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Brief Encounters: Community Connections in TR
New faces, new challenges in the community; changing
face of services, resources, and professional roles. Examples of connection,
networks, and transitions between clinical and community health & human
service providers. As presented to participants of the 1995 WVTRA conference
in Morgantown, WV.
Marcia Jean
Carter, Re.D., CLP, CTRS, Associate Professor, Ashland
University
Introduction
Social and health care reforms initiated in the
1960's and 1980's and the economic revolution of the 1980's and 1990's set the
stage for a number of changes as health and human service providers plan to
do business in 2000 and beyond. A number of individuals with increasingly intense
health and human service needs are living out their lives in the community;
cost containment and quality control measures are redirecting medical and health
services toward communities and caregivers in the community; and, the recency
of "human re-engineering" creates environments where fewer are expected
to do more with less.
Osborne and Gaebler in their 1992 classic "Reinventing
Government" list as one of the principles of entrepreneurial government
the role of management as a catalyst that spurs all sectors of the organization
into action to solve problems. By virtue of our roles and philosophical basis
we can be the change agents in our agencies who can get people to manage themselves
so that consumers realize a service continuum directed toward enhancing their
health and well-being.
A number of social, health care and economic factors
have contributed to the need to develop community networks. The social integration
efforts begun in the 1960's have been formalized by legislation as recent as
1990 with the enactment of IDEA--PL 101-476, Individuals with Disabilities Education
Act. The federal mandate of 1983 to make transitioning in the education programs
of youth a priority now includes "a coordinated set of activities for a
student, designed within an outcome-oriented process, which promotes movement
from school to post-school activities...including supported employment, continuing
and adult education, adult services, independent living, or community participation."
1990 also saw the signing of ADA--PL 101-336 the Americans with Disabilities
Act which promotes access to programs and services including employment for
individuals with disabilities including those who might not be benefiting from
IDEA.
In the 1980's the federal government initiated
the DRG system that was intended to change the health care payment system from
a retrospective to a prospective payment system. Simultaneously third-party
reimbursers began to promote payment plans that supported reductions in the
length of stay. The managed care concept introduced in the late 1980's further
emphasized collaborative efforts, patient satisfaction and rewards for reducing
length of stay while improving quality of care. Persons with medical needs are
now and will be more vigorously treated through community and caregiver interventions
as we approach and enter the next century. Service providers will continue to
be held accountable for improving quality of service while containing costs
and ensuring continuity of care.
A third impetus to do business differently results
from the application of Japanese business practices to government and private
enterprise in America. Economic reforms emanating from Deming's TQM promote
structural reorganization and "human re-engineering" as hallmarks
of successful management. Authority is decentralized, paper work and files are
minimized, employees resolve issues, competition among service providers is
encouraged, performance is measured in outputs, customers are offered choices,
services are driven by the market and citizens are empowered to act. Networks
rather than ladders are characteristic of organizational relationships. Focus
is on the customer's satisfaction and attainment of outcomes. Staffing assignments
are made according to who has the resources and talents to produce services
needed by customers.
Thus the impetus to develop networks comes from
health care, social and economic reforms that mandate attention to resource
utilization, cost containment, quality services, continuity of care, and customer
satisfaction. Principles of teamwork, systems planning, and "helping"
communication underlie successful network building. In health and human services
we have experienced networks when teams staff clients, the intervention is planned,
and discharge and transition plans are implemented. In each of these situations
a systems planning technique is used as measurable outcomes are targeted. We
communicate as "helpers" and use the community as our resource base
to provide a continuum of opportunities that foster customer independence, health
and well-being.
New Clientele
The social, economic, and health and human service
reforms that have given us the impetus to network have, simultaneously, contributed
to new clientele and programming challenges. The new clientele may benefit from
the impetus to be included yet may not have the skills, resources, and knowledge
to access their leisure and life needs without organized structural support
systems. And, for these clientele, work may not be a focal point of their day.
Their hours free may be equal to or greater than their obligated periods. Examples
of these clientele and the forces that have brought them to the attention of
our profession include:
1. The baby-boom generation contains the largest
number of persons with developmental needs who tend to age earlier and as a
result will be without primary caregiver support as they enter their 50th and
60th decades when the rest of the baby-boomers "officially" become
eligible to receive government support in 2011. Neither the "aging"
nor the "social service" agencies have planned for or coordinated
resources with the aging developmentally disabled clientele.
2. Gradual erosion of the tax base in cities along
with the reduction in trickle-down funds from the federal government have affected
persons living in the inner core of cities like the homeless, underemployed,
and at-risk populations.
3. Downsizing and rightsizing of chronic care facilities
has brought into communities persons with life-long limitations who have fewer
resources to manage caregiving.
4. Deinstitutionalization of the 1960's has brought
more people back to communities while preventing others from seeking state placement
as a living alternative. Consequently an increasing number of extended care
facilities are diversifying their services to meet consumer needs.
5. Consumer rights and advocacy has led to a greater
acceptance of the mainstreaming and inclusion philosophy. Younger parents do
not want separate programming while older parents or persons with disabilities
prefer socially appropriate options which may include "segregate"
activities.
6. Rising health care costs have resulted in shorter
hospital stays and an increase in out-patient and outreach services with clients
having chronic long term health care needs.
7. Medical advancements now permit persons who
have experienced traumatic injuries to live their lives out in altered styles;
witness Christopher Reeves. These same advancements prolong lives and, for some,
increase daily living and well-being options.
8. The rise of dual-career households and single
parents has generated the need for child and adult day care programs, latch-key,
home care, and supportive assistance programs.
9. Lastly, the decade of the 1980's brought social
attention to persons whose needs would have escaped public scrutiny like adult
children of alcoholics, eating disorders, persons who have been abused or incarcerated,
and persons without permanent residence (homeless).
New Challenges
A number of challenges or barriers exist as we
contemplate how to offer services and resources to an increasingly diverse population.
The traditional barriers of transportation, environmental access, attitudes,
financial resources, and staff preparation are intensified and exacerbated by
the persistence of change, medical and technological advancements, and a management
revolution. Challenges to inclusive programming and building connections that
would network caregivers emanate from a number of "real" and "perceived"
matters reported in the literature on integration.
1. Concerns for liability, client autonomy and
confidentiality limit information sharing.
2 Service fragmentation and limited coordination
is attributed to "territorial" issues caused by the need to survive
within the parameters of reduced resources.
3. New populations are unaware of community resources
and lack the knowledge and exposure to leisure resources and skill development.
4. Clients with significantly more challenging
disabilities are living in the community.
5. Clients lack friendships which are 75% of our
leisure experiences.
6. Clients are coming to the community without
their wants, interests, and skills adequately and accurately identified.
7. Clients lack activity specific skills and social
effectiveness others have acquired during the developmental process.
8. A lack of "welcoming" and formal inclusion
of clients in the planning process is known to discourage potential participation.
9. Persons with disabilities live below the poverty
level with limited discretionary income due to medical bills and supportive
health care needs.
10. Persons with disabilities are used to organized
or planned experiences; they find fewer structured options available in the
community.
11. Community staff unaccustomed to the broad array
of new participants have limited information and exposure to many specific limitations.
12. Increased concern for safety and risk management
challenges inclusion of persons in on-going services.
13. Realization that persons with disabilities
exhibit behaviors and expressions that are disruptive and uncomfortable for
regular customers presents supervisory concerns.
14. Reluctance of caregivers and consumers with
disabilities to leave the security of already specialized programs causes a
unique concern when staff attempt to foster social integration.
15. Lastly, the brevity of clinical intervention
time has reduced the time to plan for transitions and complete comprehensive
referral and discharge coordination.
This list presents many challenges to the programming
or intervention process. Resolution of these challenges will occur with visionary
manage-ment, willingness to take risks, and planned change. With networking,
service continuation is enhanced, resource options are accessed, and helping
personnel are encouraged to work as "teams" to address client health
and well-being needs. When networks are formalized, regardless of the brevity
of encounters with clients, client transitions are planned and programming that
benefits client outcomes is offered.
Networking
Networking involves the coordination of resources
and services through formalized communication among professionals, clients,
and caregivers, and service publics. These individuals represent a self-regulating
team whose responsibility is to design and implement a service continuum similar
to those referred to in our introductory texts by Austin and Carter, Van Andel,
and Robb. This service continuum enables the client to function at preferred
levels with support and assistance available in appro-priate amounts. The outcome
is satiation of needs, achievement of health and well-being needs, personal
satisfaction, control, and freedom; no matter how brief the encounter with any
one service provider. Formalized networks enable individualization of preferences
and choices regardless of client predisposition.
Networks operate under implicit and explicit protocols.
Yet, through continuous communication the network matures and each client and
caregiver benefits from service coordination. Within health and human services,
networks that address primary client and caregiver needs are likely to be judged
to function effectively. These need areas vary with the health and well-being
status of the individual and caregivers and the length of time of their involvement
with the various health and human service publics. To illustrate, a new traumatized
patient and their family have more need for emotional support and validation
while parents of children with ADHD are concerned about education and vocational
options and coordination among schools and community services.
To become effective network players a number of
barriers that evolve from personal backgrounds, professional expertise, job
assignments, and current socio-economic and health care trends must be overcome.
The litigious nature of society causes each community agency to enhance its
"safety net" via quality control measures that are not conducive to
co-planning and service delivery. Likewise, downsizing and right-sizing have
caused managers to focus on resource utilization. Marketing of specific services
creates competition for customers that lends itself to "territorialism"
and protection of "vested customers." Differing administrative and
programming philosophies in clinical and community settings are attributed to
such external forces as "third-party" reimbursement criteria and tax
payor revolts. Traditionally, clinical and community therapeutic recreation
specialists have not articulated a common philosophy nor have they attempt-ed
to educate each other about their unique yet common mission. Frequently, the
brevity of clinical encounters has widened the communication gap as time does
not permit implementation of each phase of the TR process. Consequently, community
therapist are including clients in their programs without the benefit of communicated
referral or transition plans.
The benefits of formalizing networks far outweigh
the barriers. The list of positive outcomes includes enhanced access to resources
and client needed facilities; sharing of information that aleviates the intense
competition for already limited resources; opportunities for members of the
team to communicate and educate each other about the intent of their interventions
and strategies to bring about common-unity. The focus of intervention is relevant
skill acquisition. When skills are acquired and practiced in environ-ments similar
to the ones in which they are expected to be performed, mastery is enhanced
so transitions are smoother. Staff share expertise so the scope and depth of
intervention is enhanced. Simultaneously staff experience support and validation
that tends to bring about renewed energy. The service enhancement that results
from networks creates a centralized powerbase or advocary unit that continues
to provide the impetus to meet client and caregiver needs.
The changes that are ocurring to promote networks
are also contrib-uting to the central role our profession will be likely to
play in the provision of health and human services in the 21st century. The
community is viewed as a "gestalt" or whole of interdependent service
providers and resousrces that exchange information in order to develop preferred
services. Within each community there are a number of key players who through
their actions, decisions and communications influence the planning process.
The action leaders actually initiate actions to form networks and advocate for
client needs. Decision makers supply the stamp of approval by approving ideas
and devoting resources to formalize networks. Communicators articulate net-work
issues and gain support among clients, caregivers, professionals, and various
service providers. These are advisory committee members, focus group spokes
persons, significant financial contributors, and/or key office holders and administrators.
These three groups of people have access to resources and information and they
are able to judge the effectiveness of service network outcomes.
A strategic action plan is developed along the
lines of our "traditional" planning process. A vision projects the
intent to serve all persons. Outcomes of forming networks to resolve client
needs are projected. Resources are organized so services are implemented to
address client needs. The effect-iveness of client community functioning is
assessed. How are the networks actually formed? Someone must assume the responsibility
to coordinate several steps or phases. TRS'S are logical personnel to assume
these responsibilities as we service people throughout the life span. Also,
we commonly articulate with people community-wide to access out-reach and extended
services. Therapeutic recreation cuts across traditional service agents such
as schools and social service agencies. And, recreation therapists promote client
health and well-being regardless of client location e.g., hospital, home, pool,
worksite. As a result we are often aware of community assets and liabilities.
The phases of formalizing relationships are outlined
in the 11 step model. Each phase accomplishes a task essential to the undertaking
of the next. And, the outcomes of the next impact preceding and subsequent planning
actions. Each phase is actually one step in a problem-solving or decision-making
approach. These steps are similar to those a therapist would take when clients
are being transitioned from an inpatient to outpatient setting. Or, if a leisure
or community resource directory was being develop-ed, similar steps, would be
undertaken to gather information for such a directory. Thus, the steps might
be used during a leisure education session or sessions to develop leisure resource
awareness.
Service Network Model
Phase I - Information Gathering. The identification
of all potential service providers, clientele, support personnel/resources,
and environmental features/barriers like accessibility, transportation, community
readiness with regard to special needs. Results of this phase set the parameters
in which the transition system must operate. This activity is ongoing as the
system is fluid and interactive in its response to client needs.
Phase II - Identification of Network Service
Providers. Study the data to select the support network with representatives
from: community recre-ation, parents and caregivers, consumers, advocacy groups,
school or day placement, medical and allied health personnel, public and private
social service agencies, and professional/educational resources. This network
of providers will come from within each of our own agencies as well as from
the community-at-large. This process should identify other agencies serving
the same clientele but with different services and other agencies providing
the same service to different clientele. Consequently, cooperating agencies
and personnel must be willing to objectively study the data.
Phase III - Selection/Appointment of Advisory
Team. Key players drawn from the network of service providers are organized
to give direction necessary to cooperate/coordinate and advocate client needs.
Consumers or their representatives should be included on the team as transition
planning is effected.
Phase IV - Assessment of Needs. A status
report of existing services is prepared. Skills needed by clients to function
in their natural environment are identified; this permits the identification
of service gaps. This process is delicate as some agencies may perceive the
clients' needs to already be covered by their service scope.
Phase V - Establish Program Structure/Content.
A common philosophy with mutual objectives is defined. Activities are presented
so they are compatible with client functional levels. A communication system
is set-up to assure all cooperative agencies coordinate service offerings in
line with client needs.
Phase VI - Design Management Plan With Operating
Policies and Procedures. A process is set up to monitor and evaluate the
ongoing activities of the transition team. Agencies adopt a common set of network
policies or a guiding protocol. A schedule is accepted around which meetings
are planned. Specifics define who is responsible for what services. Fiscal management
is an integral aspect of this phase.
Phase VII - Implement Trainign Programs.
Ongoing staff development and dissemination of information on transition programming
is shared with the total network of providers; including caregivers, consumers,
administrators and key advocates.
Phase VIII - Market Services. An ongoing
campaign to recruit and educate the community-at-large to the system is necessary.
Barriers must continue to be broken down with avenues opened to accessible experiences.
Phase IX - Implement Services. Participants
with individualized transition plans are followed through the system. Services
are intended to maintain the client at an optimal level of independent functioning.
Formative evaluation establishes the appropriateness of the transition process
to the client's needs.
Phase X - Evaluate. All phases of the system
are studied; clients, programs, management, and resources to assure that the
pre-established objectives are being attained and that transition is actually
a reality.
Phase XI - Follow-up/Monitor Process. The
key to preventing return to the hospital or loss of employment or leisure skills
is establishing a procedure to track clients' progress to assure their behavior
remains relevant to their "natural" environment. This may necessitate
the assignment of one person from the advisory team to be a "buddy"
or companion while setting certain client feedback expectations.
Client Transition Model
A client transition plan evolves from documentation
already in place at the clinic, school, or vocational center. The plan becomes
an extended service contract or re-entry process spanning the time between placements
so the client is prevented from "falling through the cracks." Clinical
and community T.R. specialists, educators, recreation personnel and adult social
service providers actually meet to formalize each clients' discharge or re-integration
program. The outcome of these efforts is a "facilitation guide" to
be used by clients and staff as clients transition among existing services,
resources, and information.
Step 1 - Orientation. A staffing or conference
with client, cargivers, agency personnel considers awareness/acceptance of all
parties for a transition; consider history of services; current functioning
level, anticipated support needs such as transportation, finances, adapted equipment,
and common client objectives.
Step 2 - Assessment. A sharing of diagnostic
and behavioral informa-tion to streamline entry and reduce costs and establish
primary/secondary transition needs.
Step 3 - Individualized Program Planning.
Develop from existing documents behavioral-oriented objectives with success
indicators being relevancy of skills to setting of application. Establish a
skill progression based on activity and task analyses culminating in age-appropriate
behaviors displayed in the natural setting using the assessment data to establish
base-line indices.
Step 4 - Implementation. Utilize network
agencies or related support services to train/educate client and caregivers
to acquisition and application of independent functioning in the community.
Training should occur with and without supervision; allow for developing necessary
adaptation whether that be with equipment, accessiblity, or skill sequences;
and include manag-ement of self in a crisis situation whether that be a dead
battery or being lost in a crowd. This step must focus on client exploration
of programming and resource options.
Step 5 - Evaluation. Are all systems in
place so that the client's objec-tives have been attained? Is the client capable
of performing independently in the natural environment? Do clients comprehend
the value of leisure as a transitional tool? Are supportive mechanisms in place
with proper amounts of information communicated? Do quantitative results support
release?
Step 6 - Documentation. A written account
of progress toward objec-tives is prepared and shared with all parties noting
past and present skill levels, circumstantial behaviors, precautions, future
goals, and the tracking process to be formalized during referral/re-entry. Consideration
is given to the sensitivity of client records.
Step 7 - Referral/Re-entry. Telephone contact,
return post-card, community volunteers, and client self-reporting on goal attainment
are ways to monitor community maintenance and prevent reversal of skill develop-ment.
Periodically the primary agency liaison may renegotiate client objec-tives.
A common file is retained with updated information respecting the sensitviity
of the information.
Each client's written transition plan results from
this process. The document may be an appendum to the existing hospital chart
or the back-ground information placed with registration materials at the community
center. Or if we are working with clients whose only transitions will be within
the facility between day - evening - weekend programs or shift changes, this
plan is shared with apropriate staff with documentation kept on progress noted
during each particular aspect of the agency program. One final illustration,
this plan may serve as the recommendation letter shared by the T.R. specialist
with the recreator in a private or public leisure service.
The concepts presented in these processes are not
new to anyone in the medical or social service professions. What is new to all
of us are the de-mands attributed to changing financial, social, political,
and legal trends placed upon our service system, and the changing nature of
our clientele. Alter-native delivery models must be developed to assure clients
and caregivers that resources and information will be accessible regardless
of decreasing financial support or intensified levels of client need. The roles
we each assume in the TR process are and will continue to change. The time periods
of intervention are "brief" in the clinical setting as a result of
rembursement and managed care issues. In the community, they are brief due to
the finan-cial exigencies causing "re-engineering" and the influx
of new clients with limited skills, resources, and preparation time. As supported
in the literature, we can remain responsive by incorporating brief treatment
strategies and innovative management techniques into the delivery of programs
and services.
Model Programs
I have had the privilege to work several summers
in Cincinnati, Ohio. The therapeutic recreation division is the first of its
kind in a municiapl recreation program. Throughout its history, changes have
been made to proactively manage the evolving nature of TR in the community.
Several of the innovations are captured in the publication--Designing Therapeutic
Rec-reation Programs in the Community--along with resources from Chicago area
special recreation districts and the Dallas TR program. Most recently, the division
has modified its service approach and planning process to facilitate inclusion.
Comprehensive programs have been structured to incorporate full inclusion as
one option. The program is organized along a skill development continuum that
incorporates participant assessments to facilitate compatible program placements.
This process is presented in a tape available from the division.
Communities, NSSRA, Dallas, Montgomery County,
have created networks through the development of integration plans and coopertive
agreements. These represent service continuums and efforts to communicate so
clients' needs are better articulated among service providers. Individual agencies
(Detroit, Des Moines, SanJose, Seattle) have created programs and client transition
models. They tend to be population specific or setting specific yet, the processes
are similar and easily modified to other therapeutic recreation settings.
At the state level, professional associations have
prepared model referral plans, Illinois and Ohio. These plans contain necessary
assessment and referral forms usable in clinical and community settings. Also,
through state departments of education (Iowa, Louisiana), individual education
and trans-ition plans present opportunities for therapists to incorporate leisure
exper-iences that enhance client functioning. Lastly, through federally funded
projects like those on the campuses of UNC Chapel Hill and the University of
Minnesota at the Twin Cities, professionals have created training and resource
materials that promote linkages among service providers in health and human
service.
All Rights Reserved. Marcia
Jean Carter, 1996.
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