A lift to the doctor's office. A home-cooked meal. Someone to shovel snow.
Demand for routine support services like these continues to grow as Americans age. But funding is getting harder to come by as welfare budgets get squeezed. Frail elderly who don't get help with daily activities could end up using more healthcare services or being institutionalized.
In a capitated environment, it pays to keep people healthy and independent. That's one reason why several HMOs are creating volunteer programs that reward drivers, cooks and shovelers for time spent helping others.
These so-called "service credit" programs are designed to spark long-term relationships with volunteers. For every hour of service provided, volunteers earn a credit that can be redeemed for services later or donated to someone currently in need of some assistance.
Say a 67-year-old volunteer "banks" four hours a month cooking meals for an older, wheelchair-bound gentleman. After three years, she's accumulated 144 hours. At 70, her arthritis worsens, preventing her from doing her own yard work and home repairs. So, she begins cashing in credits, two hours for raking leaves, one hour to have a leaky pipe replaced and so on.
Given the uncertainties surrounding federal Medicaid spending and pressures by state governments to shrink welfare expenditures, service credit programs seem to be tailor-made for the 1990s. But the concept isn't new.
The oldest known program, Milwaukee-based Work Exchange, began awarding service credits in 1974 and continues to do so. About 80 such programs currently operate across the country, and a dozen or so are being planned. Sponsors include community centers, agencies on aging, hospitals and HMOs.
However, sizing up the healthcare savings produced by such programs remains difficult. No national statistics were available.
The concept recently received a financial and ideological boost from the Robert Wood Johnson Foundation, a Princeton, N.J.-based philanthropy. Last month, the foundation awarded $616,200 in start-up grants to five HMOs and organizations that serve HMO enrollees in Minneapolis; Woodland Hills, Calif.; Seattle; Norwalk, Conn.; and Norfolk, Va., through its Service Credit Banking in Managed Care Program.
Each of the grant recipients runs or is affiliated with an HMO for Medicare beneficiaries. Service credit programs are a way to help those senior members remain independent and avoid unnecessary medical care.
The HMOs "see this as making a difference to their members," and in some markets the programs are believed to provide "a competitive edge," said Kathleen Treat, a program coordinator at University of Maryland's Center on Aging, which is helping the grantees develop and implement their service credit programs.
Seniors who've joined HMOs are beginning to need more chronic care and informal support services, said Mark R. Meiners, director of the national office of Robert Wood Johnson's service credit banking program. In 1995, some 3.2 million Medicare beneficiaries were enrolled in HMOs.
Treat said the grants cover start-up costs, primarily the salaries of support staff to run the programs, as well as computer equipment for matching volunteers with needed services and keeping track of volunteers' hours. She said the HMOs have agreed to match the money and continue funding the programs after the initial funding dries up. By Treat's calculations, a minimum of $50,000 a year is needed to run such a program.
Sentara Life Care Corp., which received a $125,000 start-up grant, is developing its service credit program, Sentara Volunteer Care Givers, to complement another program being created to keep the frail elderly out of nursing homes. On July 1, the Norfolk-based long-term-care subsidiary of Sentara Health System, which is affiliated with Sentara Health Plans, will be the first in the state to offer a "Program of All-inclusive Care for the Elderly," or PACE, a service delivery program pioneered by On Lok Senior Health Services in San Francisco.
There are 11 PACE programs across the country, and 50 or so are in development, said Christine Van Reenen, executive director of the National PACE Association, Alexandria, Va.
Sentara's first site will open in Virginia Beach, and others are planned for Portsmouth, Norfolk and Hampton, Va. Each site will serve 120 to 150 frail seniors who would otherwise qualify for nursing home care. A variety of services will be available, including nursing, hospice care, therapy and respite care. The sites also will coordinate hospital, home health, laboratory and X-ray services as needed.
Sentara's PACE program will be capitated at 95% of what it would have cost Virginia's Medicaid program to serve that population. Eventually, Medicare services also will be provided on a capitated basis, said Jeremy Schuchert, project director of Sentara Volunteer Care Givers.
Schuchert said Sentara's service credit program was conceived as a tie-in to the PACE program. "We know that they're the frailest of the population, and we know they're going to need services," he said.
The program also will benefit some 3,000 enrollees in Sentara Medicare Choice, Sentara's Medicare risk product .
Why not just recruit volunteers the old-fashioned way? "By giving them a credit, we're acknowledging (them) not only with the informal method of a thank-you...we're also giving them something back," he said.
Volunteers will be recruited from Sentara Select Plus, a club for older adults with more than 16,000 members. The program will offer more than 20 services, including transportation, meal preparation, visitation, meal delivery, yard work and light housekeeping.
The goal is to recruit 1,000 volunteers, each of whom will serve two hours a month, by the end of the third year. Using $10 an hour as an average value, those services would be worth some $240,000 a year once the goal is met.
Robert Wood Johnson Foundation's managed-care grants represent its second foray into service credit banking. In 1987, the philanthropy funded six sites in Boston, Brooklyn, Miami, San Francisco, St. Louis and Washington to test the feasibility of such programs. Over the three-year grant period, the number of volunteers grew to 4,391 from 1,167 in the first year, and hours of service rose to more than 143,000 from 37,000.
One of the six programs, sponsored by Pacific Presbyterian Medical Center in San Francisco, now part of California Pacific Medical Center, is no longer in operation. The program conflicted with the hospital's mission of increasing bed days, Treat said.
Currently about five of the nation's 80 service credit programs are sponsored by hospitals. Presumably, the growth of capitation will motivate more hospitals to offer such programs.
"The incentives have changed now," Treat said.