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Abstract

Background

Contribution

Elders as Volunteers

Service Credit

Demonstration Programs

Implications

Conclusion

References
 
 
 
 
 

Background
     Since 1980s, cutbacks in government funding for some social service programs in America increased the need for volunteers to provide services (Glascoff, Baker, & Glascoff, 1997). Volunteering is doing work in some way to help others for no monetary pay. The purposes of this paper are to illustrate the contribution of volunteers, particularly in long-term care and introduce the concept of service credit.  We will highlight demonstration programs which have used service credit as a strategy to encourage and value volunteering.  Issues concerning the use of service credit programs and needs for future research are discussed. 

Contribution of Volunteers to Long Term Care
     The rapid growth of the elderly population, the prolonged life expectancy and the high prevalence of chronic illness have increased the need for long-term care, such as home care, hospice, and nursing home care.  In 1987, Congress created the Long-term Care Ombudsman Program under the Older Americans Act as a federally mandated response to poor nursing home conditions. Most state ombudsman programs relied on volunteers to achieve the advocacy goals and monitor nursing home quality of care (Nelson, 1995). The volunteers investigated the resident’s and family’s complaints, resolved problems, and reviewed the facility routinely. In 1987, almost 90% of ombudsmen personnel nationwide were volunteers (The National Center for State Long Term Care Ombudsman Resources, 1989). 
     In addition to the advocacy role in nursing homes, volunteers provide a variety of services in long-term care. A hospital-based case management program used volunteers to address the needs of the frail elders (Netting, Williams, Jones-McClintic, & Warrick, 1989). Nurses on an AIDS Care Team Program incorporated in-home volunteer service allowing them to spend less time on non-medical needs and more time on providing clinical care (Anonymous, 1998). A walking program trained volunteers to walk with hospitalized elders experiencing delirium and thus reduced its occurrence and severity (Holmberg, 1997). Volunteers in the Chicago Health Corps provided a combination of outreach, home visit, and case management services to underserved families (McElmurry, Wansley, Gugenheim, Gomge, & Dublin, 1997). Volunteers were also involved in community-based respite care to the caregivers of Alzheimer’s disease patients (Robin & Clemons, 1999). Other services provided by volunteers in long term care include transportation, visiting, and meal preparation. Successful volunteer programs can play an invaluable role in long term care.

Elders as Volunteers 
     Elders may be the largest number of volunteers available (Manninen, 1991). A major reason for recruiting older volunteers is that older adults find themselves with free time, are eager to use their skills and want to continue making a contribution to society after retirement (Houska & Rowlins, 1986; Strenger, 1996). 
     The trend of early retirement is another reason to recruit elders as volunteers. The percentage of individuals in the labor force declines steadily after age 54 (US Department of Labor, 1985). In 1950, 86% of men aged 55 to 64 were in the workplace. By 1984, the figure had dropped to 68.5%  (US Department of Labor, 1985) [Editor’s note: and by 1998 to 68.1% (Bureau of Labor Statistics, 2001)]. The median retirement age for men was 62 (US General Accounting Office, 1985). Those elders who were retired spent more time in volunteering than those still in the paid workforce (Chambre, 1984). Also, the personal benefit of volunteering, such as “keeping me active”, “having time now” and “to help others”, are important reasons for elders to volunteer (Hodgkinson & Weitzman, 1988; Ozawa & Morrow-Howell, 1993). In fact, keeping active in their leisure time makes elders feel worthwhile and contributes to better mental health. Wheeler, Gorey, and Greenblatt (1998) analyzed thirty-seven independent studies and found that elder volunteers' sense of well-being was significantly bolstered through volunteering. 
     Elders can continue making an enormous contribution to society and to those who benefit from their experience. Although elders are more likely to use poor health and lack of transportation as reasons for not volunteering (Hodgkinson & Weitzman, 1988; Kieffer, 1986), the primary reason is that no one has asked them (Ozawa & Morrow-Howell, 1993).   This omission results in the underuse of the productive capacity of elders. Strategies for involving elders to volunteer are needed. Service credit programs may be one such strategy.

Service Credit
      Service credit, proposed since the early 1980s (Cahn, 1984; Sager, 1983), is an innovative approach to encourage volunteering. The concept of service credit, or time dollar, is to convert volunteer time into services needed by the volunteer or his/her family from other volunteers. Each hour of time donated earns one service-credit hour. 
Service credit banking system
     The service credit banking system is the heart of a service credit program. The system gives volunteers credits for providing services to others and enables them to “cash” the credits when needed. Hospitals, nursing homes, health maintenance organizations, and organizations such as senior centers, churches, housing complexes, and community colleges can recruit and train volunteers and act as the banks (Cahn, 1994). A program begins by establishing a computerized service credit system whereby volunteers can earn service credits providing services to others and can draw upon those credits to secure such services for themselves or their family when needed. 
Service Credit Demonstration Programs
      Volunteer programs based on the concept of service credit have been demonstrated since the 1980s. Between 1987 to 1990, the Robert Wood Johnson Foundation (RWJF) funded six service credit banking demonstration programs using volunteers (Table 1) (Feder, Howard, & Scanlon, 1992). The initial demonstration of service credit program took place in Missouri. The Missouri General Assembly enacted legislation in 1984 to encourage private-sector agencies to establish a service credit system. Under this system, the Older Volunteer Service Bank gave credits to volunteers over 60 years who provided respite care to elders. They could then spend those service credits to purchase respite care or homemaker services for themselves or family (Ozawa & Morrow-Howell, 1993). 
     Members of Elderplan, a Health Maintenance Organization, used service credits through a Member to Member program to buy medical coverage at a discount. Volunteers who accumulated at least 159 service credits worth of credit could redeem them for a reduction on their insurance premium, for example, 109 credits for $109 quarterly premium in 1990 (Feder et al., 1992). A monthly service credit premium covered basic services, such as an annual examination, and a sliding fee scale offered the option of part payment in service credits for specific procedures. A demonstration of a Community-Wide Service Banking Program in Washington, DC area recruited volunteers to perform a variety of helpful services, including grocery shopping, telephone reassurance, and friendly visits for the elders and persons with disability living in communities. The volunteers received redeemable credits for services they might later need (RWJF, 1999). In Miami, the members of Friend to Friend Time Dollar program staffed adult day care program and provided companionship for participants in Meals on Wheels programs. 
     Feder and colleagues (1992) analyzed the effects of the six service credit programs over three years (1987 to 1990). They found service credit programs were valuable. The programs provided a variety of services needed in long term care such as housekeeping, shopping, telephone assurance, meal preparation, transportation, and personal care. Seventy-five percent of the recipients reported getting more services than before they participated in the programs. Almost half (46%) received 1-2 hours of service and the rest received 3-8 hours of service per week. The services received represented delivery of new services, not a replacement for agency services otherwise received. Ninety percent of the providers and 97% of the service recipients reported that they were satisfied with the programs, - most of them very satisfied. Those programs attracted new elders to serve other elders in return for service credits. Over half of all volunteers had not volunteered in the year before they participated in the programs. Almost half of the volunteers provided 5 or more hours of service per week, indicating the programs increased the volume of volunteer activity. 
      Numerous health maintenance organizations nationwide have been starting their own banks. Seventy such banks in 30 states and the District of Columbia  were reported to exist in 1996 (Anonymous).   Medica Center for Healthy Aging in Minneapolis enrolled 500 volunteers and 500 recipients through its Volunteer Investment Program during a 3-year period. Services offered through the bank included chores, companionship, transportation, and grocery shopping. Group Health Cooperative of Puget Sound in Seattle cooperated with existing volunteer programs to provide services, including homemaker assistance, home maintenance tasks, transportation, and caregiver respite to seniors. Oxford Health Plans in Norwalk, Connecticut initiated the Partners in Caring program for its members. Services included transportation, housekeeping, and medical monitoring. In addition to using enrollees as volunteers, the CareXchange Program of CareAmerican Health Plans, Woodland Hills, California encouraged volunteers of all ages to work on behalf of the program. Younger volunteers may donate their credits to enrollees who are unable to earn their credits. 

Implications of Service Credit Programs and Future Research 
      Although the service credits programs funded by the RWJF indicated the feasibility and value of service credit in long term care, many issues need to be addressed.  Among these are the availability and quality of services, the availability of volunteers, coordination among programs, cost-effectiveness an overall impact of such programs.  These issues are discussed below as are future research needs.
Availability of services in service credit programs
     The concept of a service credit equaling 1 hour, no matter the nature and extent of the services (Cahn, 1994), could result in volunteers preferring to provide less labor-loaded services. However, if services needed are more labor-loaded services, these services may not be provided. The RWJF demonstration programs revealed that 24% of the recipients had difficulties with personal care, however, only 4% of recipients received personal care services. Whether the one-to-one exchange base contributes to the unavailability of services in the RWJF demonstration programs is unknown. Factors contributing to unavailability of services need to be explored to determine strategies that could be developed to make all services available. A potential strategy is to change the one-to-one exchange base. For example, 2-hour friendly visiting could exchange for 1-hour of personal care. However, methods for establishing a fair and feasible exchange scale and its effects need to be studied.
Availability of volunteers 
     Another concern in such programs is the availability of volunteers. Service credit programs are intended to expand the supply of volunteer services by bringing in new individuals and securing larger and more commitments over extended periods of time (Cahn, 1988). Although the RJWF demonstration programs indicated that the programs have attracted new volunteers and increased the volume of volunteer activity, Ozawa and Morrow-Howell (1993) reported that 51.5% of volunteers participating in the program did not provide any services during the 6-month period because of illnesses or busyness. Strategies to secure dependable commitments for volunteering longitudinally need to be developed. 
Quality of service in the service credit programs
     The recipients in service credit programs are usually vulnerable population such as elders or persons with a disability, thus volunteer background and training are particularly important to prevent volunteers from harming the recipients. Services provided by the volunteers need to be monitored so quality can be assured or improved. However, little on these issues was discussed in the demonstration programs. Research on volunteer training and quality assurance in service programs is needed. 
Coordination among service credit programs 
      Because a service program may not be able to provide a needed service through volunteers, coordination among service credit programs is needed. The programs could be coordinated to fulfill the unavailable services. Through coordination, credits earned in one program could be spent to purchase services from another program. Such features would make service credit programs more useful and popular.
     Cahn (1988) suggested a strategy to guarantee the integrity of the credits earned by enlisting the government as a backup system in the event of unavailability of services within the program. In fact, the government guarantee is a key provision. However, the government guarantee has been a primary concern to administrators who fear that they may face a vast liability. Another concern is that a person currently on waiting lists for government services may be passed over in order to give priority to volunteers who have earned service credits. These issues have not been discussed in the demonstration programs and should be studied in future programs.
Cost-effectiveness of service credit programs 
     In any exchange, costs and benefits need to be estimated. Costs of service credit may include direct, out-of-pocket costs (transportation, meals, phones, materials, computers, and rent); indirect costs (leisure sacrificed and obligation incurred, stress, and anxiety or unpleasantness about the task); and opportunity costs (employment income, time expanded for preparation, and actual provision of services, and recovery time needed to disengage). Benefits of such programs include intrinsic rewards (sense of self-worth and self-esteem, social interaction, skills and competency acquired, and reduced stigma of recipients), and extrinsic rewards (service credit payment, the market value of services that credits buy, early hospital discharge, or delayed institutionalization). 
     The RWJF provided grants of $200,000 for a 3-year period for each program at a cost of $50,000 to $70,000 per year (Feder et al., 1992). The program administrators saw the primary benefits as the ability to expand their mission and positive relations for their organizations. However, they did not see the service credit programs as a cost reduction, substituting volunteers for paid staff, or contributing quantifiable economic effect. It is difficult to compare the costs and benefits through those findings and it is impossible to conclude that service credit programs are cost-effective based on those findings. Cahn (1988) stated that service credit programs were perceived as a “no-cost” program except administrative expenses (p. 246). However, it is unknown whether the benefits of service credit programs exceed costs and whether service credit programs are less expensive than those that rely on paid staff. Research is needed to quantify program costs and benefits and to identify cost-benefits indicators. 
Impact on public service programs
      Should service credit programs substitute for already existing entitlements or only for expanding the numbers and types of services? The RJWF demonstration programs indicated that such programs were an expansion of services, not a substitute for formal service system. Cahn (1988) contended that existing services must be maintained and expanded separately from service credits. However, it is possible that the service credit programs could be turned into a rationale for cutting back on entitlement or public service programs.  Ways of preventing public service programs from being cut back and ensuring availability of the programs are needed. 

Conclusion
     Elders are the largest number of volunteers available. Strategies to get elders involved in volunteering are needed. Service credit demonstration programs have indicated that they can provide a variety of services and attract elders to volunteer, which can benefit elders in turn. However, the many issues discussed here, such as availability and quality of services, costs and benefits, and possible impact on public service programs are left unaddressed by current program reports. Given the positive results of demonstration programs, nurses should seek funding of this interesting avenue for volunteerism so the issues described here can be addressed and studied further.

References
Anonymous. (1996). Senior helping seniors: Foundation grants encourage HMOs to start “service credit banks”. Volunteer Leader, (Summer), 6. 

Anonymous. (1998). AIDS program integrates volunteers, providers: Care teams take burden off nurses. Disease State Management, 4(7), 77-79.

Cahn, E. S. (1984). Surplus people: A modest proposal. Unpublished manuscript, Coral Gables, FL: University of Miami Law School.

Cahn, E. S. (1988). Service credits: A market strategy for redefining elders as produces. In R. Morris & S. Mass (Eds.). Retirement reconsidered: Economic and social roles for older people (pp. 232-249). New York: Springer.

Cahn, E. S. (1994). Aging policies, entitlements, and the deficit. Journal of Aging & Social Policy, 6(1/2), 119-141.

Chambre, S. M. (1984). Is volunteering a substitute for role loss in old age? An empirical test of activity theory. Gerontologist, 24(3), 292-298.

Feder, J., Howard, J., & Scanlon, W. (1992). Helping oneself by helping others: Evaluation of a service credit banking demonstration. Journal of Aging & Social Policy, 4(3/4), 111-138. 

Fischer, L. & Schaffer, K. (1993). Older volunteers: A guide to research and practice. New Bury Park, CA: Sage. 

Glascoff, M. A., Baker, J. B., Glascoff, D. W. (1997). Successfully promoting volunteerism by offering extrinsic rewards in a personal health course: A pilot study. Journal of Health Education, 28, 219-223.

Hodgkinson, V. A., & Weitzman, M. S. (1988). Giving and volunteering in the United States. Survey conducted by the Gallup Organization. Washington: Independent Sector. 

Holmberg, S. K. (1997). GN management. A walking program for wanderers: Volunteer training and development of an evening walker’s group. Geriatric nursing-American Journal of Care for the Aging, 18(4), 160-165.

Houska, A., & Rowlins, T. D. (1986). Motivations and satisfactions of the Wichita volunteer. The American Journal of Hospice Care, 3, 15-18.

Kieffer, J. A. (1986). The older volunteer resource. Committee on an aging society. Productive role in an older society. (pp 51-72). 

Manninen, R. P. (1991). What do you pay your volunteers? Hospital Topics, 69(4), 20-24.

McElmurry, B. J., Wansley, R., Gugenheim, A. M., Gombe, S., & Dublin, P. (1997). The Chicago Health Corps: Strengthening communities through structured volunteer service. Advanced Practice Nursing Quarterly, 2(4), 59-66.

Nelson, H. W. (1995). Long-term care volunteer roles on trail: Ombudsman effectiveness revisited. Journal of Gerontological Social Work, 23, 25-46.

Netting, E. E., Williams, F. G., Jones-McClintic, S. & Warrick, L. (1989). Volunteers in hospital-based case management programs. Journal of Volunteer Administration, 7(4), 4-9.

Ozawa, M. N., & Morrow-Howell, N. (1993). Missouri service credit system for respite care: An exploratory study. Journal of Gerontological Social Work, 21(1/2), 147-160.

Robert Wood Johnson Foundation. (1999). Demonstration of a community-wide service credit banking program. http://www.rwjf.org/health.019150s.htm

Robin, K. M., & Clemons, J. W. (1999). Respite care-volunteers as providers. Journal of Psychosocial Nursing & Mental health services, 37(1), 30-35, 41-42. 

Sager, A. (1983). A proposal for promoting adequate long term care for the elderly. The gerontologist, 23, 13-17. 

Strenger, E. W. (1996). Retirees as resources. Volunteer Leader, (Summer), 9.

The National Center for State Long Term Care Ombudsman Resources. (1989). A study of the use of volunteers by long term care ombudsman programs. The effectiveness of recruitment, supervision, and retention. (No. 90-AT0401.). 

US Department of Labor. (1987). Employment and earning. Washington, DC: U.S. Government Printing Office. 

US General Accounting Office. (1985). Retirement before age 65 is a growing trend in the private sector. Washington, DC: Author. 

Wheeler, J. A., Gorey, K. M., & Greenblatt, B. (1998). The beneficial effects of volunteering for older volunteers and the people they serve: A meta-analysis. International Journal of Aging & Human Development, 47(1), 69-79.

Worthy, E. H., & Ventura-Merkel, C. (1982). Older volunteers: A national survey. The National Council on the Aging Incorporated. 

http://stats.bls.gov:80/opub/mlr/1999/12/art1full.pdf  

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