Food and Nutrition Services for Persons Living with HIV/AIDS

1. Food and Nutrition Services for Persons Living with HIV/AIDS AIDS Institute NYS Department of Health Bureau of Community Support Services

2. Intent of Initiative • To fund supplementary nutrition interventions that will improve, maintain and/or delay the decline of PLWH/A health status, and assist them to remain in their communities. • The goal is to have clients graduate from the program, no later than 18 months after enrollment, with increased knowledge and skills necessary to purchase and prepare nutritious foods.

3. Description of Program Food and Meal Components • Home Delivered Meals • Congregate Meals • Groceries/Pantry Bags • Food Vouchers AI Continuum of Nutrition Services • Nutritional Screenings • Nutritional Assessments/Reassessments • Nutritional Counseling • Group Nutrition Education

4. General Eligibility • Persons living with HIV/AIDS who can provide proof of status as established by the Ryan White CARE Act Guidance for Contractors. • Dependent children under the age of 21. • Clients who meet the criteria for selected meal components.

5. Food and Meal Components • Home Delivered Meals • Congregate Meals • Groceries/food pantry bags • Food vouchers

6. Meal Content Recommendations • It is recommended that each meal or the average of one week of meals contain the following: Calories Approximately 800 per meal Protein 15 - 20% of calories (30 - 40 grams) Carbohydrates 50 - 55% of calories (100 – 110 grams) Fat up to 30% of calories (26 grams) Sodium  800 milligrams per meal Cholesterol  100 milligrams per meal Dietary Fiber 9 grams • Each meal should contain three servings of fruits and vegetables (preferably fresh). • Each meal should be reasonably priced and culturally/ethnically appropriate. • Children’s meals should contain fewer calories and protein. • Meals must be stored and/or prepared in accordance with local/state food sanitation codes. • Food must be maintained at proper temperature during meal service. The recommendations for Meal Content were adapted from the Association of Nutrition Services Agencies’ Nutrition Guidelines for Agencies Providing Food to People Living with HIV Disease, Second Edition, September 2002, Model II – General Nutrient Recommendations for HIV/AIDS, Energy Expenditure and Macronutrient Breakdown. The amounts of fat, cholesterol and sodium were based on the American Heart AssociationHealthy Heart Guidelines

7. Home Delivered MealsEligibility • Clients must be unable to shop or prepare meals for themselves due to physical or mental challenges. • Clients must lack a network of family or friends to provide this support. • Agency must establish and document the criteria and process for determining eligibility (e.g. a letter of need from the health care provider, ADL needs assessments, etc.) • Can be provided to dependent children under age 21

8. Home Delivered Meals cont. • Agency must provide not less than 5 and not more than 14 meals per week. • Agency must document how nutrition needs are being met if a client receives less than 5 meals per week. • Program must include an option for the delivery of a grocery/pantry bag. • All menus must be reviewed by a nutrition professional to ensure that they meet the recommendations for meal content. • Agencies that deliver frozen meals must ensure that: a person is available to heat up the client’s meal; there is room in the freezer to accommodate the meals; and, there is a microwave or oven where the meal can be heated.

9. Congregate MealsEligibility • Clients must be unable to purchase nutritious foods due to limited financial resources and/or, • Clients must have inadequate cooking facilities to prepare meals. • Dependent children under age 21

10. Congregate Meal cont. • Must offer client five hot meals per week at the congregate site or one hot meal and a grocery/pantry bag that provides four additional meals. • Clients can not receive more than 14 meals per week. • All menus must be reviewed by a nutrition professional to ensure that they meet the recommendations for meal content. • A nutrition professional must be on-site during the meal service to answer questions and provide basic nutrition education.

11. Grocery/Pantry BagsEligibility • Client must be unable to purchase nutritious food due to limited financial resources. • Dependent children under age 21.

12. Grocery/Pantry Bag cont. • Bags must contain a variety of foods and provide enough food for the number of individuals and meals intended. • Bags must contain a minimum of 5, and no more than 14 meals. • A nutrition professional must review the bags to ensure that the food distributed in the grocery/pantry bags complies with the nutrient standards for recommended meal content. • Fruits and vegetables must be included in the bags. • Food must be stored and packaged in accordance with local and/or state food sanitation codes. • Bags can be picked up or delivered (except by COBRA staff).

13. Food VouchersEligibility • Clients must be unable to purchase nutritious food due to limited financial resources, but be able to shop for and prepare their own meals. • Amounts may be increased to include funds to provide meals to dependent children under age 21.

14. Food Vouchers cont. • Amount of the voucher should allow client to purchase a minimum of 5, and not more than 14 meals that meet the AI Food and Meal Content standard. • A nutrition professional or trained staff person must review grocery store receipts before another voucher can be issued. • Programs must develop a system that ensures that only authorized clients redeem vouchers and purchase allowable food items.

15. Allowable ItemsMilk and Milk Products (cheese, yogurt, butter); 100% Fruit or Vegetable Juice; Fresh or Canned Fruit and Vegetables; Cereals; Bread; Pasta; Grain Products; Poultry; Meat; Fish; Eggs; Nuts; Peanut Butter; Tomato Sauce; Beans (canned or dry); Margarine; Mayonnaise; Mustard; Ketchup; Salad Dressings; Flour; Sugar; Baking Powder; Baking Soda; Salt; Oils; Cooking Herbs and Spices. Non-Allowable ItemsCarbonated Beverages including Soda or Flavored Beverages such as Kool-Aid; Alcoholic Beverages; Coffee; Tea; Cigarettes; Paper Goods; Gum or Candy; Cakes including Doughnuts, Pies and Brownies; Laundry detergent; Soap; Disposable Diapers; Baby Food or Formula; Pickles; Pretzels; Popcorn or Chips; Nutritional Supplements (e.g. vitamin/mineral pills and or liquid nutritional supplements such as Ensure); Frozen sweets such as Ice Cream and Popsicles; Dessert Sauces; Syrups and Toppings; or Any Non-Food Item Food Voucher guidelines cont.

16. Guidelines for Food Voucher Programs • Supermarkets and grocery stores from which vouchers are purchased must be inspected annually for: • Quality of food • Variety of food • Price • Facility • Accessibility

17. AI Continuum of Nutrition Services • Initial Nutritional Screenings • Nutritional Assessments/Reassessments* • Nutritional Counseling* • Nutrition Group Education* • Meal Orientation *Must be provided by a nutrition professional, and are only available for PLWH/A (not dependent children)

18. Nutrition Professionals • Registered Dieticians (RD) • New York State Certified Dietician-Nutritionists (CDN) • Registered Dietician-Eligible (RDE) • Nutrition students supervised by a RD or CDN

19. Nutritional Screening • All clients must be screened to determine the level of nutritional risk* • The screening is not a substitute for the intake process (URS/AIRS), but may be conducted at the same time. • Program eligibility must be determined before conducting the screening. • Best practice is to conduct the screening annually for clients not receiving regular assessments/reassessments. • Required elements include information required for care coordination. *See Required Information for Initial Nutritional Screening of Clients

20. Nutrition Assessment & Reassessment* Required for all of the following: • Clients found to be a nutritional risk during the screening process • Clients receiving home delivered meals • HIV+ children • Adolescents • Pregnant women *See Required Information for Nutrition Assessments/Reassessments

21. Nutrition Assessment/Reassessment cont. • Assessments are to be completed within two weeks of enrollment, and reassessments approximately every six months thereafter. • May be done by telephone, but face to face is preferable.

22. Nutritional Counseling • A nutrition professional must be available to provide nutritional counseling between assessments and reassessments. • Purpose of nutritional counseling is to: • Follow-up on the care plan • Reinforce nutrition and food safety education • Answer clients’ general nutrition questions

23. Nutrition Group Education • Congregate meal programs must offer a nutritional education activity at least once a month. • Clients who receive pantry bags or vouchers must attend at least 2 workshops per year. • Nutritional assessments must be conducted every 6 months for clients who are unable to attend scheduled workshops. • Pantry bags must include nutrition education materials and recipes relevant to the foods in the bag. • Voucher programs must have nutrition education materials, including sample recipes that can be prepared on a limited budget, available to clients.

24. Meal Orientation • Clients’ rights and responsibilities • Agency’s responsibilities to the client • The hours of meal and food distribution • Nutrition service requirements • Signed contract outlining the above

25. Expected Outcomes • Improvement in clients’ health, and tolerance and adherence to their medications. • Increase in clients’ awareness of the importance of nutrition therapy and eating well-balanced meals and snacks. • Increase in the clients’ ability to plan, purchase, and prepare nutritious foods. • Increase in the food security and independence of clients at graduation from the program.

26. Outcomes are accomplished by: • Offering PLWH/A the opportunity to transition to and from the four food and meal components of the AI continuum of nutrition services that are most appropriate for their stage of illness, physical and mental abilities. • Conducting nutritional screenings on all clients and performing nutritional assessments on those who are at nutritional risk or home-restricted. • Providing intensive education and skill development in: nutrition as a co-therapy in the management of HIV disease; symptom management and adherence to HIV medications; making healthful food choices on a budget; and the preparation of nutritious, simple and economical meals. • Directing PLWH/A to utilize food resources within their communities.

27. Challenges • Developing systems for measuring and documenting nutrition program outcomes • Documenting linkages to primary care and other supportive services • Developing transition criteria for movement through a nutrition continuum • Graduating clients in 18 months

28. Questions