NYSOFA presents testimony to New York State Senate Standing Committee on Aging regarding Supplemental Nutrition Assistance Program.

For Testimony in Word Format

Testimony of Greg Olsen, Deputy Director
New York State Office for the Aging

Conducted by Senate Standing Committee on Aging on S.3340

Thursday May 14, 2009
250 Broadway, Senate hearing Room, 19th Floor
New York City

Good Morning Chairman Diaz and members of the Senate Aging Committee. My name is Greg Olsen and I am the Deputy Director of the Division of Policy, Research and Legislative Affairs for the New York State Office for the Aging. Director Burgess sends his regrets for not being able to be here himself. I appreciate the opportunity to testify on his behalf.

Before I begin, in addressing the budget crisis New York faced this year, Director Burgess' priority was to ensure that NYSOFAs core programs and services were maintained to ensure that older adults continued to receive critical services, including the Supplemental Nutrition Assistance Program (SNAP). I would be remiss if I did not recognize you and your colleagues in the Legislature for your advocacy during this difficult financial time. The enacted 2009-10 budget includes an additional $2 million for SNAP and when coupled with American Recovery and Reinvestment Act nutrition dollars, New York State will realize an additional $2 million for home delivered meals.

History of the Nutrition Program (federal & state):
The first US home-delivered meal program began in Philadelphia, Pennsylvania, in January of 1954. A social worker in Philadelphia's Lighthouse Community Center pioneered a program to provide nourishment that met the dietary needs of homebound seniors and other "shut-ins" in the area who otherwise would have to go hungry. As is the case today, many participants were people who did not require hospitalization, but who simply needed a helping hand in order to maintain their independence.

The city of Rochester, New York, began its home-delivered meal program in 1958. It was originally a pilot project initiated by the New York Department of Health and administered by the Visiting Nurse Service. The Visiting Nurse Service charged participants fees ranging from 50 cents to $1.85 per meal for dues and the Bureau of Chronic Diseases and Geriatrics of the New York Department of Health paid for the remaining costs. Eventually, cities nationwide followed with similar programs.

When the Nutrition Program for the Elderly (NPE) was authorized by Congress more than thirty five years ago, the underlying reason for its creation was to prevent malnutrition in older adults by providing meals and other nutritional services in their communities and at home. Today, the program is as necessary and contemporary as it was then! Malnutrition and chronic disease remain as critical health concerns for older adults and their caregivers and have a considerable impact on health care costs to families and this state (and country). Nutritional needs become more critical with advancing age especially as the elderly recuperate from acute and chronic health problems.

Nutrition Program for the Elderly is a foundation service (of the Older Americans Act) with a well-documented history of substantial contributions to the health and social well being of participants. It is the largest program we administer ($183 million) and it is well integrated into home and community settings through coordination with community partners.

Nutrition services include congregate meals, home delivered meals, health promotion and disease prevention, nutrition screening, nutrition education, nutrition assessments and counseling as appropriate. It is a proven, cost effective means of helping older adults maintain their health and independence, engage in community life, and stay in their own homes and communities as long as possible.

Since its inception, the nutrition program has operated statewide through 59 Area Agencies on Aging, including 2 Indian Tribal Organizations. Services are provided directly or through sub-contract. Funding for nutrition services comes from a combination of federal, state (SNAP, CSE, CSI) and local government sources; program income (contributions) and other sources at the local level. [Note: Slightly more than 47 percent of funding for all nutrition services including health promotion comes from other sources.]

The purposes of the program are:

• to reduce hunger and food insecurity;
• to promote socialization of older individuals; and
• to promote the health and well-being of older individuals by assisting such individuals to gain access to nutrition and other disease prevention and health promotion services to delay the onset of adverse health conditions resulting from poor nutritional health or sedentary behavior." (Source: 2006 Reauthorization of OAA)

Services provided under the Nutrition Program for the Elderly (NPE):

• Healthy, balanced meals at community dining sites (congregate meals) or home delivered meals for eligible individuals;
• Nutrition education and health promotion and disease prevention services, including flu shots, medication management and evidence-based chronic disease self-management programs, in a variety of settings;
• Nutrition screening to determine nutritional risk; assessments and individualized nutrition counseling for chronic disease management;
• Access to locally grown fresh fruits and vegetables through the United States Department of Agriculture (USDA) Senior Farmers Market Nutrition Program (SFMNP) for income-eligible households; and,
• Advocacy to improve access to food by those in greatest economic and social need.

During SFY 2007-08 community dining sites served 11,415,832 meals to 126,218 older New Yorkers, while 66,221 eligible older New Yorkers received 12,817,250 home delivered meals. Slightly more than 32 percent of participants at community dining sites were identified at high nutrition risk and 40 percent of home delivered meals participants were at high nutrition risk. Fourteen thousand hours of nutrition counseling and more than twenty five thousand sessions of nutrition education were delivered statewide. Almost 106,000 participants received health promotion/disease prevention services. Ninety-one thousand SFMNP coupon booklets were distributed to eligible households.

In FY 2008, allocations for nutrition programs make up 54% of the entire budget for AoA. Out of a total budget of $1.411 billion, congregate meals were funded at $411 million, home delivered meals at $194 million and the Nutrition Services Incentive Program at $151 million.

As amended by the Older Americans Act (OAA) of 2000, the NSIP is the new name for the USDA's cash or commodity program, formerly known as the Nutrition Program for the Elderly (NPE). The commodity program for NSIP participates is funded through an appropriation to USDA and administered by the Food and Nutrition Service's (FNS) Food Distribution Division.

New York State Supplemental Nutrition Assistance Program (SNAP): New York State Supplemental Nutrition Assistance Program (SNAP) began in 1984 as a Governor's Initiative, administered by the NYS Department of Health, to "improve health status and well-being of its most fragile citizens by reducing their levels of hunger, malnutrition and nutritionally related illness." Programs were expected to "provide nutritious food supplementation and be designed to target the needs of individuals, who are either homeless, frail elderly, or low-income women, infants and children who are at nutritional risk." Frail elderly were identified as persons over age 60 at or near the poverty level who were mentally or physically disabled, socially isolated or otherwise nutritionally at risk. Priority was to be given to individuals who were not receiving assistance; who were below or near the poverty level and living alone; who had one of the following chronic diseases: heart disease, cancer, diabetes, chronic obstructive lung disease, arthritis. Minority individuals were expected to be a substantial part of the priority group.

Initially NYSOFA identified services to include:

• expansion of existing congregate meal sites to daily operations (in those areas likely to reach target population) and
• the provision of second congregate and/or home delivered meals.

Consideration was given to the development of additional home delivered meals routes and opening up new transportation routes. Programs were encouraged to develop services aimed at providing nutrition education, assessment, nutrition counseling and shopping assistance. Today SNAP funding is used primarily for home delivered meals to frail elderly who are unable to prepare meals for themselves, but it is used to provide congregate meals to a lesser degree. It also provides limited funding for access and supportive services and case management.

Since SFY 1995 SNAP funding has been given directly to NYSOFA and funds are distributed to all area agencies on aging, which includes New York City, through a funding formula. Since SFY '06, funding has been augmented by a Cost of Living Adjustment to help offset minimum wage increases and the impact of inflation on items such as meal ingredients and energy.

A small amount of SNAP funds is used annually to cover coupon booklet production and distribution costs in the Senior Farmers Market Nutrition Program (SFMNP), a USDA program administered by the NYS Department of Agriculture and Markets. While it became a permanent federal program in FY 07, it has operated in New York since 1989 when it began as a state initiative supported with SNAP funds. The program provides income-eligible (185% FPL) older adults with a one-time $20 allotment, as coupons, to use at farmers markets. The purpose of this very popular program is to increase the consumption of fresh fruits and vegetables, provide nutrition education and support local farmers (a major component of New York State's economy.) This year, New York State expects to receive $1.6 million in federal funding, which covers approximately 10 percent of the need statewide.

Number of Meals Provided Annually:

• Nationally, New York State provides the greatest number of meals per year (as reported to Administration on Aging) through its nutrition program
• Statewide SFY 2007-08: 11,415,832 congregate meals to 126,218 participants (90 meals/person/year); 12,817,350 home-delivered meals to 66,221 participants (193 meals/person/year)
• Average unit cost: $7.18 ($8.14 for congregate meals and $6.23 for home-delivered meals)

Profile of those served: The nutrition program is not a means-tested program; therefore, it is available to all those who meet the basic criteria. For congregate meals, a participant must be age 60 or older and for home delivered meals, individuals must be aged 60 and older and assessed to be incapacitated due to accident, illness or frailty; lack the support of family, friends or neighbors; and be unable to prepare meals due to a lack of or inadequacy of facilities, or an inability to shop, cook or prepare meals safely, or a lack of knowledge or skill.

The Office for the Aging uses various targeting criteria to deliver available services to those most in need. Targeting criteria in the Older Americans Act include low-income older individuals, including low-income minority individuals; those with limited English proficiency; those residing in rural areas; and, those who are frail, vulnerable. For SNAP, criteria included serving frail elderly (60 years old or older) who were unable to eat adequately and thus were unable to maintain their health and nutritional well-being. Emphasis is placed on serving individuals who are: handicapped, impoverished, living alone, in danger of becoming physically or mentally ill as a result of nutritional deficits, have a chronic health condition and are 75 years old or older.

Home Delivered Meal Clients (Statewide):

• 35.6 % were age 75 to 84; 36.1% were 85 or older
• 65.9% were female
• 53.2% lived alone
• 20.3% were low income
• 50.2% Resided in rural areas
• 21.1% were minority by race and/or ethnicity
• 38.4% have one or more ADLs
• 73.2% have one or more IADLs

Home Delivered Meal Services for Older New Yorkers
A Three- County Longitudinal
Surveillance Study - 2002

Highlights of the Study

• Over 12 million meals were provided to over 56,000 older adults in 2000.
• Each meal provides 33% of the Recommended Daily Allowance (RDA)
• On average, participants received 2 meals per day, five days a week.
• In addition to meals, programs provide nutrition education and counseling, shopping assistance, transportation and links to other cost effective community services that promote and support one's independence.
• Services are targeted to the seniors most in need.
• Many of the program participants need help preparing meals, cooking meals and shopping due to chronic illness.
• Home delivered meal program screen seniors for their need for other support services.

Study Participants

• 71% were 75 years old or older
• 65% were women
• 58% lived alone
• 29% had incomes below the federal poverty level.
• 13% were minority elderly
• 93% needed help to prepare and cook meals.
• 89% needed help shopping
• 88% needed help in doing both - shopping, preparing and cooking meals

The data confirms that the Meals on Wheels program targets and successfully serves older, poorer, more isolated seniors who need help preparing, cooking and shopping. If this help were not available, many of these seniors would find it difficult to live independently, forcing a higher and more expensive level of care.

Study Participants: Prevalence of Illness

• Chronic conditions and illnesses are prevalent among those participating with 87% averaging 2 of the 8 leading causes of death.
• 43% had diseases of the heart
• 38% had hypertension
• 33% had diabetes
• 28% had respiratory conditions/illnesses and
• 18% had cancer.
• 80% of participants averaged 2 of 11 chronic conditions.
• 60% had arthritis
• 24% had vision impairments
• 28% had digestive conditions
• 13% had osteoporosis and
• 17% had hearing impairments.

The data confirms that home delivered meals are an important community support service for older New Yorkers utilizing the health care system. It has become more important as hospitals discharge patients quicker and as outpatient and in-home care have increased.

Study Participants: Levels of Food Insecurity:

• Food insecurity and food rationing were reduced the longer a person participated in the home delivered meal program.
• Participants experienced stability in their weight over time

Good nutrition is the cornerstone of one's health and helps in the management of chronic conditions and aids in disease prevention. This fact becomes more relevant as one ages because older adults require foods that are lower in calories but higher in nutrients, and our programs provide meals that are well balanced in order to meet the nutritional requirements of seniors.

Importance of nutrition to older adults (nutrition is medicine): Nutrition plays an integral role in keeping older adults healthy and independent in the community by preventing malnutrition, reducing risk of chronic diseases and related disabilities, supporting better mental and physical functioning, and managing common chronic diseases. Malnutrition, including obesity and underweight, is closely associated with decreased functionality. Underweight and obese older adults need more caregiver assistance and are at greater risk of falls and hip fractures. Thus, a primary goal of improving nutritional well-being through a healthy diet is to prevent these two serious conditions, which produce high medical costs. Nutrition services are vital in helping older adults achieve good nutritional status and remain healthy, physically active and independent with a good quality of life.

Nutrition services strive to prevent or reduce the effect of chronic disease associated with diet and weight; strengthen the link between nutrition and physical activity in health promotion for a healthy lifestyle; improve accessibility of nutrition information, nutrition education, nutrition counseling and related services, and healthful foods.

Sixty-six percent of home-delivered meals clients (nationally) reported that the meal provided one half or more of their daily food intake; 29 percent reported their own health as Poor. In New York's nutrition program, 32.4 percent of congregate meal participants are at high nutritional risk while 40 percent of home delivered meals participants are at high nutritional risk.

Area agencies on aging use congregate meal sites, home delivered meals programs, multipurpose senior centers or other appropriate sites to deliver health promotion and disease prevention services, thereby allowing them to integrate such services with the nutrition program. Priority is given to areas which are medically underserved and where there are a large number of older individuals in greatest economic and social need. Broad services include health risk assessments; routine health screening; nutritional counseling and educational services; evidence-based health promotion programs, including programs related to the prevention and mitigation of the effects of chronic disease, falls prevention and improved nutrition; physical fitness programs; home injury control services; mental health screening services; information and education about Medicare preventive care benefits including influenza and pneumonia vaccinations. All area agencies on aging provide medications management screening and education.

Place of nutrition services in long term care system: Older adults and their caregivers indicate a preference to stay in the community, in their own residence, and remain active and engaged in community life, as long as possible. Without nutrition therapy and other long term care services to support recovery from illnesses, individuals are at greater risk of premature nursing home placement and other poor and costly outcomes. For example, in one study, congregate meal recipients who ate more meals per week had significantly fewer inpatient admissions and emergency department visits than those eating fewer meals. Home delivered meals recipients receiving more meals per week (3 or more) also had significantly fewer inpatient admissions than the comparison group. [Note: our HDM participants receive three to four meals per week.] Providing meals and other nutrition services is a valuable support service to family caregivers as they provide long term care services at home.

Emergency preparedness: Local nutrition programs assist older individuals with emergency preparedness in several ways ranging from providing information, training and assistance to create personal plans to providing shelf-stable meals for emergency use or opening as community kitchens for disasters such as floods. Meal sites often are used as cooling and heating centers as needed. One of the significant challenges in disasters is that local offices for the aging often serve a much greater number of older individuals than they normally serve, which may strain their resources for normal service provision.

Standards: All nutrition programs funded through NYSOFA are required to follow the most current Dietary Guidelines and meals must provide one-third of Dietary Reference Intakes (DRIs) to ensure healthy, balanced meals for participants. This is especially important given their overall health and nutritional risk status. The federal program required adherence to these standards long before other national feeding programs implemented nutrition standards.

In addition to meal standards, all local programs are required to have a registered dietitian on staff or under contract to oversee the food service operation including tasks such as menu planning, nutrient analysis and monitoring as well as providing nutrition health services such as nutrition education, screening, assessments and nutrition counseling as appropriate.

To aid in the safe operation of nutrition sites, NYSOFA has a longstanding Memorandum of Understanding (1978) with the New York State Department of Health (NYSDoH) to ensure that all food preparation and dining sites are routinely inspected and provide NYSOFA with inspection data from all nutrition sites; provide annual food safety training statewide, and provide ongoing technical assistance concerning food safety, sanitation and food recalls and outbreaks of food borne illness.

The intent of S.3340 is laudable as the importance of nutrition has been well documented. Senate 3340/Assembly 7152 amends the elder law to create a new § 224, establishing the supplemental nutrition assistance program, providing that any person sixty years of age or older is eligible to receive services of the supplemental nutrition assistance program provided that such person meet specific criteria, based on a standardized assessment procedure that is approved by NYSOFA. Such person must:

1. be incapacitated due to accident, illness or frailty; and
2. lack the support of family, friends or neighbors; and
3. be unable to prepare meals due to a lack or inadequacy of facilities, or an inability to shop, cook or prepare meals safely, or a lack of knowledge or skill.

To address the questions on the hearing notice, local providers can provide more detail on administering the program as dollars from the federal government and from the state are allocated to the counties.

NYSOFA does not currently collect waiting lists so measuring the actual demand for home-delivered meals is difficult. Waiting lists are also not the best indicator of need as many home-delivered meal recipients receive meals on a short-term basis, following discharge from a hospital for example.

County offices for the aging and their subcontractors can provide detailed information on the amounts they are able to raise through private donations, through their own county budgets and by individual contributions.

Specifically on the proposed legislation, nutrition and nutrition related issues will continue to be a major focus and priority of NYSOFA. It is critical to the health of older adults, helps maintain them in their homes, is important when transitioning from the hospital to home, helps to manage chronic conditions and is important in helping to ensure that older adults who do not leave their homes have consistent contact with someone. As demonstrated in this year's budget, the state's fiscal conditions required that each agency identify their core programs and services.. Home-delivered meals are clearly a core service. This year fiscal realities required difficult choices and sacrifices by all agencies. However, as I stated earlier, with Governor Paterson's commitment to older New Yorkers and specifically the SNAP program, and your advocacy for SNAP, additional resources were allocated that will help provide additional meals to older adults in need.

Senator Diaz and members of the Senate Standing Committee on Aging, we sincerely appreciate the opportunity to continue to work with you on issues such as home-delivered meals, long-term care reform and any other issues that the state's older population confronts. We thank you again for your leadership and advocacy on behalf of older adults.

Appendix A