The client discharge/referral system;
Does it work?
by
Norma J. Stumbo, Ph.D., CTRS
Therapeutic recreation professionals have spent an incredible
amount of time and energy on developing various standards and
guidelines for improving practice at both the national and state
levels. Most of the time, though, little in known about the use and
usefulness of the standards because we fail to adequately research
and understand the difficulties of implementing these standards in
practice.
In 1982, the Community Referral Committee developed the
Illinois Therapeutic Recreation Section (ITRS) Therapeutic
Recreation Discharge/Referral Process — Standards and Guidelines document. Since its initial development, the standards and
guidelines have undergone several revisions. They have also
experienced periodic shifts in acceptance and use by practitioners.
In late 1989, a research project was funded in part by ITRS to
determine the current status and use of the standards.
After a review of past information provided by the committee, an instrument was developed and pilot tested by the research
team, and it addressed demographic questions, general questions
about the implementation of the discharge/referral process and
specific questions concerning the adherence to the standards and
guidelines. The revised survey was mailed to a sample of 98
therapeutic recreation professionals in the state for their responses.
Of the 98 questionnaires that were mailed, 65 (66.33 percent)
were returned after one follow-up letter. These returned surveys
represented 35 clinical agencies, 26 community-based agencies,
and three agencies in the "other" category, with one non-respondent to this question. Of the 65 respondents, the majority were
from the Northern region of the stale.
Population groups served
The most prevalent service groups for all respondents included individuals with mental illnesses, emotional disturbances/behavior disorders and orthopedic impairments. However, when
the respondents are divided into clinical and community settings,
some interesting differences are noted. Clinical agencies most
often served individuals with mental illnesses, aging, emotional
disturbances/behavior disorders, orthopedic impairments and
substance abusers. Community agencies most often served individuals with mental retardation, mental illnesses, and orthopedic
impairments. While clinical agencies primarily served individuals with mental illnesses, the community group primarily served
individuals with mental retardation. Both types of agencies
typically served over 250 individuals annually.
Number of therapeutic recreation staff
Regarding the total number of therapeutic recreation staff
employed, there was a wide variation among responding agencies.
Almost half of both types of agencies employed only one or two
therapeutic recreation personnel (31 or 47.69 percent), but only
three clinical agencies employed 12 or more staff while seven
community agencies employed that number.
Awareness and use of ITRS Discharge/Referral Standards
The next series of questions examined the agencies' awareness and use of the ITRS Discharge/Referral Standards. Frequencies and percentages of responses equal more than 100 percent
because respondents could select all options which applied. The
four most common reasons for all agencies for not using the
standards were: "Standards do not fit agency's needs;" "Was
unaware of the Standards;" "Not required to use;" and "Not sure
how to start the process." Clinical personnel were less likely to
know how to start the discharge/referral procedure, and community staff stated they were not required to use the standards.
In summary, while 50 of the 65 responding agencies knew
about the standards and 45 reported having a copy, only 25
currently used the standards. Of those who used them, the
majority had done so from one to three years. Two of the four
main reasons given for not using the standards related to unawareness of the standards or the discharge/referral process, and the
other two related to not being mandated to use the standards.
Reasons for not using the standards varied among the two types of
settings. Eighteen agencies requested further information about
the standards.
Adherence to and use of the discharge/referral standards
Both clinical and community agencies were asked about their
use of the standards and guidelines. Seven of the clinical agencies
reported an increase in the number of referrals they had sent in
recent years, however, most also reported that few clients actually
followed through and participated in the community-based programs. Similar information was found with the community
agencies, with 13 responding that referrals had increased in the
last two years, but few clients registered and attended programs.
One discrepancy found between the two types of agencies' responses was the types of programs available to clients. Clinical
respondents reported that there were not enough or inadequate
community programs for client referrals.
Illinois Parks and Recreation 31 January/February 1991
Agency respondents were also asked about their adherence to
the ITRS Standards. Clinical agencies have five standards and
community agencies have a different set of 10 standards to follow.
While the ability to generalize from such a small sample is weak,
for the most part, community agencies followed the guidelines
more closely that did the community agencies. The clinical
agencies were most likely to do follow-up services. Community
staff were best able to make determinations of appropriate programs for referred clients and suggest alternative programs if non-existed within the agency. They were least successful at providing
in-service staff training concerning disability information and
utilizing consumer service evaluations.
Several conclusions can be made from the data discussed
here. While they are discussed more fully in the final research
report, they are simply listed here due to space limitations.
Clinical and community therapeutic recreation agencies may
be serving distinctly different types of population groups (e.g., individuals with mental illnesses in clinical settings versus individuals with mental retardation in community settings).
While the number of client referrals being made by clinical
staff arc increasing, few clients actually participate in the community-based therapeutic recreation programs to which they are
referred.
Fewer therapeutic recreation staff are employed per agency
in clinical settings, although the number of clients served is comparable with community-based programs.
Those agencies which used the discharge/referral standards
did so with some .consistency and regularity. There seemed to be
a "core" group of regular, committed users and a "fringe" group
which have a lesser commitment.
Based on the results and conclusions, six recommendations
were made to the ITRS Discharge/Referral Committee. These
include:
1. Maintain and/or increase education efforts to therapeutic
recreation practitioners and students.
2. Review the current standards documentation to determine
if the process may be made more "user friendly."
3. Re-institute the "liaison" concept to assist in creating a
grassroots support for the discharge/referral system.
4. Reward those who use the system well.
5. Conduct further research to examine issues uncovered by
the present study, especially the differences in populations served
and the number of staff and time usage.
6. Consider creating a directory of therapeutic recreation
services for people with disabilities on a statewide basis.
At the present time, the ITRS Discharge/Referral Committee
is reviewing the results of this study and developing plans to improve the system. The committee would welcome any input and
comments from ITRS members. The complete research report is
available through ITRS at the IPRA office.
About the Author
Norma J. Stumbo, Ph.D., CTRS, is an Associate Professor
and Coordinator of Therapeutic Recreation at Illinois State
University where she has been employed for seven years. Most of
her research publications and presentations are targeted to applying research findings to the improvement of practice.
Illinois Parks and Recreation 32 January/February 1991