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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


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 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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