Department of Health Professions and Family Studies
Chronic illness or frailty, often associated with old age, can make even the simple tasks of changing a light bulb or shopping for food insurmountable for older adults. Being able to fill a prescription, make a doctor’s appointment and arrange for transportation can mean the difference between successful recuperation from a health crisis or a hospital readmission. In a largely mobile and impersonal society, older adults can no longer rely on families and neighbors for the support they need.
Older persons living with chronic illnesses or functional impairments are in a particularly precarious position because the types of support they need to remain independent are largely non-reimbursable by health insurance, and are not provided by existing health care systems. Even expanded private or public insurance may not cover the types and intensity of long-term care assistance needed by older adults with disabilities. Also, no health care organization refers to the types of services often needed by older adults as “health services,” and even if an individual has the means to purchase assistance on his or her own, few social service agencies offer such support, and even fewer offer the flexibility or intensity required. Furthermore, for those with weak social networks, isolation as a result of being homebound can lead to depression, which, in addition to negatively affecting quality of life, can exacerbate physical symptoms and put the individual at risk for additional health crises and possibly institutionalization. Even older adults without serious health problems are at risk for isolation and its health consequences if they lack regular social interaction.
Building Social Support as a Means for Maintaining Independence
Indeed, physical and emotional well-being has been found to be strongly influenced by a person’s ability to stay connected to social networks in meaningful ways (Berkman et al., 2000; Fried et al., 2004; Rowe and Kahn, 1998). Much has been written on the disintegration of traditional social networks due to changing family structure and dispersed geographic location. In addition, older adults face another emotional struggle transitioning from employment to retirement, where they are confronted with changing realities about the meaning of community and social worth. Growing attention has been given to new strategies aimed at building social connectedness in ways that foster the personal networks needed to sustain independent living and physical and emotional well-being.
For decades, community-based organizations have been experimenting with volunteer programs to assist the elderly to remain in home settings by creating the informal social support that is so critical to their well-being. Volunteers have typically assisted with transportation, home maintenance, and meal preparation when these services were not available. However, the tasks conducted by volunteers are often poorly managed by their sponsoring programs due to insufficient resources and low priority status within the sponsoring organization. Traditionally, community service organizations have been inflexible in their program design, emphasizing simple tasks that can be completed without much planning or supervision, rather than focusing on how to use volunteers to accomplish their organizational mission in meaningful ways that foster connectedness (Center for Health Communication, Harvard University, 2004).
But there is another way, argue Cobb and Johnson (2003), who believe that by creating more sophisticated, individualized matches between volunteers and service recipients, volunteers can experience greater personal growth and social value. An additional benefit of this enhanced program design and organizational commitment may be the volunteer’s greater loyalty to the sponsoring agency. However, developing these more sophisticated relationships is not easy. The costs associated with the very resourceintensive tasks of program planning, management and coordination are often left out of agency budgets or funding proposals because the benefits are not considered cost-effective. Organizations often look for immediate cost savings; however, Cobb and Johnson argue that this is an incorrect approach to determining the value added. The tasks traditionally provided by volunteers are hard to quantify because they rarely have parallels in the marketplace (for those with social support systems, these services are often provided informally by family members), and they rarely substitute for existing services.
Creating Opportunities for Nontraditional Volunteers – The Service Exchange Model
Many believe that retired, older adults represent the largest pool of willing volunteers with the necessary skills. However, Prisuta (2004) reports that more people volunteer in mid-life than in their later years. He theorizes that after retirement, people are less likely to be asked to volunteer, and that being asked is the greatest motivator for volunteerism. According to this theory, older adults in retirement may indeed represent a large, available andinterested pool; however, they remain a largely untapped resource.
Twenty years ago, The Robert Wood Johnson Foundation (RWJF) attempted to tap into this population by funding six demonstration sites, on a short-term basis, to test an innovative model of volunteerism. To attract older volunteers, the model provided a means for these adults to expand their limited insurance benefits while fostering social connectedness among organizations and their constituents (Feder et al., 1992). The demonstrations were based on the Time Dollar (renamed TimeBanks USA) model of service exchange, where participants earn service credits for each hour they provide assistance to others. Assistance is defined quite broadly, drawing on the experience, skills and needs of the specific program’s participants. All participants are viewed as both capable of helping and of needing help at some point in time. What makes time dollar programs unique is that “they transform volunteering from a one-way street into a two-way street” (www.timedollar.org, 2006). Credits earned are saved (or banked) for future needs, creating social networks that support older people and persons with disabilities so they can maintain their emotional health and independence.
Time dollars are touted as a tax-exempt currency that creates purchasing power out of personal time. One hour of helping another earns one time dollar. From a social welfare perspective, time dollars make it possible for communities to rebuild themselves by helping each other and by becoming “co-producers” of outcomes. Edgar Cahn, who developed the TimeBanks USA approach, states that time dollars create this process of co-production by focusing on four simple, interlocking principles: assets, redefining work, reciprocity and social capital (Cahn, 2000).
Putnam (2003) describes the type of reciprocity inherent in the time dollar model of service credit banking as a means for fostering connectedness throughout the community, which in turn builds social capital. The benefits of social connectedness for the individual can be physical, emotional and social. The benefits of social capital for both the individual and community have less to do with the actual services provided than they do with the sense of connectedness it fosters.
Brooklyn-based Metropolitan Jewish Health System, a continuum of care provider of health and long-term care services for the elderly and the chronically ill, was one of the six sites awarded an RWJF grant in 1987 to develop a TimeBanks USA model of service exchange as a part of its social health maintenance organization (SHMO), Elderplan (1). Elderplan created the Member to Member (M2M) program, which drew on the rich and varied skills of its consumer membership to mediate the problems of limited health insurance coverage. Fully supported by Metropolitan Jewish Health System since the RWJF grant ended in 1990, M2M has helped its sponsoring organization to expand its service package by offering long-term care types of services, traditionally associated with instrumental activities of daily living such as shopping and home maintenance(2). More than 100 members are active on a regular basis, contributing more than 15,000 hours of service a year.
In fact, the M2M program has generated substantial media coverage and has received numerous awards (for example, in a 1996 issue, U.S. News & World Report cited M2M as one of the top ways to save the world). However, its success has been reported mostly through case studies and personal anecdotes. While such methods are certainly effective for disseminating information, the program itself, its sponsoring organization and others in the fields of time dollars and service credit banking wanted a better picture of the impacts of the M2M program. An early evaluation of all six sites conducted by Feder and colleagues (1992) found that the programs were indeed successful in attracting older people to provide services along the lines of Instrumental Activities of Daily Living (IADLs), and that there was preliminary evidence suggesting that the time dollars were working to build reciprocity and social capital. With only a three-year timeframe, this early evaluation was unable to document patterns of credit use, or correlations with health-related outcomes. Furthermore, Feder and colleagues discussed the challenges in trying to quantify benefits, regardless of timeframe, as no savings can be directly linked to services that would not have been provided in the first place. The primary benefits that sponsoring organizations derived from their service credit arrangements were determined to be the ability to extend their service mission and positive public relations (Feder et al., 1992). In 2000 Metropolitan Jewish Health System, with funding from The Fan Fox and Leslie R. Samuels Foundation (based in New York City), began an outcome evaluation to further delineate the benefits of the program for participants, the sponsoring organization and the community at large. The purpose of the outcome evaluation was two fold. The first was to describe the M2M program and its participants, and the second to examine whether program participation resulted in improved emotional health and decreased levels of loneliness.
The first phase of the evaluation sought to identify benefits to the sponsoring organization, and to examine the role of TimeBanks USA and whether evidence could be uncovered regarding their impact on creating connectedness for elders and building reciprocal helping relationships. Data was collected from a population with a lengthy history of participating in the M2M program so that credit redemption could be examined and benefits to the organization observed. A retrospective, descriptive study involving a population-based survey, selected face-to-face interviews, and focus groups was conducted.
The second phase of the evaluation sought to examine relationships among program participation and health-related outcomes, such as emotional health and feelings of loneliness. To ensure that all study participants were recruited, enrolled and integrated into the M2M program in similar ways, a study was conducted following new health plan members. Differences in selected health-related outcomes between new Elderplan enrollees who participated in the M2M program, and those who did not participate, were examined over a six-month period. Selected findings from that study are summarized below.
Highlights From the Evaluation
The M2M population was found to be predominantly female and more than 75 years of age, with a majority living alone. M2M participants who were identified as “providers of services only” tended to be younger. The findings also indicated that there were great disparities across the sample according to functional status, confidence with living alone and social interaction. And even though the group identified as “receivers of service only” was found to need more assistance and to have poorer confidence and lower social interaction (as expected), large numbers of “providers of service only” and people who “both provide and receive services” reported poor confidence about living alone and poor levels of interaction (a proxy for social isolation).
While objective data from the program files was available to inform us who among the sample was a provider, receiver or a person who both provided and received services, we nonetheless asked respondents to label themselves. Interestingly, respondents saw themselves quite differently than did the program files. The majority of participants in the group who both provide and receive services labeled themselves as providers of services only; only 8 percent saw themselves as only receivers; 22 percent identified themselves as people who both provide and receive services; and 6 percent chose not to answer the question. This discrepancy speaks to at least two important issues:
- The problem of labeling participants, especially in a program that seeks to establish a culture of reciprocity without having distinct groups of givers and takers.
- The anxiety that moving from a provider to a service recipient may engender (most, if not all, people who are both providers and recipients of services began as providers).
The majority of providers labeled themselves as providers, with a small minority describing themselves as both providers and recipients of service. Finally, the majority of service recipients also viewed themselves as such, with a small minority labeling themselves as both providers and recipients.
Benefits to Consumers: Building Reciprocity, Connectedness and Maintaining Independence
One focus group participant, who considered herself a provider of service only, remembered upon reflection that once she did call upon the program to fix a light bulb; however, she hadn’t realized that she was utilizing a service, and thus was redeeming time dollars she had accrued. To her, this service was provided because she was a member of the M2M program, a community that helps out and is helped out in return. Another focus group participant who has become inactive recently due to poor health could not distinguish the services she received from the M2M program from “a neighbor helping out.” This concept of creating a community connected through reciprocal caregiving is reflected in the qualitative interviews as well, and gets at the core of the time dollar philosophy – creating value for traditionally unmarketable skills, and purpose for traditionally undervalued people.
While many program participants see the assistance they receive (or provide) as essential to maintaining physical health, they also view such assistance as more than just helping out with Activities of Daily Living (ADLs) or IADLs. In fact, they often describe the services they receive through the M2M program as having a psychological component. For instance, one focus group participant stated, “[M2M helps me] get better in my mind …” Another participant said, “They [the volunteers] keep you going, keep you informed about what’s going on in the world.” As a group, the receivers who participated in this focus group agreed that the assistance they receive is vitally important to their remaining independent in the community. Ten percent of the M2M sample reported that M2M participation helps them either communicate with their doctor or keep doctor appointments. More than 40 percent of survey respondents who receive services stated that they do not know how they would manage without their M2M partner, and more than 40 percent reported that because of M2M they feel more connected to people in Elderplan.
Just as interesting and important is how providers of service view the impact of their participation. One focus group participant stated, “M2M allows us to retire to something, not just from something.” Another qualitative interview participant stated, “I could help him [his partner], and in doing so could help me … When you give to somebody, you get so much in return. It keeps you young. You want to keep going.” Findings from Phase II of the study parallel these qualitative state- ments. The rate of decline in emotional health over time was found to be less for M2M participants. Likewise the rate of increased feelings of loneliness over time was found to be less for M2M participants. Therefore, participation in the program, regardless of whether participants receive or provide services, was found to be associated with better emotional health and decreased feelings of loneliness.
Benefits to the Community: Building Social Capital
From the perspective of building social capital, the M2M program was found to attract new volunteers to the program and to create new opportunities for service. More than 30 percent of all providers reported never having volunteered before joining the M2M program. A qualitative interview participant stated that he began volunteering in M2M because he wanted to do home repair for “elderly people.” Although technically elderly himself, this respondent stated, “I didn’t think of myself as elderly.” For as long as he can help out other people, he will not think of himself as old. Not only does society affix labels and thus profiles to people because of their age, but we do so to people based on their functional status. An 86-year-old woman who is legally blind would be considered “disabled” by our society, and not traditionally thought of as someone who can help out others. However, in the M2M program, this woman provides a service called “telephone reassurance,” where she regularly calls other members on the telephone to provide social interaction and companionship by discussing the latest news or events of the day. This provider noted that some of her telephone companions are “shut-ins” who are disconnected from the world. She is proud of her skills and provided service which, in her words, serves two purposes: first, to reduce the social isolation of her peers, and second, to provide for her the occasion to feel that despite her problems, she is still alive to the world and has something valuable to offer. “Just because we’re old,” she said, “doesn’t mean we’re stupid or useless.” Previous research has linked social isolation and subsequent depression to increases in morbidity, mortality and risk for institutionalization (Stek et al., 2005; Berkman et al., 2003). Keeping people connected is one way to reduce the risk of such negative health outcomes.
Benefits to the Sponsoring Organization: Building Relationships
The survey from Phase I asked longtime M2M participants about their feelings toward the sponsoring organization. More than 90 percent of survey respondents reported that they were indeed happy with the care they received in Elderplan, and that they would recommend Elderplan to family and friends. Likewise, more than 80 percent of survey respondents reported that they were very or somewhat satisfied with the M2M program, and more than 92 percent would recommend the program to family or friends (32 percent stated that they are more satisfied with Elderplan because of their participation in M2M). An examination of retention trends for 1998-2000 showed that Elderplan members who were active participants in M2M during that time (i.e., they had more than 10 service transactions a year), disenrolled at a slower rate than non-participating members, and for involuntary rather than voluntary reasons (e.g., death, nursing home placement, relocation).
From a sponsoring organizational perspective, this research and previous work show that service credit banking programs can help provider organizations achieve their missions, enhance their pub- lic image, and most importantlyfrom an operating perspective, foster relationships among their constituents and themselves in ways that can increase utilization and loyalty. This has potential for member-based health plans like the one described in this report. However, there may be even greater gains possible for health care organizations such as hospitals and home care agencies, where relationships between providers and patients/consumers are usually episodic driven and often one time only. Service credit banking programs can create a community from patients served, filling gaps in service both during and in-between treatment. This has the potential to improve discharge planning, enhance the comprehen- siveness of the service package, and encourage repeat visits when hospital or home care is needed.
The promise of programs like M2M – a promise that is now based on some evidence – is that it can achieve multiple societal goals:
- To close health insurance and social net work gaps.
- To foster social connectedness, which decreases the risk of isolation.
- To build social capital to strengthen communities.
- To give health care organizations ways to increase their competitiveness in socially responsible and productive ways.
Service credit banking programs sponsored by health care organizations, represent good business and good social policy.
Corinne Kyriacou is an assistant professor in the Department of Health Professions and Family Studies. She earned a Ph.D. in social policy and health services research from the Heller School at Brandeis University, where she was an Agency for Healthcare Research and Quality Fellow, and she earned a Master of Public Health in health administration and policy from New York Medical College. Dr. Kyriacou currently teaches Ethical, Legal and Critical Health Problems; Intro- duction to Research and Writing; Planning, Implementing and Evaluating Community Health Programs; and Introduction to Grant Writing.
Prior to joining the Hofstra faculty in 2004, Dr. Kyriacou spent five years as director o research at Metropolitan Jewish Health System, a premier network of health care providers for the elderly and chronically ill based in Brooklyn, New York. In that position, Dr. Kyriacou served as the principal investigator on more than $1.5 million in grant- funded projects focused on improving mental health care for the elderly, developing palliative care programs for chronically ill elders and nursing home residents, and evaluating existing health and social services.
Dr. Kyriacou’s research interests center around improving access and quality of care for people living with chronic health conditions. She is currently working with the United Hospital Fund, evaluating an initiative aimed at linking community agencies serving the elderly with health and hospital systems, in an effort to improve continuity of care. Other projects that Dr. Kyriacou is presently developing include: assessing the impact of the Medicare Modernization Act’s Part D program on Long Island beneficiaries, providers and employers; designing a long-term care fellowship training program for mid-career professionals; and, investigating the housing and structural factors associated with falls among the elderly. Dr. Kyriacou has published articles on hospital-nursing home transitions, consumer- directed care, integrated health and social care for the elderly, managed care for chronic illnesses, and the importance of experiential training in palliative care for health professionals. She also co-authored an Institute of Medicine book evaluating the Pew Health Policy Fellowship Program.
Dr. Kyriacou serves on the editorial boards of The Gerontologist, The Journal of Gerontology: Social Sciences, and the International Journal of Integrated Care. She is a policy and planning advisor for the Brookdale Center on Aging and a policy associate of the Hofstra Health Policy Center.
- An SHMO expands coverage for community-based long-term care and is designed to keep functionally impaired older people living at home as long as possible. The program integrates medical, social and long-term care services and merges the HMO concepts of capitation, financing and provider risk sharing with the case management and support services concepts of long-term care providers.
- Activities of Daily Living (ADLs) include: bathing, dressing, eating, toileting and in-home transferring. IADLs include: cooking, cleaning, outside transferring (moving about the neighborhood), handling household maintenance, managing money, using the telephone, and comprehending and following instructions.
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