Building transition bridges for the disabled.

Congratulations! Graduation day has arrived, and a transition to new roles and opportunities is imminent. With each new role comes access to a broader expanse of community resources, including leisure experiences and social relationships. Individuals with disabilities gained increased access to community living opportunities with the passage of PL 101-336, the Americans with Disabilities Act (ADA), in 1990. Legislation like ADA has set the stage for individuals to play new community roles. For individuals with disabilities, the true meaning of "community" will come when they graduate to supportive social relationships and experiences among community friends.

Leisure service professionals are central figures in transition networks. Networks formed by community social service providers enhance access to information, services and resources relevant to independent social relationships and community leisure experiences. Planned transitions among service providers foster consumer maintenance and generalization of community living skills, interactive friendships and companionship. Coordinated service efforts bring increased expertise and resources to bear on intensifying consumer needs.

Transition means passing from one step or level to another place or condition. Individuals with disabilities move from one program or service to another through referrals, discharge or integration to outpatient, day treatment or community services. Transition occurs when information is transferred from one manager to another or one service site to another. When additional participant privileges or responsibilities are acquired from changing service levels (in-patient to out-patient) or sites of intervention (hospital to homes), a transition results. Transition planning occurs when programs reinforce or continue developing skills necessary for increased levels of independence in the community. Transition plans link leisure and social service providers.

The need to build bridges to link community services has intensified, as have the needs of people with disabilities who live and recreate in the community. This need is attributed to several trends evident in the closing years of this century. Medical and technological advancements enable people with life-threatening illnesses or injuries, cancer and head injuries, to remain functionally active in the community during and following the trauma or illness. The present interpretation of de-institutionalization is no longer the prevention of hospitalization, but early intervention to all people, regardless of ability level, over their entire lives. The rising costs of health care have been the impetus to discharge patients after shorter stays in hospitals and clinics. Leisure and community social service providers have fewer dollars available to purchase operational resources. Additionally, service providers are being held accountable to document consumer gains and satisfaction, avoid service duplication and eliminate gaps in service continuums to reduce recidivism rates.

Self-Directed Leisure Levels

Increase

The philosophy of transitioning parallels the concepts inherent in leisure education and flow models that describe the intent and qualities of a leisure experience. As consumers' abilities increase and supportive relationships are developed, they move toward increased levels of self-directed leisure among community service providers. The types of supportive resources and information provided to consumers depends on their skills and the nature of their surrounding environments. The outcome of planned transitions is guaranteed consumer services over extended time periods regardless of service separation policies or the agency's calendar of programmed leisure events. Leisure experiences occur over one's life irrespective of one's physical location or skill level or providers' service schedules.

When the leisure professional formalizes a community network, multiple benefits result: expanded access to facilities and programs; shared expertise and information; enhanced communication and training resources; relevant consumer-focused services a centralized advocacy base; and formal and informal staff education and training opportunities. Support groups and active professional societies like the National Recreation and Park Association exemplify the outcomes of networking. Each offers access to resources and a collective strength not found among individual members.

Networks that ensure participant transitions among community services are founded on three concepts: individualization, coordination and relevancy. Each consumer's needs are documented and plans are prepared for each transition. Communication among service providers results in coordinated resources and information. Transition planning assures that the consumer practices and uses the relevant skills in his or her natural environment. Preparing a transition plan uses a process similar to developing a community master plan or consumer program plan. The leisure service professional is in a key position to apply this process to assure linkages among community resources and social relationships. The very nature of leisure service position brings practitioners into contact with participants community-wide as well as a broad spectrum of service providers. Leisure experiences occur throughout the community in a variety of settings. Also, the outcomes of leisure participation include social interactions, friendships and leisure companions. Practitioners in the community are therefore in positions to view the "gestalt" or interdependence among resources, services and information and assume primary roles in developing service networks and supportive social relationships.

The proposed process assumes that the phases are sequential yet fluid, so as additional information or new consumers and service providers enter the network the community is expanded to include their needs or resources A tangible result of employing the process is a community leisure resource directory to use during consumer referrals. Planning that occurs during this problem-solving process builds linkages while enhancing staff training and education opportunities. These opportunities are essential to socially integrating individuals with disabilities.

Planning Community Service

Networks

* Phase I - Gather information. Identify all potential service providers, consumers, support personnel/resources, and environmental features/barriers like accessibility, transportation and community readiness with regard to individuals with disabilities. Results of this phase set the parameters in which the transition system operates.

* Phase II - Identify network service providers. Review the collected information in order to select the support network. Representatives include parents and caregivers; consumers; advocacy groups; school, medical and allied health personnel; public and private social service practitioners; and other providers of leisure services. This process also results in the identification of agencies serving the same consumer groups but with different services and agencies providing the same service to different consumer groups.

* Phase III - Select/appoint advisory team. Organize key representatives to coordinate resources. Consumers or their representatives are included on the team as transition plans are prepared.

* Phase IV - Assess consumer needs. Prepare a report of existing and needed services, identifying consumers skills, preferences and social needs.

* Phase V - Establish program/structure content. Prepare a mission. Identify programs that are compatible with consumer preferences and abilities and arrange a communication system to ensure that cooperating agencies coordinate service offerings.

* Phase VI - Design management plan. Set up a process to monitor and evaluate the transition team's ongoing activities. Adopt a common set of network policies or a guiding protocol, set a schedule of planned meetings and coordinate finances. Team members assume oversight responsibility for respective services.

* Phase VII - Implement training programs. Train staff and disseminate information on transition programming with the total network of providers, including caregivers, consumers, leisure and social service administrators and key advocates.

* Phase VIII - Market services. Inform the community of the social integration processes put into place, and recruit volunteers and resource personnel to support community living opportunities.

* Phase IX - Implement service. Monitor consumers as they move into community social and leisure experiences. The goal is to maintain consumers at their optimal level of social independence. Formative evaluation establishes the appropriateness of the transition process to consumers' needs.

* Phase X - Evaluate services. Examine all phases of the system: consumers, programs, management and resources, and determine the appropriateness of services provided to support consumer transitions.

* Phase XI - Follow-up/monitor process. The key to preventing return to the hospital or loss of companionship or leisure skills is establishing a procedure to track each consumer's progress to ensure that social skills are relevant to the "natural" environment. This, for example, might necessitate assigning one person from the advisory team or a volunteer to be a "buddy" or companion while setting certain consumer feedback expectations.

Developing Consumer

Transition Plans

Developing community service networks is a prerequisite to assuring consumer transitions. A consumer transition plan evolves from existing documentation and the activities of the community service network. The plan is an extended service contract that spans the time among services offered to prevent consumers from falling through the gaps in the community. The advisory team formed during the networking process conducts support meeting to ensure consumer transitions among community resources. Preparation of consumer transition plans includes several steps.

* Step 1 - Orientation. Meet with consumers, caregivers and agency personnel to consider awareness/acceptance of all parties for a transition; consideration of the history of services and the consumer's current functioning level; anticipated support needs such as transportation, finances, adapted equipment; and social skills training.

* Step 2 - Assessment. Share diagnostic and behavioral information among service providers to streamline inter-and intra-agency placements and to establish primary/secondary transition goals.

* Step 3 - Individualized program planning. Develop behavioral objectives from existing documents. Success is judged by the relevancy of skills in the consumer's natural community environment.

* Step 4 - Implementation. Use network agencies and support services to teach consumers and caregivers how to acquire and apply social skills.

* Step 5 - Evaluation. Prepare and test evaluation tools to collect data on consumer transitions and the network's effectiveness.

* Step 6 - Documentation. Prepare a written account of progress toward objectives and share it with all parties, reporting past and present skill levels, precautions, future goals and the outcomes of the tracking process.

* Step 7 - Continuance/additions. Encourage the consumer to expand into additional recreation programs and social relationships. Adjust individualized transition plans following your evaluation and documentation of the consumer's progress.

* Step 8 - Referral/re-entry. Use telephone contact, return postcard, community volunteers and/or consumer self-reporting on goal attainment as alternatives used to monitor social integration.

Leisure practitioners are often at the center of their communities' social fabric. By virtue of their agency's mission and constituents, they are exposed to resources community-wide and consumers throughout their life spans. As a consequence, leisure professionals are key figures in the design of community networking structures and consumer transition plans. Our challenge is to use alternative strategies to facilitate social integration with individuals with disabilities who have more intensified needs. Forming networks and transition plans provides collective dedication of resources and expertise. Consumers are less likely to experience service gaps and more likely to realize true "common-unity" with planned transitions.