Facts & Myths about OAA Nutrition Programs 1/10/2018

Facts & Myths about OAA Nutrition Programs 1/10/2018

September 16, 2019 0 By Ewald Bahringer


Good afternoon. This is Jennifer Mead from Oregon State Unit on Aging and I’m looking at the time – it’s 1:29 – we’ll give it another minute or so but just wanted to welcome those of you who are getting on the call. We’re really delighted to have people joining us today, and we will start
in another couple seconds here. As long as we’re waiting I’d point out the chat function and actually if somebody’s willing to chat in whether they can hear me that might be helpful. Great thank you. So it’s 1:30, and again this is Jennifer Mead with the State Unit on Aging. Welcome to all of you who are calling in today and are participating in this webinar. Really delighted to have you here and very excited to have Shelly Zylstra presenting for us on Facts and Myths about Nutrition Programs with a focus on Oregon. I had the opportunity to hear her do a similar presentation a month or so ago and was excited and said please will you come and do this for us here in Oregon and she said sure she was willing to. Shelly is the Aging Services Program Specialist for Region 10 which includes Oregon Alaska Idaho Washington and we were just hearing that she’s adding California too. She has many years of experience with aging programs and Area Agencies on Aging and specifically with nutrition programs and now is serving in this regional role so is our go-to person with questions around nutrition programs so brings a great deal of expertise to us. So really excited to have
her presenting. Just a couple logistics as we get going. We do have everybody on mute so
if people have questions we would ask that you send them in by chat and we will to the best of our ability convey those questions to Shelly so that she can answer them. We’re doing this to keep down the background noise but also because we are recording this webinar and we hope to be able to have it archived on the State Unit on Aging website within the five or so days after this presentation today. So for folks that have missed it it will be available and then one last comment is Lori Watt was sending out the copy of the powerpoint to folks that registered in advance. If for some reason you didn’t get that please just follow up with Lori or myself afterwards and we’ll make sure to get you a copy of it. In the meantime we’ll go ahead with the webinar today and turn things over to Shelly Zylstra. Thank You Shelly. Thank you so much Jennifer for those kind words I’m going to leave this primary slide up there too in case you have questions about something I say today or want to want to discuss it with me. My contact information is there and I would encourage you to give me an email or a telephone call and I’ve asked Jennifer if that’s okay with her and she said ain’t no thing at all. So that will be helpful for you down the road here a piece. Sorry, a janitor just walked in to get my garbage, wouldn’t you know. All right the Older Americans Act is of course the basis for all of the programs that we do and they have some very basic descriptions of requirements for nutrition programs. The goals are listed here to reduce hunger, promote socialization, assist access into services which delay the onset of adverse health, meet nutritional requirements, have input from participants, someone with nutrition and a person knowledgeable about the needs of older adults and program development, and then there also are some targeting language and there really isn’t a lot of specifics about it and so we we wind up with a kind of a skeletal list of requirements which states and programs often embellish to meet their own needs. Some facts about the nutrition program I added. The federal language there is in black and the Oregon language is in red and I thought it was kind of interesting when you start looking at the total number of meals and clients that are served, the meals per client substantially lower for congregate and home-delivered actually compared to the national average. 33 meals per client for congregate and 50 at the national level. 133 meals per client in Oregon 165 meals per client in at the national level. I don’t know that those are necessarily something that tells us a story but I just thought it was kind of interesting to look at the differences there. When you look at clients that are at high nutritional risk we see that 73% of all clients that are measured – and this would be those clients like not just nutrition clients but also congregate – sorry – case management clients and others that receive the nutrition screening risk screen 73% are at high nutrition risk nationally and only 26% are at high nutrition risk in Oregon. That could be related to not so much that they aren’t at risk but that the the scores are not being included in the screening and so that’s something to kind of keep in mind. We’re in a time now where we’re being looked at from an outcomes perspective and are we targeting our services is becoming even more important than it was maybe a year ago. We’re looking now at people saying why are we doing this, why are we giving old people free lunch, and we need to be able to justify it. So this is just kind of a commercial message to tell you to please work as hard as you can to get as much data in there. It’s very difficult to go to Congress and say yeah we’re feeding meals to people but we really don’t know much about them. The questions below are two questions that I think are really helpful to include in for example a home delivered or congregate assessment. Sixty-two percent of folks nationally said that they received half of their food from the program and this wasn’t from the intake it was from a study that was done. In Oregon we don’t ask that question necessarily and so it might be something to consider adding to an assessment that you’re doing in Oregon. 25% of participants said that they did not have the resources to buy food those can be very helpful from an advocacy perspective because everybody understands food, everybody understands eating, and nobody wants to see grandpas and grandmas going hungry. And so if in fact you can gather that information it can really help to tell your story. This is I thought it would be interesting to look at the states in region – I did not include California because I received the gift of California shortly after I did this presentation – but I thought it would be helpful just to kind of look at the little bit of differences. On the left side which you see the red is congregate the blue is home-delivered. The other way
around the blue is congregate the red is home delivered, and on the left you see the meals and on the right you see the number of people served and you can see and as we go through here you’re going to see virtually in every state there’s very very similar things. In virtually every state Idaho is a little different we see that the number of congregate meals served is less than the number of home delivered meals and I ran or worked with nutrition programs up in our area for 30 years and I had two programs that served way more congregate meals and home delivered meals and I had one program that served double the number of home delivered meals compared to congregate meals. I never could explain the difference but it does vary but this tends to be what you’re seeing here tends to be the information that you would see. So I’m going to flip through the other states Alaska pretty similar I’m going to go back and forth here so you can kind of compare them but very very similar to Oregon where you see increases in home delivered meals and relative static or decreases in congregate meals. In Idaho I will tell you that in 2014 they got new software and so between 2014 and 2915 they were trying to figure out what was going on they discovered that some of the transition when they move their data over to the new software system it didn’t work well and so we’re just kind of kind of throw out 2014 and you know question 2015 but what we saw in 2013 where they were collecting good information was that they were serving more congregant than home delivered meals and you know there is no difference between targeted populations in terms of congregate or home delivered. I think we tend to think of home delivered as being the more frail and more targeted individuals but congregate is equally important because it helps people from becoming frail and that’s really one of the goals of the program again excuse me you see the congregate participants outnumbering the home delivered by a long shot. In Washington we see a decrease in congregate meals that’s really quite dramatic and in an increase in home delivered meals by and large the 2014 could just be an aberration but again congregate participants and home delivered participants are really quite dramatically different. How can this be so simple you know it’s a simple program how can how come it’s so hard. Well one of the things is that over time things attract ideas or urban myth like lint and I think that what happens is you know someone will say this is the way it’s got to be and you’re a new project director and you don’t really know what’s supposed to be done and he said it so loudly and with such authority that it becomes a law of the land. I think sometimes we’re afraid to cross the registered dietician and I can say that because sometimes we are nasty. I was .that registered dietician. I am no longer a registered dietician but I spent many years in that capacity. The other thing is that states have choices in how they interpret the bare-bones requirements of the Older Americans Act And AAAs have choices because AAAs will interpret the state standards and the state decisions differently. But I think it’s important for all to go back to the source document and make sure that things that we have added to the program are not for example impinging upon reaching those individuals who are in the target population. An example of that is that let’s say that you have a legislator that requires you to that says it’s not fair you you need to prove these people are all 60 and so you need to have them show their driver’s license to prove that they’re 60. Well if a person has no driver’s license or if a person is not in this country potentially they’re undocumented that’s going to screen them out at the door and they will not be able to receive it. And so most states use the honor system but there are a few states that do actually card people to get into the program. And then the last one is the blind man and the elephant I don’t know if you’ve heard that old Buddhist story but basically the story goes that there was three blind men and they were asked to describe the elephant and one of them was feeling the front of the elephant one was feeling the back of the elephant and one was feeling the side of the elephant and they were describing a totally different animal Got into a huge argument and caused all kinds of havoc because it looks different depending upon what side you’re standing on and the nutrition programs are a lot like that. If you’re a client it looks one way if you’re a project director it looks another way if you’re a director of an Area Agency it looks different and finally from the state or federal level it looks entirely different as well. So I thought it would be kind of fun to go through some of the myths about good nutrition for older people to start with and then we’ll actually get into some project myths so let’s go through these Myth number one when you get old your metabolism slows down and you don’t need as many nutrients and and the truth of that is that older adults don’t need as many calories because their metabolism is slowing down however many of the nutrients actually need an increase which can cause all kinds of problems because they need more calcium B-12, D fiber and potassium but they can’t eat as much food because they can’t have the calories. The other thing that we note is that medications can also cause a need for increased nutrients of one type or another so the only real nutrient that decreases is calories and so older adults need to be more astute about what types of foods they’re going to pick Second myth all humans crave the nutrition nutrients they need. I hear this expressed about kids a lot but I also hear it expressed about older adults. Oh I don’t I don’t need that because my body just doesn’t crave it And will choose what’s healthy well that guy there is making the choice that probably I would make given a piece of chocolate cake or a granny smith I think I’d go the chocolate cake. It’s not true for either end of the spectrum. People do not instinctively choose what’s good for them or we would not have the obesity epidemic that we’re seeing in our country many of the chronic illnesses that we’re dealing with as older adults the experiences are caused by lifelong poor food choices and lifestyle choices to go along with it. So if there was a mantra for older people in good nutrition mine would be variety Pick lots of different kinds of foods Pick lots of colorful foods Pick foods that have a variety of really vibrant colors Make sure you’re getting enough fiber and moderate in calories so that you’re eating as you would need to as a person whose metabolism has slowed a bit. Nutrition myth three – once you’ve joined
the over-the-hill club it’s too late to improve your diet and the damage is done And the reality is it’s never too late to eat healthier. A lifetime of poor eating likely puts you in the in the seat of receiving lots of chronic illnesses related to it We know that heart disease cancer osteoporosis and a number of other chronic illnesses are related to what people ate. But eating well also helps you feel well now and so you can really dramatically affect change the quality of the time that you’ve got left so again paying attention to fiber vegetables and foods that interact with your medications is probably not a bad idea. Now that being said I don’t want to give any kind of a clue that suddenly you can cure things with food. Unfortunately that tends to be something that we see a lot with older adults or they’ll try supplements of things to try to save their bacon and it usually doesn’t work seeking or using nutrition instead of good medical care is really ill-advised. Next myth if you drink when you’re thirsty you’ll always get sufficient fluids. The reality of this one is that older adults do not perceive thirst like they did when they were younger. I can remember being outside as a kid and just all of a sudden it’s like something hit me in the head. I had to have a drink of water I went running into the house and gulped down one or maybe even two big glasses of water and ran back outside to play. Well older adults it sneaks up on them they do not realize that they’re thirsty they do not realize that they’re losing fluid and we find older adults getting into a lot of trouble particularly in hot weather and particularly if they’re struggling with incontinence because people who struggle with incontinence don’t want to pay for extra diapers or pads and so they will skimp on fluids So medications can also cause a problem. The rule of thumb is eight glasses of water. The reality is that each person is going to have their own their own need for water and I think the best thing to do is just drink throughout the day you know make sure that you’re getting at least a small drink of water every couple of hours and that will probably be sufficient. Skipping meals is a good way to lose weight and save money Well it’s not a good idea for either blood sugar falls when you skip meals and then the older adult can fall too so because a lot of lightheadedness is related to low blood sugar The other thing that happens is you just kind of lose your appetite and forget to eat and so older people may just miss a meal and then miss another meal and then pretty soon we’ve got them on a spiral The other thing that will happen is you get you’re not hungry and all of a sudden you get starved and so then you go over to the cupboard and you find easy and sometimes very expensive foods with lots of calories like a bag of cheetos or something equally horrible Not much nutritional value High in salt high in fat and really no redeeming social value So you have an issue if you’re hungry eat something is usually the recommended at regular mealtimes and eating a regular meal at regular mealtimes is really helpful for managing chronic illnesses because you’re taking medications often tied with meals or avoiding meals and so it helps you to keep everything on a regular schedule and that can be really critical for the well-being of an older person Number six there is no such thing as a free lunch Well it’s very hard to convince the volunteer registrars at meal sites to believe this. Non-donators are really at risk of not coming if people lean too hard on them and frankly they’re probably the target population. They’re probably the low-income person the person who’s living in substandard housing the individual who may have a little dementia There’s all kinds of reasons why leaning on somebody for a donation is not a good idea And I know that challenge when you’re working with a volunteer work force to get out and get those folks trained. I remember one meal site that I actually had to put carpet down in the bottom of the collection box because there was one volunteer I think she was actually the secretary at the church could hear who was not putting money in or who could count the change as it was going in and determined how much they were giving and she got her knickers in a knot – she would lean on them about you can give more than that and so we carpeted the bottom of the box you know tried to train her Eventually I think we found her much more proficient at dipping gravy and that seemed to work pretty well for her A good idea for these folks is sponsorship We used to use punch cards where we would say you can buy ten meals and the seniors who were not targeted appreciated that – we would say you know donate for ten meals and the suggested donation for a ten meal punch card is And it was ten times whatever our suggested donation was And what we would tell the seniors liked them and the staff liked them a great deal And we would give them to those individuals who were very low-income and at risk of not coming in because they they looked just like everybody else And so we just tell them that this was a sponsored card and we’d really like to offer it to them and they were always very happy to take it So that’s one way of kind of getting around that nasty volunteer When you talk about nutrition program practices you get it you know I had a really hard time trying to keep this under three hours and I knew you didn’t want to listen to me doing that but there are so many ideas that are out there and I just thought we could have some fun with some of these Program myth number one milk must be served at every meal and I’ve had some programs say well and they’re required to take it if they drink it or not drink it they can throw it away but they’re required to take it Well here’s the deal you know we’re dealing with adults here and adults are allowed to make poor choices and we are an offer versus serve program If somebody doesn’t want the broccoli on their plate they don’t have to have the broccoli on the plate The requirement is simply that the menu includes the broccoli and if the menu includes it that it be served The important thing about milk however is the two really leading nutrients in milk are calcium and vitamin D and they’re the primary reasons it’s recommended Sources of calcium can be offered There’s a lot of opportunities out there people who are lactose intolerance for example usually can eat cheddar cheese if it’s sharp or very sharp cheeses are generally very low in lactose often no lactose there Some tofus have a lot of calcium in them others have none so you have to read the label on those Almonds are very high in calcium Almond milk may not be Bok choy the Chinese cabbage is a very good source of calcium And then fortified bread and orange juice are often places that we can get calcium So calcium is not hard to find The problem comes with vitamin D because vitamin D is only found in fortified dairy products And they don’t fortified dairy products they don’t fortify for example the milk that’s being made into cheese so cheese is not a good source of vitamin D Other things like cottage cheese may or may not have vitamin D you have to read the label but often it has no vitamin D So it’s found only in fortified dairy products sardines sunlight and liver which is not a big combination And the sunlight one is actually somewhat suspect because in older adults kidney function is somewhat suppressed and the process of turning sunlight into vitamin D requires a renal function and so sometimes it’s very depressed The other thing is if you haven’t noticed a lot of times even in the summer time we’ve got older ladies wearing sweaters and older gentleman wearing their Pendleton shirts and so the sunlight doesn’t get to the skin where this activity takes place So it’s very important that people talk about calcium and vitamin D. Vitamin D is taking on some interesting roles so we’re seeing it implicated in all kinds of things and again nutrition I’ve been in nutrition for boy howdy pushing 50 years and I’ve seen things change. I’ve seen recommendations changed dramatically from when I started to where I am now and I think it’s important to realize that as a science nutrition is a fairly new one And so making sure that people have good information and making sure that your information is current is really important. Program myth two – using a menu pattern is not allowed now that computer programs are available Computer programs are really only as good as their database and if you’ve seen printouts from many of them excuse me some of them have very old information and have many NAs or not available and usually what that means is you know there may be that nutrient there but they don’t know what it is And depending upon how good the database is and how well you’re using it you could get false positives and false negatives with regard to how much needs to be served. The benefit of computer programs is every little bit of each nutrient that’s found in each food adds up and so you can make sure that you’ve got enough vitamin C because you’re getting a little bit from the spaghetti sauce and you’re getting a little bit from the jello and you’re getting a little bit from the broccoli However with a pattern with a nutrient pattern or a menu pattern you’re just filling in the boxes and so you have to have a fair understanding of what program or you know what foods are good vitamin C foods and which foods are good vitamin A foods and that’s important to have that understanding. I think menu patterns with guidance that emphasizes variety color and specific nutrients like calcium and fiber and specific foods like on the side you say that make sure you’re including some green leafies some whole grains and some legumes will probably get you to the same place and I think we do a pretty good job We recognize now that a large percentage of our people are very food insecure and making sure that those nutritional components are met is a really good idea because many people this is the big meal of the day and in some cases it’s the only meal of the day Hey Shelly this is Jennifer I’m just gonna interrupt with a quick question and that is can you clarify what a new pattern is for folks that are not familiar with the term Sure a menu pattern would have for example the days of the week across the top and then on the side it would say entree vegetable vegetable grain you know fruit milk and dessert So basically you’re filling in the boxes It’s just a big old chart I’ve got one I’d be happy to share I use it quite a bit with my Title six programs but I have I based it on one that I developed for my Title three programs many many years ago and it’s just kind of a simple way an old-fashioned way of filling it out Does that answer your question Yeah hopefully they’ll respond if not but I would also say that we have one on the SUA website – which may be easier for folks just to get to The one that we recommend using here in Oregon Sure and I think it’s mine So there you have it so easier I forgot I’d even sent that on along so there you have it But that’s what a database or that’s what a menu pattern is Program myth number three you are prohibited from catering or providing special meals for fundraising and this is an odd one to me because I operated food programs up in the Pacific Northwest that were very very involved in fundraising and catering and doing everything they could to make money So when this one first came to me I thought good heavens you know why would they prohibit that with You are prohibited from using Older Americans Act funds from doing catering but the funds that we’ve been providing have not been keeping up with inflation Wages have increased benefits costs have skyrocketed food costs are going up and programs need to stay in business I mean you have to find other places where you can raise money just to stay alive Federal funds cannot be used to these meals so you if you’re going to get into this business what you need to do is have a very good handle on what the cost of your meals are so that you can say okay the cost of my meals were was last year was $6.75 and I’m charging the Kiwanis Club $10.50 a plate and so therefore I’m not using any federal funds because I’m making a profit and then using that profit to help to fund your other programs Usually not a problem at all and really not a bad idea. I’ve long been a proponent of people or communities you know we have school food service programs we have the Head Start food service program we’ve got all kinds of daycare programs we’ve got the senior meal program we’ve got the youth program I’ve often thought you know think about all that kitchen equipment and all of the labor that’s going into it If we were to build a huge commissary in each community to do all of that food preparation it would probably save everybody lots and lots of money. I don’t think that will take place in my lifetime but I used to think it would be a good idea And we had programs that were catering for example the Head Start lunch It really isn’t that much different the requirements are very similar to the ones that we have. We had some people that were working in providing meals to the schools And in Alaska many of the villages way out in the hinterlands only have a school that’s the only commercial kitchen available and so the elders program the elders may go to the school and eat school lunch with the kids in exchange for listening to reading or doing other things and so it can be a really good nice intergenerational opportunity So do think outside the box I recall one program in Washington state that had a really nice gourmet restaurant and they operated the gourmet restaurant which then drove the profits and everybody in town thought it was the best place to eat and the profits from that restaurant it used to be called Blackberries would get driven back into the nutrition program and they basically filled their their deficit by running that restaurant Program myth number four takeout meals are forbidden No, takeout meals are fine as long as you don’t have a takeout program only Food insecure adults actually may benefit from a takeout meal congregate meals are a socialization program in an access program in addition to just being a nutrition program but don’t forget that the goals include reducing hunger as well So takeout meals are perfectly fine I have people all over the United States saying but what if they get food poisoning Well once again I’ll remind you that we’re feeding adults and you can put a little sign on the top of it or hand them a post card that says please keep me cold or keep me hot This is a problem if somebody decides to stop off at Walmart and leave their meal in the car Not a problem so much in the winter and not a problem so much in the summer because in the car it will be a hundred and eighty degrees so we don’t have to worry about it there but I do think that it is something that if you’re going to have leftovers I would I would encourage you to give them to those individuals who are probably not going to get another meal. I do not encourage programs to refreeze leftovers or freeze leftovers and put them into into home-delivered meals. And I don’t know if that’s happening in Oregon I know it’s happening in Washington Unless you’re using what’s known as a flash freezer which freezes stuff you know to below zero in a matter of seconds it really is not safe even if you’re using a walk-in refrigerator Walk in commercial walk-in refrigerators were designed to hold frozen food not to freeze food and so that’s lost on a lot of us but flash freezing is the only way to safely do it So I really say you know send it home with a participant If you can give them a whole meal then that’s really great because you get to count it as two meals going to one individual and that’s perfectly acceptable Anybody have questions about that one that’s what I usually do get questions about? Yeah not some questions coming but encourage folks to send in their questions and we’ll relay them on Okay hearing none we’ll move along but we can talk about it later if you need to. Salad bars are not an acceptable menu for a senior meal Offer versus serve I can’t say that often enough. We offer a well-balanced meal we don’t necessarily have to serve a well-balanced meal If I’m standing in line and I don’t want delivering onions there’s no reason for you to put it on my plate Am I getting a well-balanced meal with 1/3 RDA? No but have I broken a law? No because you have offered it to me and I have chosen not to accept it. Seniors are adults they shouldn’t be wrestled to the ground to make sure that they eat their harvard beets. They should be treated as adults A salad bar is really a nutritionally rich way to get the meal down. I recall one time going to a a restaurant in Phoenix Arizona with my father who lives down there and it was a salad bar that looked like it was at least a mile long and it had a gazillion different toppings and lots of different choices and they had a pot of soup and they had a casserole of some type and they had homemade bread And that was pretty much what was at this place and you couldn’t get in there There were senior standing in line outside waiting to get in and I think that model actually would have some merit in some of our programs Now this is a good opportunity for nutrition education because if somebody is eating a bowl of bacon bits covered with blue cheese obviously we’ve missed a cog But the salad bar model really is going to attract younger elders it allows people to feed themselves and serve themselves It’s a great attraction for people who are coming off the streets If you’re senior center happens to be downtown or near businesses it can be a good moneymaker for you to come on over to the Senior Center and have a $5 salad bar or excuse me charge by the ounce and see how much you know see what people get Younger people pay five bucks an ounce and older people pay a buck an ounce or you know whatever you want to do So you can you can offer your donation as a discount to the older people just making sure you’re covering your cost. Shelly, I have a question for you on the actually the previous slide Myth number four The question is I understood that only one meal per day can be reimbursed for federal dollars If a senior at a meal site dines and takes a meal home how can that be reimbursed If you look back at the Older Americans Act it says that if a meal provides one-third RDA that you can charge for one meal If it provides two thirds if you provide two thirds of the RDA you have to meet that with two meals and you can provide percent of the RDA actually RDI or DRI with with a hundred percent of the meal So it’s absolutely not true that you can only provide one meal with federal funds and many programs I’ve got some Title six programs that provide three meals a day seven days a week Rare heavily subsidized by the Tribes but do exist and so do not think I know I have a lot of because many of the menus that we’re providing provide two thirds of a meal or two thirds of the requirements If you wanted to you could do a light breakfast a light dinner and a heavy lunch and send them out in a takeout and count them as three meals and so there are ways of actually making this into a money-making proposition So no absolutely no prohibitions That’s another one of those standing on one side of the elephant Myth number six locavores need not apply it’s too expensive to buy local Ah no this isn’t true Local farmers and Oregon is such a wonderful place for working with the local agricultural community They love to have their menus advertised their products advertised on the menus Farmers have coffee at the local coffee shop where the seniors also have coffee and the seniors say hey Joe I ate some of your broccoli yesterday boy it was really tasty So they get comments You can put it in the newspaper and say you know Great thanks to Joe for the wonderful broccoli at the Senior Center on Tuesday Often what happens when you do that because they’re feeling so good about their contribution to the community they often charge much less We had an experience in one of my communities in Skagit Valley there’s a huge farming community lots and lots of truck farming very similar to the Willamette Valley berries and and all kinds of fruits and then root crops and lots of other things They ordered potatoes from one of the local potato growers and he gave them a pretty good price on the potatoes and they advertised it as you know old McDonald’s potatoes au gratin was right on the menu And so many people contacted that guidance that hey thanks for the potatoes they were really good that he started to give them all the potatoes they could use And then pretty soon he was just given them you know he gave them everything they could use cheap and next year it was everything you can use free He just gave us all the potatoes and so it was you know potatoes are not hugely expensive but we eat a lot of them and it was a great way to make sure that people understood that local is better that it’s fresher and it gives the recognition where it needs to go and really was very very helpful in identifying people that were part of the community and contributing to the well-being of the older folks around Program myth number seven states AAAs or programs absolutely have to have an RD on staff to help them manage and plan nutrition programs for the elderly and I love that Keep Calm and Ask a Registered Dietician Well the Older Americans Act says that states must utilize a dietician or other individual with equivalent education and training or if that individual is not available an individual with comparable expertise or what we call an ICE individual with comparable expertise An RD is a great asset to your team There’s lots of ways to meet the requirement other than employment You can have a consultant that would come in and work with you You could have somebody write your menus for a full year and call it good You can do all kinds of things. I think a registered dietitian in fact when I left the programs up in Northwest Washington I had RDs in each of the directorships and they were very much value-added They could do nutrition education materials They were experts at purchasing equipment They knew how to cook They knew good nutrition They could write their own menus it was a win-win. But it is not a requirement that they they have person on staff And what I have told my Title six programs to do because in many cases they’re living in a community where there isn’t a registered dietitian I’ve told them to go onto the city website Senior Center websites and steal the menus because everybody is required to have an RD check the menus And you guys can do the same thing You can steal menus from other senior centers that have been approved by a registered dietitian and use those menus The only rule is that you can’t take the vegetable for Monday and move it to Tuesday’s entree You have to eat the menu or prepare the menu as it has been written up so no switching and swapping but it is a great way to find menus And I would have a menu exchange statewide so that people get an opportunity to look around and see what’s going on It’s a great way to get good ideas You’re all serving effectively the same population Yes I get it that rural communities do different things differently than do the suburban or urban communities But in reality food is food and people are people and menus that are popular in one location are generally popular in another location Shelly, a question here how do you determine if a person is an ICE Good question yeah and that’s an interesting question because there is no definition of an ICE okay what what I have written up there excuse me what I have written up there with equivalent education and training and nutritional sciences okay so a dietitian or individual with equivalent education or training in nutritional sciences or an ICE and they do not define that so that’s kind of left up to your thought process. I think probably in some cases a nurse may be helpful They do have some nutrition In some cases if you have a Extension home economist that would be a person that could also help Your Extension agencies are not used as much as they as they could be Some states absolutely limit it to an RD but the Older Americans Act does not require that it just requires that somebody help And they are not just menu checkers you know you want to incorporate their talents in other ways as well in developing nutrition education materials doing diet counseling helping to spot and do assessments in the home There’s a lot of different things that can happen We had contract all of our nutrition programs had a contract with with the Medicaid Waiver system to provide nutrition education and nutrition counseling for clients that were eligible for the Medicaid Waiver program And so that was how they funded their registered dietician I believe the reimbursement rate was somewhere near $70 an hour which of course wasn’t what they paid their dietician but for those hours that they were doing counseling they were making money And that that was what they used to kind of subsidize the salary So it kind of all came out in the wash They kind of paid for themselves if you will So I don’t tell you that there is a definition of an ICE I think you use your good judgment. Jennifer can take a peek at it. Jennifer will likely call me and we can discuss it. I would be cautious of an individual who is especially because of the population we’re dealing with an individual who has sort of got an alternative look at nutrition and well-being Often times people try to discourage people from taking their medications or taking a food or an herb in place of a medication We aren’t in that business But if they’re a pretty well grounded individual with good information and if you can’t afford an RD again steal menus from somebody who can So that’s a good good plan Myth number eight Statewide required menus are a good way to assure good nutrition And there are a number of states where they registered dietician at the state writes the menu and every nutrition program in the whole state is required to serve that menu And I took this one off the internet that little picture there it’s a Thanksgiving menu planner Tell us your holiday plans and we’ll find the perfect menu for you You know we all know what our family’s traditions are for holiday meals and to turn that over to somebody else seems a little bit odd And I feel the same way about programs yYu know your people you You know local produce and local things that are available You know what’s available in your community that you can get for a lot cheaper so it’d be something that you would use or even on a donation basis and I think that people need to write there is a requirement that participants participate in the development of the menus And if in fact you’ve got someone at the state level who’s writing the menus for the whole state what context do they have with program participants So I think it’s good practice to include people There’s a variety of ways of doing that you could have a food committee to help you identify things You could do a survey to determine which menu items are the favorites and include those in your menus You could do tasting tables where you have a new menu item served and you just get a taste kind of a Costco model where people would come in and try something and then you in question do you like it would you like to see it incorporated in the menu and then leave it at that if people like it they’ll like it and if they don’t you don’t have to serve it you just kind of leave it go There are regional differences There are temperature differences you know People on the coast of Oregon might enjoy soup in the wintertime but people over in Eastern Oregon probably won’t enjoy soup in the summertime so I think it’s important that we allow regional choices You’re lucky because Oregon does not have such a thing but there are a number of states in the United States that say that you know this is what you’re going to serve and if you go to any Senior Center anywhere in that state that’s what you’re going to get and I don’t really see the benefit there One thing I like to always remind people is excuse me menus and foods that are not eaten have virtually no nutritional value and so that’s something to ponder a little bit Another question back to the RD I think that’s inspiring some interest but question about what about using a dietitian that specializes in diabetes? I think that you know I think dietitians come in a variety of flavors okay Many of us focused on therapeutic dietetics and we were looking specifically at clinical and that’s all we wanted to do was work with people who had diseases and work with them on knowing what to eat to fix their disease And I think we have a large number of people who have diabetes in our communities and it is not a bad person to have available That being said, not everybody has diabetes and so if you have a diabetes specialist or a certified diabetes educator it’s great because they can do lots of things but make sure that they aren’t sort of overzealous about avoiding sugar You know there’s nothing wrong with a piece of cake particularly if you’re going to eat one meal a day and you don’t get cake every day And so I would say that you know interview carefully and make sure that the person you pick isn’t so clinical minded that they’re no earthly good That they can make sure that they understand that food which is in season is tastier and cheaper That a variety is incredibly important with this population And also you want this person to have be well-rounded enough to be able to help you to spec a food bias steam jacketed kettle It’s kind of an art not necessarily a science and so you want somebody who’s going to be well-rounded enough Diabetes is great we have lots of folks with it excuse me but I think it’s important that we make sure that we’re covering our bases because our programs are more than feeding diabetics That answer that? Okay moving along yep. I actually got asked this today. I heard we weren’t allowed to have salt shakers I know oh myGgod this thing’s been around since Columbus But congregate meal sites are allowed to have salt shakers I wrote my little thing there if you build it they will come remember that from the movie Field of Dreams and here’s my voice of experience tells me that if you eliminate salt shakers they’re going to bring their own It’s kind of like the the programs and you know what I’m talking about The programs that serve a lot of people and say you can’t take food home how many old ladies have old margarine cups in their in their purses and they load them up before they leave and their milk goes in there and they march out the door You know sometimes I’m sure those margarine cups get pretty gamey by Monday morning but you know that’s what’s going to happen Keeping sodium low is important We have a lot of people who have hypertension but equally important is potassium from food and I’m not talking about potassium chloride in salt substitute I think the best way we handle it is looking at our menus and if we have a food particularly an entree which is very high in salt let’s say that we’re offering ham we’re having our Easter dinner So we have ham and instead of serving scalloped potatoes from a box which is also very high in salt and then canned green beans which is also high in salt and pretzel jello which is also high in salt we want to make sure that we’ve got options for people And so if you have an entree that is high in salt like ham you might want to offer you know cook up a pork roast for individuals who can’t do the ham People with congestive heart failure a piece of ham could tip their wagon and you would wind up throwing them into an episode of congestive heart failure and so offering an alternative But if you’re going to serve a high salt entree serve it with baked potatoes Serve it with a fresh vegetable not something that’s canned Forget the pretzels in the jello I don’t know who invented that in the first place And make sure that you’re offering fresh fruit as a dessert because baked goods will also be high in salt. Sodium education is critically important a lot of people are unaware of fact that many of their medications are actually high-end solved and so making sure. My father has congestive heart failure and I got in his house and sitting on the counter was this thing of alka-seltzer and I went Holy Smokes because alka-seltzer is very high in salt and he couldn’t understand why he kept having problems and I said you know you’re having problems because this is not your choice For you know if you’ve got don’t take sodium bicarbonate if you have heartburn we want to give you an alternative and So sodium education is important and treating people like adults is also important Se’re dealing with big people here they’re allowed to make poor choices and my dad is allowed to have his bicarbonate of soda and his alka-seltzer if that’s what he truly wants as long as he has been informed about the consequences of doing that So he is allowed to make poor choices and he’s very loud if he is not allowed to make poor choices so let it go Program myth number ten Every site must provide meals 5 days per week well the Older Americans Act says that every nutrition program must provide meals 5 days per week unless a waiver is granted. You know technically it’s not ideal but if you have five meal sites you could serve one day per week in each meal site and offer and cover your bases because as a program you are serving in these areas. So we had programs that served urban and rural communities all by one program We generally didn’t do it by individual senior centers obviously we had a nutrition program that served a whole county and that would be or whole service area in some cases they had a couple of counties And they were allowed to determine they had some meals that were Tuesday Thursday and other meals that were Monday Wednesday Friday and then the ones in the urban site served five days a week so it’s kind of a misunderstanding that I run into quite a bit As we’re seeing the number of meals or that the dollars are not keeping up with inflation I recognize that As we’re seeing the money diminish I think you know cutting back a meal day is probably a better way of looking at it rather than starting a waiting list and having people standing outside the door looking in while you’re feeding half of the population that needs a meal. We looked at expanding and contracting meal sites What we found out was that if you expanded a meal site from Monday Wednesday Friday to three days or to five days a week what we generally did was serve the same number of meals but instead of serving them you know over the course of a week instead of serving them over three days we were serving them over five days because people wouldn’t come every single day They would come intermittently and people were just given more choice about when to come So I really think that having experienced that a number of times it’s probably not a bad idea to allow that and take a peek at how things are going in those areas What we finally wound up with in most of our meal sites with the exception of those that were central kitchens were that we had no paid staff they were all volunteer staff and it worked pretty well for the most part So that was one way of saving money. Program myth number eleven all food must be inspected by the US Department of Agriculture Well the USDA has a branch called FSOS Food Safety and I can’t remember what Inspection sSrvices and it is the inspection arm of USDA and it only inspects meat poultry and eggs okay There are inspection acts 1906, 1957 and 1970 where they wrote the rules for what is meea there’s actually a law called the Meat Act the Poultry act and the Egg Act and these set up the requirements for healthy wholesome meat poultry and eggs And those are the only things that are routinely inspected Foods like I don’t know a pre-prepared food like frozen lasagna those kinds of things are inspected but the foods themselves are not inspected The plants are inspected to make sure that they’re keeping temperature records and that their equipment is in working order and that they have the place is clean and they’ve had health inspections Those are the kinds of things that they’re inspected for but actual inspection of food is only done on meat poultry and eggs. Now USDA does grade produce okay There’s the agricultural marketing service of USDA grades produce it grades it but it’s for quality not for safety So for example you know that you’ve eaten a pear and sometimes the pear has those little hard lumps in it and those lumps are affectionately known as corns in the pears And if a pear has lots of corns it is not as desirable as a pear without corns and so one may be a grade A and one may be a grade B. Does it mean that if you eat a pear with corns it’s unhealthy for you no it just means that once in a while you’re going to bite down on something hard But there is no safety implication by the grade You can eat grade B anything you want and it’s still going to be wholesome and healthy it just isn’t going to look good or it may not taste quite as good The other thing is is that fish for example is not inspected And what I’m getting to here is that we live in an agricultural community where people are willing to give things to us and then I’ve had programs call me and say well we can’t accept it because it hasn’t been inspected by USDA And USDA does not inspect produce They do not inspect fish There is no inspection process for fish How do we inspect fish? We smell it and if it smells like a rotten fish it’s probably a rotten fish So only meat poultry and eggs are inspected and most of the time every piece of meat that comes to our table is not inspected There is a lack of inspectors The plants are inspected the process is inspected and periodic inspections of hanging carcasses is done but it’s not done nearly as much as it used to be So again another myth. USDA does not inspect everything and they don’t have to Program myth number twelve is the reason I included program myth number eleven Donated food cannot be served. Certainly our nutrition programs are effectively governed by the same rules that cover restaurants and if somebody made some home canned green beans and brought them in to offer them we have to say no I’m sorry Myrtle we can’t use your green beans but thank you so much they look beautiful you ought to think about entering them in the fair okay. Those are prohibited and the reason for that is because I doubt Myrtle kept retort records on how hot the canner was when she did her beans And that is what’s required in a commercial canning establishment They have to show that they were watching that the temperature was kept at a certain level for a certain length of time and they have to have those records in writing for every can of beans that comes off of that cannery So home prepared foods are prohibited okay Now some of them are not a big deal cookies are pretty hard to screw up However if you accept cookies and you’re going to find yourself being offered pies and pies can be problematic particularly cream pies So generally what we say is no home prepared foods However garden produce fresh fruits and vegetables are often offered You don’t just have to give them away You can add them to your salad In the summertime with a number of gardens that I bet we have in the Willamette Valley with the seniors I’m going to guess that you know you probably could get some tomatoes or I know you can get zucchini and mix it in with your other vegetables and serve them that way There really is very little risk in serving a donated zucchini and so I would encourage you to not to ask for them because if you ask for them, what happens is you get pies and you get jam and you get other things But if people want to bring produce in there’s no reason not to use them in the program. Another thing that you can do with them is make CSAs for elders. CSAs are the agriculture baskets that we often can you can kind of like a subscription service or to a vegetable basket and every month you get a different vegetable basket or every week we get a basket of vegetables. You could do something like that for your home delivered meals or even for your people who are food insecure. A lot of times people just put them out on the table and that seemed to work really well for us Se actually did had one program that did that with our farmers market vouchers They took some of the money in cash which is an option They purchased food from local farmers and brought it in and put it out for the people to take with them and they signed an attestation form that said they were low-income and we’re eligible to participate and that was it and they actually were able to serve a lot more seniors using that model than using the the vouchers from the farmers market program program. Myth number thirteen Participants need to show proof of age to participate And here we have a driver’s license that says some old guy who’s old as the hills from somewhere. The Older Americans Act is actually silent on this one. Most states I think rely on the honor system to attest to the age of participants If you have someone who looks like they’re 33 and likely is not you know old enough you can say to them these programs are for people who are 60 and over and if you eat here you’re taking money out or you’re taking food out of the mouths of someone who is 60 and over if they insist they’re 60 you know I suppose you could ask for ID but it’s kind of iffy ground because if you ask that person for ID shouldn’t you really be having a rule about who you ask So it can be real dicey particularly as I said before if we’re talking about members of the target population or minority individuals who might be a grandpa or a grandma from El Salvador who is up to do farm work and they take care of the children at home and they may be undocumented and they are eligible to participate there is no requirement in the Older Americans Act that people be Americans oddly enough and so I would encourage you to really look at how you do things and make sure that you’re not discriminating. I think often people forget about who is eligible for programs so I just want to rush over that a little bit First of all it’s people who are sixty and over this is congregate sixty and over Sheir spouse of any age so some old guy gets lucky and finds himself a 23 year old beauty she gets to come to the meal site right along with him. If they have a child with a disability who lives with them and comes to the meal site with them that person is also eligible and when we talk about eligibility we’re talking about receiving the meal on a donation basis and counting that meal for NSIP The other person who is eligible is a volunteer and volunteers for the meal program. I think this gets stretched sometimes the Senior Center manager who really doesn’t do much for the meal program says that her volunteers should be allowed to come in The person who runs the Tai Chi class. Now if you want to do that, that’s fine but make sure that you’re looking at them. They are not eligible for NSIP. They should be volunteers of the meal program. The other individuals who live in a facility like a high-rise apartment building where there is a meal site at the facility. They are eligible to come down to the congregate meal site with their neighbors and so that’s another one. With home-delivered it’s again the person 60 and over, the spouse of the individual regardless of age, a disabled adult child or child who lives with them who is a dependent on them, they can also receive a meal. Can volunteers receive home delivered meals? wW say of course they can Well that means that they go home and we deliver a meal to them. No you can offer them a congregate meal but probably not a home delivered meal. So I think sometimes we’re writing state Standards we we neglect that. The other thing that is not included is that individuals who live in a housing facility who are eligible for congregate meals are not eligible for home delivered meals. So that is not an option for those folks. Keep that in mind as you’re going forward I think so often you know we’re so focused on the people with gray hair that sometimes we forget about the individuals who come to the meal site who are with a person and if we couldn’t feed them we couldn’t feed their mother and they are eligible. In every meal site that I’ve really had anything to do with ever there’s always a younger individual usually developmentally disabled who really didn’t fit in with his class in school and has found kinship and a social group at the Senior Center And that individual is not 60 they are disabled they are on SSI they will turn 60 and be part of the target population but probably not for another thirty years What do we do with them? Well my recommendation is make them a volunteer. Give them something to do because that is really your responsibility to make sure that you’re serving program meals to people who are program eligible and that’s one way to make them eligible for the program. Shelly, a question came in here and this may be more of a reporting on our Oregon Access system but it says how do you make note that the person has a disability and is living with a 60 and over person. I think the answer there is just simply ask them you know Is this your son and you know usually we’re talking about a person if it’s not in an urban situation we probably know okay in the rural locations we know that that’s his son and he’s living with them and that’s the way it’s gone. I would ask them if they say yes and fine Otherwise make them a volunteer. Because if in fact you turn away the kid you’re probably going to turn away the elder as well and so find something you know. He can’t he can’t eat here for a donation unless he’s a volunteer can I offer him something, can I put him to work today? and usually that works great or just don’t even give them the option – just say hey George I need you to come on over here and hand out napkins you know this is important for me to have you do and that’s one way of putting them to work. It’s your call you know it’s your call but what we want to always ask ourselves is – is it in the best interest of the older adult? what’s in the best interest of the older adult? and if it’s trying to figure out a way to make their son be eligible for a meal that you’re not losing your shirt on then figure out a way to make them eligible because otherwise the mom isn’t going to show up. So I don’t know if that’s clear but that’s usually kind of been my bottom line all along. And then the last one is Program Myth 14 Everything is in the Older Americans Act and states cannot add to it. States unfortunately and fortunately are given the authority to add requirements beyond those in the term in the Older Americans Act and that’s part of the reason that myths exist. There are states that outlaw salt shakers okay and they’re allowed to do that if that’s what they believe is in the best interest of the seniors. When you when you hear a discussion about something maybe you’re at a national meeting and you’re overhearing something don’t all of a sudden clam up and say oh my god we don’t do that. What I want you to do is say huh that’s interesting we don’t do that in our location and and I think I would rather than clam up I would sort of share with them that that isn’t the way you do business and share it because neither one of them is wrong It’s just a different way of looking at the elephant. Wo keeping in mind that what’s good in one area may not work well in another is important and although the Older Americans Act is the authority document it is the source document, there really isn’t a whole lot there and there’s a lot of discretion placed on States and on AAAs who can add requirements as they see fit. And States oversee the AAA’s to make sure that they’re not putting in a requirement which could then screen out or cause problems for members of the target population and so that’s how we you know kind of look at it. In closing I’m happy to take any questions that you have if you want to call me up and chew me out feel free. I think it’s important to keep in mind that we all have a heart for seniors and if you have a heart for seniors you’re motivated in a good direction and you’re working towards a common goal regardless of whether you’re serving broccoli or green beans. And and we share a common value in that we value and see the benefits of older adults and we want to see them thriving in their community. And if you can say yes to all of those things I think you know you’ve kind of got it licked. Do not hesitate to contact Jennifer. Give me a call if you’re stuck. Jennifer trumps Shelly shall we say because she is the state authority. I can talk to her about issues that I become aware of but by and large because there aren’t any hard and fast rules about what needs to be done it’s often left up to the discretion of the state and so again if you can say, is this the kindest most loving thing I can do for this senior at this time, you’re probably going in a good direction. So I thank you for your time and I would be happy to take any questions that might come. Great Shelly thank you so very much and we do have some more questions that are coming in so I appreciate your being willing to stick around for those. Tere’s one did I hear you say that an underage 60 adult residing in a housing facility is not eligible for a home delivered meal? We have facilities that are primarily occupied by persons with mental illness and who do not fit well in the congregate environment we would prefer to serve them in their home. The rule is if you go to the Older Americans Act and read it it says that for a congregate meal they are eligible. For a home delivered meals they are not eligible and I get that that can be really dicey because you’ve got a Center where you’ve got seniors who are kind of afraid of those other people. I’ve seen it happen over and over again. And so they’re afraid to come out and if they’re in the seniors eat One thing that I would recommend is that if you have folks like that you may want to say and if they want to take their meal back to their room I would say in that case what’s the kindest thing you can do for the elder. I think that’s fine but in terms of delivering a meal to them I would make them come down and get it and haul it back to their room. Of course that sets a precedent for the seniors. They’re going to want to do the same thing and that eliminates the socialization piece about it. But no technically they’re not eligible for home delivered meals they’re not included in that eligibility category so delivering a meal to them doing the home delivered meals assessment for them You know home-delivered meal is more than delivering like a pizza It is an assessment to assure that they’re getting what they need to look for service needs and to look for nutritional well-being and that’s a home-delivered meal and folks are just not eligible for those. Thank you and perhaps a somewhat related question but can you go back over who is eligible for Older Americans Act meals besides those who who are 60 plus and this is specifically in regards to home delivered meals. Okay with home delivered meals and I’m going to open my Older Americans Act right now so that I can make sure I’m looking at as I’m going through it but with home delivered meals the person who is 60 plus, the person who is living at home with the person who is 60 plus okay, they’re homebound. And homebound is defined usually as unable to leave home without assistance. And people can be homebound because they’re developmentally unable to do it, they physically they can’t do it, they may have a mental health reason for not being able to do it, so they have to be homebound. Their spouse of any age, homebound or not, is eligible and a disabled child that lives with the person who is homebound is also eligible, but that’s basically it. Volunteers can receive a congregate meal but it’s not a home – obviously not a home delivered meal it’s kind of a silly thing but that’s the way it is. And those are basically the folks that are eligible. Now in some states they have included serving the caregiver of the older adult so let’s say that grandma’s living with her daughter and it gives a respite to the 38 year old daughter who’s got grandma living with her. That’s fine Those meals are not eligible or NSIP but they are eligible for payment through the family caregiver program if the state has it in their plan and wants to go in that direction. So the comment that I would make there is make sure that they’re getting the full cost of the meal and because you’re not going to be getting any NSIP for it. You may want to add a little bit to it and charge the caregiver program additional funds. Terrific I’m looking to see if more questions are coming through. Right now we are at the end so I guess I would just say looks have one last question that they want to send in, that would be great and otherwise as Shelly said either Shelly directly or through through me, happy to answer things that you think of later on. I’ll just say while we’re seeing if there are any last questions coming in that a reminder that this webinar, we have been recording it so it will be archived probably within a week or so on the State Unit on Aging website. And that if you did not receive a copy of the powerpoint and would like it to contact Lori Watt or myself and we’ll make sure to get you a copy of it. Wo we’re getting just some comments and thanking you Shelly for the presentation finding it interesting and informative so thanks for those comments coming in And it looks like we do not have any further questions at this point. Great and I’ll have to give my apologies to those people that have been around as long as I have and had to listen to me at Mennucha so my apologies to those of you who are old like me. all right well many thanks to everybody for calling in on a busy day really appreciate it and Shelly thank you so very very much for sharing all that you have with us. Really appreciate it we’ll probably have some follow-up questions over the coming days and weeks but nice to know that you’re available to us as a resource. So thank you all. Have a good rest of your afternoon. Thank you for the invite take good care. Bye-bye Thank you