs. It includes topic suggestions f and additional resources such as state and county health departments, cooperative extensions, hospitals and health clinics, colleges and universities, health care practitioners, federal and state public health agencies, and other agencies, organizations, and businesses in relation to specific diseases, services, and/or products.

Information from the National Policy and Resource Center on Nutrition and Aging:

Hotlinks: Nutrition / Health Information

Resources: Education and Health Promotion

Bibliographies: Education and Health Promotion

It is the position of the American Dietetic Association that health promotion and disease
prevention endeavors are the best population strategies for reducing the current burden
of chronic disease. Dietetics professionals should be actively involved in promoting
optimal nutrition in community settings and should advocate for the inclusion of healthy
eating, in addition to other health-promoting behaviors, in programs and policy initiatives
at local, state, or federal levels (13).

There is an increasing need for nutrition services in OAA Nutrition Programs because so many older adults have chronic conditions which can be managed with appropriate nutrition interventions. Dietitians and nutritionist are the primary information resource regarding the relationships among diet, health, and disease prevention. When OAA Nutrition Programs ntegrate Healthy People 2010 into their programs, dietitians and nutritionists are vital to helping meet these objectives. They can contribute significantly to the design