Norma J. Stumbo, Ph.D., CTRSNorma J. Stumbo, Ph.D., CTRSPresident, Education AssociatesPresident, Education Associates

Defining Accountability, Intervention, Quality, Outcomes

Leisure Ability Model

Therapeutic Recreation Accountability Model

Principles of Intervention Programming

Components - Practice

What is Accountability?

How is Quality Defined?

What is Intervention (and how does it differ from other services)?

What are Client Outcomes?

How Does TR Produce Client Outcomes?

What Client Outcomes Should be Expected in High-Quality TR Intervention Programs?

Being held responsible for the production and delivery of therapeutic recreation services that best meet client needs and move clients toward predetermined outcomes in the most timely, efficient, and effective manner

as possible (Stumbo & Peterson, 2009, p. 73)

A program that is designed and implemented to be intervention has as its outcome some degree of client behavioral change (that is, behavioral change is the purpose of the program) (Stumbo & Peterson, 2009, p. 79)

The direct, causal link between the process or delivery of care and the outcomes expected from it (Riley, 1991a)

Providing the right patient with the right service [at] the right time in the right setting at the right intensity and for the right duration (Navar, 1991, p. 5)

Intervention programs that lead to predictable and measurable client outcomes (Peterson & Stumbo, 2009)

Achievement of some pre-established standard or a desired level of service (Stumbo, Pegg, & Carter, in press)

Degree to which health services for individual and populations increase the likelihood of desired health outcomes (quality principles), are consistent with current professional knowledge (professional practitioner skills), and meet the expectations of healthcare users (the marketplace) (Buttell, Hendler, & Daley, 2006, p. 62)

Change in clinical status (effect of tx. on pt. symptoms)

Change in functionality (effect of tx. on pt. lifestyle)

Change in utilization of medical resources (effect of tx. on using additional health care services)

Recidivism (examining patterns of relapse or re-entry into medical system) (Gorski, 1995, p. 33)

Observed changes in a client’s status as a result of our interventions and interactions... Outcomes can be attributed to the process of providing care, and this should enable us to determine if we are doing for our clients that which we purport to do (Shank & Kinney, 1991, p. 76)

Need to have relevance and importance to the client’s future lifestyle and are attainable within the time frame of service delivery (Riley, 1987a, 1991a)

• Observable changes that result from intervention (Client status, functional status, well-being, care satisfaction, cost/resource utilization

• Changes over specified time• Clinical results• Results of performance• Direct effects of service• Difference between input (assessment baseline) and

output (discharge)• Both planned and unplanned• Both beneficial and harmful• Straightest line between A and BStraightest line between A and B

Client characteristics at end of treatment

(re-assessment)

(e.g., health status, functional status,

quality of life, etc.)

Client characteristics at baseline

(assessment)

(e.g., health status, functional status,

quality of life, etc.)

InterventionEntry Exit

Difference between Point A/Entry and Point B/Discharge= Outcomes

11

Accountability?

Intervention?

Quality?

Client Outcomes?

Application to Your TR Program?

Leisure Ability Model◦Content Model

Therapeutic Recreation Accountability Model◦Process Model

13

Schematic Representations

Communication Tools◦ Explanation of TR Practice◦ Expression of Philosophy and Theory

Defines TR Practice◦ Directs Service Development, Delivery to Clients◦ Directs Selection of Client Outcomes ◦ Directs Program Evaluation & Quality Improvement◦ Foundation for Research, Public Policy, & Future

Two Types◦ Content Models◦ Process Models

Ross & Ashton-Schaeffer, 2009

14

15

Purpose of Therapeutic Recreation:

To aid individuals with physical, intellectual, emotional, and/or social limitations in developing an independent leisure lifestyle aimed at improving their overall health, well-being, and quality of life through the provision of functional intervention, leisure education, and recreation participation services.

16

Functional Intervention Functional Intervention

(formerly Recreation Therapy and Treatment)

Leisure EducationLeisure Education

Recreation Participation Recreation Participation

(formerly Special Recreation)

17

Functional InterventionFunctional Intervention

◦ Addresses functional abilities that are prerequisite to, or a necessary part of, leisure involvement and lifestyle

◦ Baseline abilities that peers without limitations would possess

◦ PhysicalPhysical Endurance, strength, hand-eye coordination

◦ CognitiveCognitive Orientation, ability to follow directions

◦ EmotionalEmotional Anger management, emotional expression

◦ SocialSocial Refrain from biting, kicking, etc. 18

Leisure EducationLeisure EducationBroad category of services that focuses on the development and acquisition of various leisure-related skills, attitudes, and knowledges

◦ Leisure AwarenessLeisure Awareness

◦ Social SkillsSocial Skills

◦ Leisure ResourcesLeisure Resources

◦ Leisure SkillsLeisure Skills

19

Leisure AwarenessLeisure AwarenessCognitive awareness of leisure and its benefits, a valuing of the leisure phenomenon, and a conscious decision-making process to activate involvement

◦ Knowledge of LeisureKnowledge of Leisure

◦ Self-AwarenessSelf-Awareness

◦ Leisure and Play AttitudesLeisure and Play Attitudes

◦ Related Participatory and Decision-Making Related Participatory and Decision-Making SkillsSkills

20

Social SkillsSocial SkillsDevelopment of social interaction skills through direct instruction

◦ Communication SkillsCommunication Skills Assertiveness, Conversation, Active Listening,

Information-Seeking, Information-Giving, etc.

◦ Relationship-Building SkillsRelationship-Building Skills Greeting Skills, Friendship Development, Cooperation,

Competition, Negotiation, Compromise, Social Networks

◦ Self-Presentation SkillsSelf-Presentation Skills Etiquette & Manners; Hygiene, Health & Grooming

Skills; Appropriate Attire, Responsibility for Self-Care

2000

21

Leisure ResourcesLeisure Resources◦ Knowledge and ability to utilize a wide

variety of leisure resources

◦ Activity OpportunitiesActivity Opportunities

◦ Personal ResourcesPersonal Resources

◦ Family and Home ResourcesFamily and Home Resources

◦ Community ResourcesCommunity Resources

◦ State and National ResourcesState and National Resources

22

Leisure Activity SkillsLeisure Activity Skills◦ Activity skill development

◦ Traditional Leisure SkillsTraditional Leisure Skills Sports, Dance, Drama, Music, Hobbies

◦ Non-Traditional Leisure SkillsNon-Traditional Leisure Skills Social Interaction, Community Services,

Relaxation, Food Preparation, Living Things Maintenance

23

Recreation ParticipationRecreation Participation◦ Structured, supervised programs with

opportunities to practice skills learned previously, express preferences, display talents

◦ Example: After teaching leisure awareness, social interaction skills, activity opportunities, and decision-making skills, taking clients to an arts performance or sporting event of their choice.

24

TR Service Model – Conceptual Content Model◦ Addresses Spectrum of Services◦ Disability-, Setting-, & World-Inclusive

Definition of Scope of TR Practice Pro-Intervention – Focused on Change of Client

Behavior, Skills, Knowledges Difference Between Entry to and Exit from TR Services Evidence, Intervention, Measurement, Outcomes

Based on Leisure Behavior Based on Normalized, Inclusive Ideals Based on Health, Wellness, Well-Being, & QOL

25

A Panacea for All that Ails TR

Not Based on Diversional Recreation Provision*◦ Recreation for Recreation’s Sake

Not Anti-Intervention◦ Not Loosy-Goosy Excuse to Program Poorly

Not Based on Activity Provision◦ Is Based on Evidence-Based, Outcome-Focused

Program Provision

Not Focused on Medical Model – Sick Roles/Pathologies

* Diversional activities are not within LAM

26

27

Comprehensive & Specific Program Design Activity Analysis, Selection, Modification Protocol Development Client Assessment Plan

Intervention Programs◦ Assessment Implementation◦ Client Tracking & Documentation

Program Outcomes & Client Outcomes

Quality Improvement/Efficacy Research

28

LAM = Content of TR programs◦ Scope of practice

TRAM= Process of TR programs◦ Systems approach (whole greater than parts)

Results◦ Expansion of APIE into programs (instead of activities)◦ Greater accountability for input/process/output◦ Better standardization of practice/uniformity of

services◦ Improved “teach-ability” to students

29

Programs Developed Conceptually

Programs Drawn from Evidence & Protocols

Programs Based on Targeted Outcomes

Programs Provided Based on Systematic Plan

Program & Client Outcomes Measured

Program & Client Outcomes Reported

30

Connections Relationships Outcome-Driven

31

Connections between Content and Outcomes◦ Comprehensive Program Design

◦ Activity Analysis, Selection, Modification

◦ Protocol Development

◦ Assessment Plan

◦ Client Documentation

◦ Program and Client Outcomes

◦ Quality Improvement/Efficacy Research

Logical, planned, proven connection between ◦ Client Needs/Deficits

Ex: barriers to leisure◦ Client Goals Ex: reduce barriers◦ Interventions

Ex: programs to reduce barriers◦ Immediate Client Outcomes (^ Leisure K, S, A)

Ex: ability to remove or reduce leisure barriers

◦ Ultimate Client Outcomes (Life Satisfaction, Wellness, Quality of Life)

Ex: independent functioning/invisibility

Needs/BarriersGoal Setting

Activities/Programs/Interventions

Long Term/ UltimateOutcomes

IntermediateOutcomes

Problem:lack of energy (Can’t walk 1 block)

Goal:Increased energy

Objective:Walk 12 blocks

Program:

Exercise Program 4x/wk.

Intermediate

Outcome:

Measurable increased energy

Outcome: Ability to walk 12 blocks

Long-Term Outcome:

Sufficient energy for work, leisure, and personal efforts

Outcome:

Walk 1 mile

Functional InterventionIncreased ability to manage anger appropriatelyIncreased emotional control and healthy expression

Leisure EducationIncrease ability to make decisions related to leisure participationIncreased knowledge of the importance of leisure in one’s life

Recreation ParticipationImproved ability to express self within leisure contextImproved ability to select and participate in activity(ies) of one’s choice

Efficiency and effectiveness of demonstrating client change

Reasonable relationship between the services provided and expected outcome(s)

Connection between occurrence of outcome and timing of data collection

Relevance to client and society

Goals and intent of the program

Appropriate level of specification, but not trivial detail

Individual client variation within any given program

Long-term and short-term goals and objectives

Social and home environment to which client will return

Behaviors that are generalizable and transferable to variety of settings and situations

Using LAM and TRAM to build programs and activities, based on goals and outcomes

Key ConceptWhat program goals/areas will meet the

needs of your client group(s)?

My example: TR program for individuals with addictions

1.0 Functional Intervention

1.1 Emotional Control

2.0 Social Skills

2.1 Communication Skills

2.2 Relationship-Building Skills

2.3 Self-Presentation Skills

3.0 Stress Management

3.1 Personal Responsibility

3.2 Seeking Alternatives

3.3 Decision-Making

3.4 Social Support Networks

4.0 Leisure Awareness

4.1 Knowledge of Leisure

4.2 Self-Awareness in Leisure

4.3 Leisure and Play Attitudes

44 Related Participatory and Decision-making Skills

5.0 Leisure Resources

5.1 Activity Opportunities

5.2 Personal Resources

5.3 Family and Home Resources

5.4 Community Resources

5.5 State and National Resources

1.0 To provide programs which teach emotional control…

2.0 To provide social skill instruction programs …

2.1 To provide programs which directly teach a variety of communication skills, such as compromise, cooperation, negotiation, persuasion, active listening skills, etc.

2.2 To provide direct instruction in relationship-building skills, such as self-disclosure and privacy skills, greeting and initiation skills, locating sober leisure partners, building social networks, etc.

1. Get into small groups of no more than three or four individuals (with common clients)

2. Choose comprehensive program areas based on client needs.

EX. Functional abilities, leisure awareness, social skills, leisure skills, leisure resources, recreation

participation.

3. Develop comprehensive program goal statements.

4. Develop specific program areas based on client needs.

5. Develop specific program goal statements.

Key Concept

What activities meet the purpose of the program goals?

Programs Related to Goal Areas/Protocols/Assessment

Meet Needs of Clients

Leads to Client Outcomes

Your Ideas. . .

Key ConceptHow can you standardize program delivery to

clients to ensure outcomes?

Problem Definition Defining Characteristics Outcome Criteria Process Criteria Related factors/

Etiologies

Your Ideas. . .

Key ConceptThe content of the assessment must match

the content of the programs.

Questions Relate to Goal Areas/Protocols

Simplify the Scoring System

Leads to Program Placement

Your Ideas. . .

Key Concept

Document only that behavior which relates to program goals/client needs

Assessment Results Treatment Plans Progress Notes Discharge/Referral Summaries

Your Ideas. . .

Key ConceptOnly expect as an outcome, what you plan

into and design the program to do

Relates to Program Goals

Relates to Client Goals

Relates to Client Documentation

Achieved through Program Participation

Your Ideas. . .

Key Concept

How effective are your programs at producing targeted outcomes?

Major Aspects of Care Indicators (Outcomes) Criteria/Thresholds Methods/Data Sources Evaluate Care

Your Ideas. . .

Comprehensive and Specific Goals Activity Analysis, Selection and

Modification Protocol Development Assessment Plan Client Documentation Program and Client Outcomes Quality Improvement/Efficacy Research

Connections Between Content and Outcomes

◦Comprehensive and Specific Goals◦Activity Analysis, Selection and Modification

◦Protocol Development◦Assessment Plan◦Client Documentation◦Program and Client Outcomes◦Quality Improvement/Efficacy Research

Norma J. Stumbo, Ph.D., CTRSnjstumbo@gmail.com