Norma J. Stumbo, Ph.D., CTRS
President, Education Associates

Defining Accountability,
Intervention, Quality, Outcomes
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Leisure Ability Model
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Therapeutic Recreation Accountability Model
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Principles of Intervention Programming
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Components - Practice

What is Accountability?

How is Quality Defined?
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What is Intervention (and how does it differ from
other services)?
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What are Client Outcomes?
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How Does TR Produce Client Outcomes?
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What Client Outcomes Should be Expected in HighQuality 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 B
Client characteristics at
baseline
Client characteristics at
end of treatment
(assessment)
(re-assessment)
(e.g., health status,
functional status, quality of
life, etc.)
(e.g., health status,
functional status, quality
of life, etc.)
Entry
Exit
Intervention
Difference between Point A/Entry and Point B/Discharge
= Outcomes
11
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Accountability?

Intervention?
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Quality?
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Client Outcomes?
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Application to Your TR Program?
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Leisure Ability Model
◦ Content Model

Therapeutic Recreation Accountability Model
◦ Process Model
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Schematic Representations

Communication Tools

Defines TR Practice

◦ Explanation of TR Practice
◦ Expression of Philosophy and Theory
◦
◦
◦
◦
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
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15
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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, wellbeing, and quality of life through the provision
of functional intervention, leisure education,
and recreation participation services.
16
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Functional Intervention
 (formerly Recreation Therapy and Treatment)
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Leisure Education
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Recreation Participation
 (formerly Special Recreation)
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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.
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Leisure Education
Broad category of services that focuses on the
development and acquisition of various leisurerelated skills, attitudes, and knowledges
◦ Leisure Awareness
◦ Social Skills
◦ Leisure Resources
◦ Leisure Skills
19
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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
20
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Social Skills
Development of social interaction
skills through direct instruction
200
0
◦ Communication Skills
 Assertiveness, Conversation, Active Listening, InformationSeeking, 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
21
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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
22
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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
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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.
24
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TR Service Model – Conceptual Content Model
◦ Addresses Spectrum of Services
◦ Disability-, Setting-, & World-Inclusive

Definition of Scope of TR Practice
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Pro-Intervention – Focused on Change of Client
Behavior, Skills, Knowledges
 Difference Between Entry to and Exit from TR Services
 Evidence, Intervention, Measurement, Outcomes
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Based on Leisure Behavior
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Based on Normalized, Inclusive Ideals
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Based on Health, Wellness, Well-Being, & QOL
25
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A Panacea for All that Ails TR
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Not Based on Diversional Recreation Provision*
◦ Recreation for Recreation’s Sake
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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
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27
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Comprehensive & Specific Program Design
Activity Analysis, Selection, Modification
Protocol Development
Client Assessment Plan
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Intervention Programs

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◦ Assessment Implementation
◦ Client Tracking & Documentation
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Program Outcomes & Client Outcomes
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Quality Improvement/Efficacy Research
28
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LAM = Content of TR programs
◦ Scope of practice
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TRAM= Process of TR programs
◦ Systems approach (whole greater than parts)
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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
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Programs Developed Conceptually
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Programs Drawn from Evidence & Protocols
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Programs Based on Targeted Outcomes
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Programs Provided Based on Systematic Plan
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Program & Client Outcomes Measured
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Program & Client Outcomes Reported
30
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Connections
Relationships
Outcome-Driven
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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/Barriers
Goal Setting
Problem:
lack of energy
(Can’t walk 1
block)
Goal:
Increased
energy
Objective:
Walk 12 blocks
Activities/Programs/
Interventions
Intermediate
Outcomes
Program:
Intermediate
Exercise
Program
4x/wk.
Outcome:
Measurable
increased energy
Outcome: Ability
to walk 12 blocks
Long Term/
Ultimate
Outcomes
Long-Term
Outcome:
Sufficient energy
for work, leisure,
and personal
efforts
Outcome:
Walk 1 mile

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

Efficiency and effectiveness of demonstrating client
change
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Reasonable relationship between the services provided
and expected outcome(s)
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Connection between occurrence of outcome and timing
of data collection
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Relevance to client and society
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Goals and intent of the program
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Appropriate level of specification, but not trivial detail
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Individual client variation within any given program
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Long-term and short-term goals and objectives
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Social and home environment to which client will
return
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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 Concept
What 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
3.0 Stress Management
3.1 Personal Responsibility
3.2 Seeking Alternatives
3.3 Decision-Making
2.1 Communication Skills
3.4 Social Support Networks
2.2 Relationship-Building
Skills
2.3 Self-Presentation Skills
4.0 Leisure Awareness
5.0 Leisure Resources
4.1 Knowledge of Leisure
5.1 Activity Opportunities
4.2 Self-Awareness in
Leisure
5.2 Personal Resources
4.3 Leisure and Play
Attitudes
44 Related Participatory and
Decision-making Skills
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 relationshipbuilding skills, such as self-disclosure and privacy
skills, greeting and initiation skills, locating sober
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
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Meet Needs of Clients

Leads to Client Outcomes
Your Ideas. . .
Key Concept
How can you standardize program delivery to clients
to ensure outcomes?
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Problem

Definition

Defining Characteristics
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Outcome Criteria
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Process Criteria

Related factors/
Etiologies
Your Ideas. . .
Key Concept
The content of the assessment must match the content
of the programs.

Questions Relate to Goal Areas/Protocols
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Simplify the Scoring System

Leads to Program Placement
Your Ideas. . .
Key Concept
Document only that behavior which relates
to program goals/client needs
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Assessment Results
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Treatment Plans
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Progress Notes

Discharge/Referral Summaries
Your Ideas. . .
Key Concept
Only expect as an outcome, what you plan into and
design the program to do

Relates to Program Goals
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Relates to Client Goals
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Relates to Client Documentation
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Achieved through Program Participation
Your Ideas. . .
Key Concept
How effective are your programs at
producing targeted outcomes?

Major Aspects of Care

Indicators (Outcomes)
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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., CTRS
njstumbo@gmail.com