September 19, 2016
Susan Jenkins, Ph.D.
Director, Office of Performance and Evaluation
Administration for Community Living
Department of Health and Human Services
330 C St SW
Washington, DC 20201
Re: Information Collection re Outcome Evaluation of the Title III-C Nutrition Services Program (OMB Control Number: 0985-0037)
Dear Dr. Jenkins,
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit comments to the Administration for Community Living (ACL) at the United States Department of Health and Human Services (HHS) related to its July 19, 2016 information collection, "Outcome Evaluation of the Title III-C Nutrition Services Program (OMB Control Number: 0985-0037)." Representing more than 100,000 registered dietitian nutritionists (RDNs),1 dietetic technicians, registered (DTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States and is committed to improving the nation’s health through food and nutrition across the lifecycle.
Older Americans Act (OAA) nutrition programs provide critical services, including healthy meals, to older adults who might otherwise be at risk for malnutrition. These critical services are intended to promote health and quality of life, while delaying adverse health conditions. It is well established that nutrition therapy interventions are cost effective, and assist older adults remain independent in their homes. Older adults with good nutritional status are better able to fight infection, prevent injury, and heal more quickly.
The Academy supports this survey and evaluation as vital to begin linking health outcomes to receipt of OAA nutrition services. We offer the below suggestions for improvement and clarification. In addition, we recommend conducting outcome evaluations for nutrient offerings from other entities not participating in the OAA programs (but perhaps funded through local city or county funding) as a baseline for comparison. Few of the questions appear to address objective 1 (program planning), which could be remedied by including additional questions, including questions that relate to purposes of the program to enhance independence and create community among recipients.
A. Proposed Survey Questions
Academy member experts reviewing the ACL questions observed that they focused primarily on obtaining numbers of those participating in senior meal services rather than measuring nutritional and health outcomes. In addition, reviewers noted that the ACL questions may need to be reworded to prevent confusion and frustration from those answering the questions.
Experts reviewing the proposed survey questions also noted the questions appeared to focus more on the length of time participants were using the program as opposed to ascertaining feedback regarding the quality of the program. In addition, we are concerned that the "look-back" questions specifically asking about 3-6 or 6-12 months' time frame would be too confusing, particularly given that many respondents may not remember what happened months ago.
The Academy has specific concerns and recommendations with the following proposed survey questions:
- A1: How can this question be reconciled to situations in which the dining center is a restaurant?
- A8b: One of the answers relates to the difficulty and although the inference is that obtaining transportation is difficult, it would be useful to ascertain if respondents answer that it is difficult because perhaps they are not feeling well or the trip is too long and grueling or some other interpretation of difficulty.
- A12 and A17: Consider changing the word “lunch” to meal” to ensure consistency across programs.
- A13 – A16 could potentially confuse seniors by the way they drill down on timing.
B. Performance Outcome Measurement Project (POMP) Questions
We encourage ACL to utilize all relevant available surveys when assessing the larger objectives—have health outcomes improved and is the program working effectively and efficiently. We note at the outset that some questions outlined in the Performance Outcome Measurement Project (POMP) (e.g., questions 42-46 of the POMP survey) appear better suited to answer questions relevant to objective 2 of this information collection (i.e., financial outcomes, program efficiency, and cost issues) than the proposed questions. The proposed questions also do not reach issues of program cost.
In addition, the Academy notes that the follow-up survey appears to focus on participation in senior meal programs, but does not ask discernable questions related to outcomes and program effectiveness specified in objective 3 (i.e., improved nutrition and food choices, improved health, decreased or improved nutrition risk score, increased independence and ability to live in one's own home). Certain questions in the POMP survey (i.e., 4-6, 33-37, and 40) appear better suited to measure health outcomes; we suggest ACL consider additional questions to better ascertain outcomes, such as those below:
- Answer the following questions about the meal program. Do services received at the meal program help you to:
- Eat healthier foods
- Achieve or maintain a healthy weight
- Improve your health and feel better
- See your friends more often
- Continue to live at home
- Do you like the meals you get from the meal program?
- How much of the meals do you usually consume? Less than half of the meal or more than one half of the meal?
- Would you recommend the meal program to a friend?
- As a result of attending or receiving the meal program, did you receive guidance about where to get information about other services?
- As a result of attending or receiving meals from the program, do you have a better idea of where to get assistance/information from a registered dietitian nutritionist?
- As a result of attending or receiving meals from the program, did you learn how to eat more healthful and nutritious meals?
- Do you always have enough money or food assistance/food stamps/SNAP to supply the food you need?
- During the past month, did you have to choose between buying food or buying medication or paying your rent and utility bills? (Or, alternatively, to reach the same purpose, ask "Do you eat the same quantity and quality of foods at the beginning of the month as you do at the end of the month?")
- On one or more days during the past month, did you skip at least one meal because you had no food and no money or food assistance/food stamps/SNAP to buy food?
- In general, would you say that the meal program has helped you? Please comment.
- Are you charged for the meals? (Alternatively, "Do you pay for the meals?")
- What prompted you to start receiving meal assistance (financial, medical, family change crisis, desire for socialization, availability at a venue you already frequent, etc.)?
- Do you share your meals with others or save some of the food to eat?
- Do you have an option to receive a "sack" meal for dinner or to save for weekends?
- Do you have transportation available to take you to the site for lunch?
- Is there a variety of food served throughout the week?
- Is the menu posted on a monthly basis?
- Is your participation for meals based on the menu?
- Do you have the opportunity to eat with others in the same venue or setting as part of the meal program?
- Are your food preferences or special medical or religious diet needs considered in the meal program in which you participate?
The above questions address food choices, health, independence, socialization, quality of services, availability of services and food security. In addition, the questions may be simpler for respondents to answer and better at assessing the effectiveness of the program.
The Academy sincerely appreciates the opportunity to offer comments regarding Title III-C Nutrition Services Program and the assessment and evaluation of the nutrition programs. Please contact either Jeanne Blankenship by telephone at 312/899-1730 or by email at firstname.lastname@example.org or Pepin Tuma by telephone at 202/775-8277, ext. 6001 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Policy Initiatives and Advocacy
Academy of Nutrition and Dietetics
Pepin Andrew Tuma, Esq.
Government & Regulatory Affairs
Academy of Nutrition and Dietetics
1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.