Goal Oriented Activities and Outcomes Norma J. Stumbo, Ph.D., CTRS President, Education Associates

Topics Defining Accountability, Intervention, Quality, Outcomes Leisure Ability Model Therapeutic Recreation Accountability Model Principles of Intervention Programming Components - Practice

Background 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?

Accountability 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)

Intervention 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)

Quality 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)

Quality 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)

Client Outcomes - Categories 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)

Client Outcomes 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)

Client Outcomes 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 B

Client Outcomes Intervention Entry Exit Client characteristics at baseline (assessment) (e.g., health status, functional status, quality of life, etc.) Client characteristics at end of treatment (re-assessment) (e.g., health status, functional status, quality of life, etc.) Entry Exit Intervention Difference between Point A/Entry and Point B/Discharge = Outcomes

Questions? Accountability? Intervention? Quality? Client Outcomes? Application to Your TR Program?

TR Service Models Leisure Ability Model Content Model Therapeutic Recreation Accountability Model Process Model

Purpose of TR Service Models 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

2009 Leisure Ability Model Functional Intervention, Leisure Education, Recreation Participation

Current Leisure Ability Model 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.

Current Leisure Ability Model Functional Intervention (formerly Recreation Therapy and Treatment) Leisure Education Recreation Participation (formerly Special Recreation)

Current Leisure Ability Model Functional 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 Physical Endurance, strength, hand-eye coordination Cognitive Orientation, ability to follow directions Emotional Anger management, emotional expression Social Refrain from biting, kicking, etc.

Current Leisure Ability Model Leisure Education Broad category of services that focuses on the development and acquisition of various leisure- related skills, attitudes, and knowledges Leisure Awareness Social Skills Leisure Resources Leisure Skills

Current Leisure Ability Model Leisure Awareness Cognitive awareness of leisure and its benefits, a valuing of the leisure phenomenon, and a conscious decision-making process to activate involvement Knowledge of Leisure Self-Awareness Leisure and Play Attitudes Related Participatory and Decision-Making Skills

Current Leisure Ability Model Social Skills Development of social interaction skills through direct instruction Communication Skills Assertiveness, Conversation, Active Listening, Information- Seeking, Information-Giving, etc. Relationship-Building Skills Greeting Skills, Friendship Development, Cooperation, Competition, Negotiation, Compromise, Social Networks Self-Presentation Skills Etiquette & Manners; Hygiene, Health & Grooming Skills; Appropriate Attire, Responsibility for Self-Care 2000

Current Leisure Ability Model Leisure Resources Knowledge and ability to utilize a wide variety of leisure resources Activity Opportunities Personal Resources Family and Home Resources Community Resources State and National Resources

Current Leisure Ability Model Leisure Activity Skills Activity skill development Traditional Leisure Skills Sports, Dance, Drama, Music, Hobbies Non-Traditional Leisure Skills Social Interaction, Community Services, Relaxation, Food Preparation, Living Things Maintenance

Current Leisure Ability Model Recreation 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.

LAM: What It IS 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

* Diversional activities are not within LAM LAM: What It IS NOT 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

Therapeutic Recreation Accountability Model

Therapeutic Recreation Accountability Model 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

Connection Between LAM and TRAM 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

Relationship of TR Models and Evidence-based Interventions and Outcomes 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

Principles of Intervention Programming Connections Relationships Outcome-Driven

Principles of Intervention Programming 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

Principles of Intervention Programming 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

Connections Needs/Barriers Goal Setting Intermediate Outcomes Activities/Programs/ Interventions Long Term/ Ultimate Outcomes 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

Typical TR Client Outcomes Functional Intervention Increased ability to manage anger appropriately Increased emotional control and healthy expression Leisure Education Increase ability to make decisions related to leisure participation Increased knowledge of the importance of leisure in one’s life Recreation Participation Improved ability to express self within leisure context Improved ability to select and participate in activity(ies) of one’s choice

Guidelines for Outcomes 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

Guidelines for Outcomes (cont’d) 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

Building Goal Oriented Activities and Outcomes Using LAM and TRAM to build programs and activities, based on goals and outcomes

Comprehensive and Specific Program Goals Key Concept What program goals/areas will meet the needs of your client group(s)? My example: TR program for individuals with addictions

Comprehensive and Specific Program Goals 3.0 Stress Management 3.1 Personal Responsibility 3.2 Seeking Alternatives 3.3 Decision-Making 3.4 Social Support Networks 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

Comprehensive and Specific Program Goals 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 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

Comprehensive and Specific Program Goals 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.

Comprehensive and Specific Program Goals – Your Turn! 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.

Activity Analysis, Selection and Modification Key Concept What activities meet the purpose of the program goals?

Activity Analysis, Selection and Modification Programs Related to Goal Areas/Protocols/Assessment Meet Needs of Clients Leads to Client Outcomes

Activity Analysis, Selection and Modification Your Ideas. . .

Protocol Development Key Concept How can you standardize program delivery to clients to ensure outcomes?

Protocol Development Problem Definition Defining Characteristics Outcome Criteria Process Criteria Related factors/ Etiologies

Protocol Development Your Ideas. . .

Assessment Plan Key Concept The content of the assessment must match the content of the programs.

Assessment Plan Questions Relate to Goal Areas/Protocols Simplify the Scoring System Leads to Program Placement

Assessment Plan Your Ideas. . .

Client Documentation Key Concept Document only that behavior which relates to program goals/client needs

Client Documentation Assessment Results Treatment Plans Progress Notes Discharge/Referral Summaries

Client Documentation Your Ideas. . .

Program and Client Outcomes Key Concept Only expect as an outcome, what you plan into and design the program to do

Program and Client Outcomes Relates to Program Goals Relates to Client Goals Relates to Client Documentation Achieved through Program Participation

Program and Client Outcomes Your Ideas. . .

Quality Improvement/ Efficacy Research Key Concept How effective are your programs at producing targeted outcomes?

Quality Improvement/ Efficacy Research Major Aspects of Care Indicators (Outcomes) Criteria/Thresholds Methods/Data Sources Evaluate Care

Quality Improvement/ Efficacy Research Your Ideas. . .

Application to Your Program Comprehensive and Specific Goals Activity Analysis, Selection and Modification Protocol Development Assessment Plan Client Documentation Program and Client Outcomes Quality Improvement/Efficacy Research

Key Concepts 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

Thank You!!! Norma J. Stumbo, Ph.D., CTRS njstumbo@gmail.com