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

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

3. 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?

4. 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)

5. 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)

6. 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)

7. 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)

8. 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)

9. 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)

10. 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

11. 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

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

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

14. 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

15. 2009 Leisure Ability Model Functional Intervention, Leisure Education, Recreation Participation

16. 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.

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

18. 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.

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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.

25. 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

26. * 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

27. Therapeutic Recreation Accountability Model

28. 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

29. 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

30. 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

31. Principles of Intervention Programming
Connections
Relationships
Outcome-Driven

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

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

39. 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

40. 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

41. 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

42. 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.

43. 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.

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

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

46. Activity Analysis, Selection and Modification
Your Ideas. . .

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

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

49. Protocol Development
Your Ideas. . .

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

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

52. Assessment Plan
Your Ideas. . .

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

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

55. Client Documentation
Your Ideas. . .

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

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

58. Program and Client Outcomes
Your Ideas. . .

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

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

61. Quality Improvement/ Efficacy Research
Your Ideas. . .

62. 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

63. 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

64. Thank You!!!
Norma J. Stumbo, Ph.D., CTRS