THE ROLE OF  NUTRITION IN HOME
AND COMMUNITY-BASED LONG TERM CARE

Administration on Aging
National Nutrition Advisory Council  Meeting
September 12 and 13, 1995

Doubletree Hotel,  Arlington, Virginia
Drafted by Floristene Johnson, M.S.,  R.D.
Region VI Nutritionist, Administration on  Aging

ISSUE: The issue facing the Administration on  Aging (AoA) and the National Nutrition Advisory Council (Council) is how to ensure that the aging network develops greater capacity and fosters the  development and implementation of comprehensive and coordinated nutrition  services within emerging, multi-funded infrastructures for home and community-based long-term care.

BACKGROUND: Nutritional well-being is an  integral part of the overall health, independence, and quality of life of older persons. Despite the acknowledged links between nutrition, health, and functioning among older adults, few of the existing mechanisms within the aging  and health care networks of providing community-based health and supportive  services to the older population include a nutrition services component.

Although Title III, the primary service title of the Older Americans Act (OAA), indicates that the purpose of the title is to foster the development and implementation of a comprehensive and coordinated service system including nutrition services, the role of nutrition in home and community-based long-term  care has been primarily limited to the delivery of congregate and home-  delivered meals. The nutrition services mentioned in the OAA are meals,  nutrition education and other appropriate nutrition services for older individuals. State units on aging (SUAs), Tribes, area agencies on aging (AAAs)  and nutrition service providers (NSPs) have varied widely in their development and coordination of nutrition services beyond meals. The provision of nutrition  education had been an optional service until the 1992 amendments of the Older Americans Act required nutrition education on at least a semi-annual basis. Under Social Services Block Grants (SSBG), reimbursement for nutrition services has been limited to meals and most States have chosen to limit service to meals under the Medicaid Waiver programs. Medicare, Medicaid, and private insurance  may provide third-party reimbursement for nutrition services; however, coverage  varies considerably depending on the health and social setting and funding  source. The reimbursement for home-based nutrition services such as home-health,  health maintenance, hospice or respite programs vary considerably and is at best  minimal.

Long term care consists of many services aimed at helping people with  chronic conditions compensate for limitations in their ability to function independently. Home care is a system of providing case management and a wide  range of medical, nursing, social, and related services in the individual's  home. It provides several documented benefits over institutional care: shorter hospital and nursing home stays, reduced admissions to hospitals and nursing homes, reduced length of hospital stays, earlier diagnoses of illnesses, earlier  treatments, and possibly lower treatment costs. Case management usually begins  with an initial medical and social assessment and screening. With the exception of an assessment of dentition and activities of daily living (ADLs) such as  eating impairment, there is not usually a nutrition component in the assessment  tool.

The largest proportion of elderly persons with severe disabilities need  nonmedical services, according to a recent Government Accounting Office (GAO) survey of directors of SUAs and Medicaid. Although most of their States' assessment instruments included other indicators to determine need in addition  to ADLs, they reported that an elderly person's ability to perform ADLs was the  best indicator to determine need for publicly-funded, home and community-based services. The State Directors most often cited personal care, housekeeping, meal preparation, and other home chore services, and case/care management as the services needed by the largest proportion of elderly persons with severe disabilities. Only personal care and homemaker services include assistance with  meal preparation and shopping.

Although numerous studies describe the impact of nutrition services on prevention or delayed onset of certain chronic diseases and their complications,  better resistance to infection, maintenance of independent living, and potential  savings in the costs of medical and institutional care, surgery and drug  therapy, assessment of need for and the provision of nutrition services other  than meals are not commonly included. The major nutrition-related components of home and community-based long- term care are as follows: nutrition screening; nutrition assessment; individualized nutrition intervention planning and care  management; referral to other appropriate providers of services related to nutritional status; intervention monitoring; and evaluation of nutritional intervention.

Nutrition screening is a focused activity that is designed to identify persons who need a particular program or type of service such as home-delivered  meals or food stamps. Nutrition assessment is designed to determine an individual's nutritional status, identify problems, their etiology and  appropriate solutions. Nutrition intervention is accomplished through the provision of appropriate services to the older client and family. Such  interventions include congregate and home-delivered meals; more than one meal a  day, more than five days a week depending on need and caregiver support; health  promotion/disease prevention activities; medical nutrition therapy; client, caregiver, and family nutrition education; individualized or group nutrition  counseling for the client, family or caregiver; and enteral/parenteral feeding. Referral to other appropriate services related to nutritional status could range  from shopping assistance and meal preparation to dental services. Monitoring  includes an continuous review of changes in an individual's nutritional status over time. Evaluation means determining the success of the intervention and whether changes need to be made to meet changing client needs. The current home  and community-based system includes safe, and nutritious congregate and  home-delivered meals, usually five days a week; transportation to and from the site; nutrition education; limited nutrition screening, assessment, counseling,  monitoring, evaluation and referral to other services. Concern has been raised regarding the level of expertise of those providing services, creative ways to provide educational and counseling services to those at home, the lack of meal service seven days a week instead of five-days/week, ways to provide screening,  assessment, and monitoring to those at greatest nutritional risk.

Despite the provision of this limited service, there is consistent evidence of the significant impact of congregate and home-delivered meals on the improved dietary intake and nutritional status of older persons receiving these services as well as program impacts on socialization and decreased isolation.  Studies have shown over a number of years that both congregate and home-delivered nutrition programs offer their clients a nutritional advantage  over those who don't use them.

Other community nutrition services include food assistance programs such as the Food Stamp program that reaches about 2 million elderly households.  Nutritional benefits for the elderly have been reported to be minimal. Due to  multiple barriers, older individuals do not participate in the Food Stamp program in proportion to their need. The Food Stamp program is at best loosely  integrated with other available nutrition services.

Third-party reimbursement is virtually non-existent for nutrition  services. While more than 15 States have included the provision of home-delivered meals as a reimbursable service under Medicaid waivers, and the SSBG grants to States allow for the service of home-delivered meals, other nutrition interventions are omitted. However, a recent survey of SUAs revealed  several efforts to fill the gaps in/supplement existing nutrition services. The following State programs were identified: A nutrition case management system demonstration; statewide screening tool for coordination with Medicaid waiver;  mini-breakfast program; nutrition supplementation with doctors sign-off; statewide low-fat award program; and week-end meals programs.

DISCUSSION: At present, no comprehensive or coordinated mechanisms exist to ensure the availability, accessibility, and  provision of appropriate nutrition services to the elderly across a continuum of care. The nutrition services offered in the non-institutional health and community-based setting are often limited and are at best loosely integrated. The extent to which nutrition is seen as a major part of home and community-based care remains secondary to other components of the vast array of  services. Since nutritional status is a major indicator in overall health status and is related to functional status and impairment, the inclusion of nutrition screening as a component of the initial assessment and periodic reassessment for participation in all state, Federally and privately-funded service programs is crucial. If the position of nutrition services in home and community-based  long-term care is to expand beyond meal service, certain changes must occur. Research should address the delineation of potential beneficial nutrition  services that could be provided in the home and community; the impact of  nutrition services and programs on nutritional and functional status; and their  relationship to health status, health care utilization and cost, functional  status, rates of hospitalization and rehospitalization, maintenance in the  community versus institutionalization, and psychosocial well-being. Research is needed to examine the effectiveness of nutrition services and programs and  identify ways to improve them. Most research on congregate and home- delivered  meal programs has focused on service delivery (who is served, how individuals  are served, etc.) rather than on outcomes, impacts and interrelationships with  other services and service use. Better research on outcomes and impacts could facilitate the design of more comprehensive and coordinated nutrition services that better address the needs of nutritionally at risk older people.

The 1995 White House Conference on Aging addressed several aspects of the  delivery of nutrition services to older persons resulting in approximately 27  resolutions. These resolutions support policies that would: E facilitate the provision of information to all persons, regardless of age, that address the role of nutrition in health promotion and disease prevention. Emphasis is placed  on prevention as a cost-cutting measure and the important role nutrition  screening plays as a proven, preventive method and the need for it to be a  standard component of geriatric assessment tools; E maintain existing nutrition  services and also strengthen and expand them to include the provision of seven  day a week service of home-delivered meals with consideration given to cultural, ethnic, medical, and social needs of older persons; E provide a "seamless"  continuum of quality services which includes nutrition services on par with all  other long-term care services. Through partnerships at the community level, nutrition screening and intervention programs are recommended for development; E  increase research into the causes and treatment of malnutrition. Medical schools should have nutrition training as a part of their basic curricula and all  nutrition programs should offer education.

The aging network cannot wait until all research is complete. The aging  network is innovative and flexible and can begin to design and facilitate the development of comprehensive and coordinated nutrition services as specified by the OAA. At all levels of the service system, policy and decision-makers,  researchers and practitioners need to recognize the benefits of nutritional care and incorporate a more global view of nutrition services into their  conceptualization of home and community-based long-term care. In addition, since the major payers of long term care services are Medicaid and Medicare, mandates  for nutrition services must be incorporated into their program directives for nutrition services to be integrated with other preventive and therapeutic  programs and accessed by persons of all ages. The number of Americans needing  long term care will continue to grow. Experts agree that the number of disabled  elderly will also increase. The extent to which medical advances and changes in  death rates will impact the need for services as well as the availability of  caregivers and workplace policies is debatable at this time. For nutrition  services to become a well-recognized and vital component of home and  community-based long term care, nutrition professionals must continue to demonstrate the efficacy of nutrition services and become more pivotal in the delivery of health and related social services to the elderly. Future research is needed to explore the role of nutrition services in maintaining health, improving the quality of life, and containing health care costs.

SUMMARY: Nutritional well-being is an integral part of the overall health, independence, and quality of life of older persons.  Despite the acknowledged links between nutrition, health, and functioning among older adults, few existing programs incorporate comprehensive and coordinated nutrition services into the community-based health and supportive services system. The issue facing the AoA and the Council is how to facilitate the incorporation of a broader array of nutrition services into the system at a time of increasing service needs, decreasing Federal funding, and increasing  competition for the service dollar.