Are You an OUTCOME ENGINEER?

THERAPEUTIC RECREATION PRACTICE IN THE THIRD MILLENNIUM

In therapeutic recreation, we cannot afford to leave outcomes to chance. Today's therapeutic recreation professional must purposefully develop a plan that clearly identifies measurable outcomes. The Outcome Engineering Model may be the tool you need to determine the effectiveness of your program.

Arguably, the 1990s were the decade of accountability in health and human services. For example, the decade witnessed attempts to legislate accountability of health care plans through patient protection legislation (Bell, 1999) and ever increasing demands for accountability of public schools for student performance, particularly as it related to standardized testing (Gergen, 1999). During this same decade, there was an evolution of the nature of accountability. Stumbo (1996) noted that historically, human service agencies have been held accountable for "designing and implementing quality programs" (p. 247). In this environment, the focus of accountability was on the management or improvement of quality services. However, the present approach to accountability emphasizes service performance over service provision. In turn, performance has become synonymous with service outcomes. Within therapeutic recreation, providing outcome-based services requires a conceptual shift that embraces strategies to be an "outcome engineer." Carter, Van Andel, and Robb (1995) stated that:

   "Given the pressures of cost containment and more effective service
   delivery, it is becoming necessary for all [emphasis added] practitioners
   to show administrators, insurance companies, consumers, and other health
   care providers how selected therapeutic recreation interventions affect the
   client's function, health status, and/or quality of life" (p. 93).

One approach to addressing this increased demand for accountability in therapeutic recreation service is through the use of a service model that expressly incorporates outcomes. The Outcome Engineering Model represents a winning strategy that may prove critical to our profession if we are to proactively meet the challenges in today's rapidly changing health care and human service environments.

Concepts of Outcomes

Simply, an outcome is the end result of a provided service or intervention (Hegyvary, 1991; Schalock, 1996). Shank and Kinney (1991) define outcomes as "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" (p. 76). Within medicine, outcomes have been defined in conjunction with a clinical end point, functional status, well-being, and satisfaction with care (Tarlov, et al., 1989). An important premise in the outcome-oriented approach is that if outcomes can be accurately measured and quantified, they also can be predicted. If the antecedents can be identified and outcomes predicted, outcomes logically can be manipulated and controlled. This premise underlies the Outcome Engineering Model.

The Outcome Engineering Model

The Outcome Engineering Model is based on an existing therapeutic recreation process model (c.f., Austin, 1999; Carter, Van Andel, & Robb, 1995) as depicted by the yellow boxes in Figure 1. The Outcome Engineering Model expands our thinking by incorporating the new concepts as demonstrated in the added green boxes. The Outcome Engineering Model begins with a thorough awareness of possible therapeutic recreation outcomes, and this understanding underscores and informs all subsequent phases of the process.

[Figure 1 ILLUSTRATION OMITTED]

Awareness of empirically based therapeutic research outcomes. An outcome engineer knows which outcomes are appropriate targets for therapeutic recreation intervention. For example, research has shown that certain therapeutic recreation services for people with mental illness facilitate greater self-efficacy (Tate & Ellis, 1997). Other therapeutic recreation interventions have been demonstrated to improve coping skills (Shank, Coyle, & Kinney, 1991). Advanced theoretical knowledge of therapeutic recreation outcomes with specific populations serves as a foundation. Shank and Riley (1996) identified a comprehensive list of specific therapeutic recreation outcomes based on their review of existing empirical research. In order for therapeutic recreation specialists to facilitate outcomes as a result of services, they must first know what outcomes are possible; otherwise the results can happen only by chance. We cannot afford to leave outcomes to the laws of chance, but we must purposefully create them by design based on empirical knowledge of therapeutic recreation outcomes.

Assessment and maximization of outcome potential. It is important for an outcome engineer to be knowledgeable of the mental, physical, emotional, and social functioning as well as other factors (e.g., availability of social support) that may markedly influence the outcomes. The outcome engineer should be able to identity individual clients' needs, and at the same time see the broad perspective of what outcome the engineer can offer individuals. An outcome engineer focuses on specific functional strengths and weaknesses that have particular relevance to the outcome(s) being assessed. Furthermore, by understanding the social, emotional, physical, mental, spiritual, and recreational needs of the client in relation to outcome opportunities, an outcome engineer can facilitate the design of plans that will maximize outcomes.

The outcome-oriented transition between assessment and planning requires that the outcome engineer consider the results of the assessment in light of the potential or desired outcomes. At this stage, the outcome engineer looks at the intervention from a broad perspective in order to allocate resources to maximize potential outcomes for individual clients and groups. For example, intensity or duration of an intervention may be varied to maximize the possibility of outcome achievement. Furthermore, an outcome engineer should identify and prioritize specific outcomes based on the assessment data. This information directs goals and objectives toward outcomes and should inform the development of the treatment plan.

Treatment plans and target outcomes. Establishing clear and realistic goals related to identified outcomes with each client is a logical next step in this planning process. The outcome engineer must account for the constraints placed on services, such as short length of stay and budget constraints. These limitations must be incorporated into the planning and designing phase, that is, therapeutic recreation services require a detailed plan prior to implementation. For example, the therapeutic recreation professional needs to develop a plan that clearly identifies measurable outcomes. These may exist as goal statements in a treatment plan or behavioral objectives in an individualized treatment plan. In addition, the outcome engineer selects intervention activities based on demonstrated evidence of the intervention's ability to produce the desired outcome. By prioritizing the targeted outcomes, an outcome engineer develops a treatment plan. At this stage, an outcome engineer also determines the best ways to maximize the production of the desired treatment results. In the targeting outcome phase, this prioritization shows the importance and connection between the client's needs and outcomes. Before moving to the implementation stage, the treatment plan must be finely tuned as the outcome engineer targets outcomes.

Implementation and documentation of specific outcomes. Wilhite and Keller (1992) stated that "The implementation phase ... is described as a `make-it-or-break-it' phase that depends heavily on the personal and professional skills of therapeutic recreation specialists" (p. 121). In other words, an outcome engineer should possess not only good programming skills, but also competent facilitation skills, such as small group dynamics and effective communication skills. An outcome engineer who keeps outcomes in mind modifies the plan throughout its implementation to enhance the likelihood of outcome attainment.

Outcome engineering includes a systematic way of documenting professional practice with the intent of ascertaining the extent of functional improvement. Outcome-oriented documentation requires awareness of and sensitivity to the importance of outcomes. Specifically, an outcome engineer must meticulously document what has or has not been achieved. Goal attainment scaling, which requires that the therapeutic recreation practitioner target a goal (outcome) and then develop related goal statements reflecting performance that fails to meet or exceed targeted performance, is a useful example (Kiresuk, Smith, & Cardillo, 1994). Through this process, an outcome engineer can track and document the degree of outcome achievement. Outcome oriented documentation specifically pinpoints therapeutic recreation outcomes that the client has achieved.

Evaluation and advocacy of therapeutic recreation outcomes. An outcome evaluation is a systematic process of monitoring the efficacy of the treatment provided. The intent of the evaluation is to provide specific feedback on client performance and outcomes as they relate to the intervention. Further, the evaluation can offer a more specific direction for performance improvement. After completing the evaluation process, an outcome engineer takes one additional step; providing information about the therapeutic recreation outcomes to stakeholders. Stakeholders include both clients and other groups that have an interest in our clients' well being (Sluyter, 1998). An outcome engineer commits him/herself to develop publicity/advocacy strategies to promote and "sell" therapeutic recreation outcomes to internal (e.g., clients, interdisciplinary team members, agency administrators) and external (e.g., families, third party payers, etc.) stakeholders. Frequently, the potential stakeholders have limited, if any, knowledge of therapeutic recreation services and have an unclear understanding of how they might benefit from these services. Therefore, an outcome engineer disseminates the products of therapeutic recreation outcomes effectively and takes a proactive approach by promoting positive outcomes.

Conclusion

An Outcome Engineering Model is being proposed to facilitate efficient, effective therapeutic recreation outcomes to meet tomorrow's social, economic, political, health care, and human service needs. Some aspects of this model are different from the existing "APIE" process (c.f., Austin, 1999; Carter, Van Andel, & Robb, 1995). This model is highly sensitive to an outcome engineer's:

* knowledge and awareness of therapeutic recreation outcomes,

* ability to focus program intervention toward specific outcomes,

* ability to facilitate the intended outcomes,

* ability to document specific outcomes obtained,

* ability to identify outcomes from evaluation, and

* advocacy and promotion of the therapeutic recreation outcomes.

Therapeutic recreation specialists must be accountable (Stumbo, 1996) for what we do, why we do it, and what the outcomes are. Healthcare and human-service consumers will most likely be directed to providers who have demonstrated the outcomes of their intervention efforts. Are you a traditional therapeutic recreation specialist who tends to want things to stay the same? Do you do things the same way, even when you may be threatened by today's rapid changes in a market driven economy? Or do you gravitate to more challenging opportunities to enhance client services and our profession? If you do, maybe you are an outcome engineer!

References may be obtained by visiting the Internet at http://php.indiana.edu/~ylee/ oereference.html.

The 1990s were an era of accountability for the health and human services profession. Designing and implementing quality programs was of utmost importance. Within therapeutic recreation, providing outcome-based services requires a shift that embraces strategies to be an "outcome engineer." Youngkhill Lee, Ph.D., CTRS, and Bryan McCormick, Ph.D., CTRS, both faculty members in the Department of Recreation and Park Administration at Indiana University, and Shari Perkins, Ph.D., CTRS, assistant professor in the School of Recreation and Sport Sciences at Ohio University, explore ways to implement outcome engineering in your therapeutic recreation program.

A graduate of Western Washington University in 1985 with a degree in recreation and parks with an emphasis in therapeutic recreation, Mary Ann Curulla has been a certified therapeutic recreation specialist (CTRS) since 1986. She worked in inpatient psychiatric and physical rehabilitation settings for eight years until she joined Mobility International USA as an international exchange program coordinator and the manager of the National Clearing-house on Disability and International Exchange. Currently she is working in Ohio as an independent consultant on projects related to international exchange, recreation, and people with disabilities.