NEW OPTIONS FOR THERAPEUTIC RECREATION IN THE NATURALLY OCCURING RETIREMENT COMMUNITY.

Where do adults want to live when they pass the age of sixty? Amazingly, 86% want to stay right where they are and therapeutic recreation is becoming one of the vital services offered to help them maintain and improve the quality of their lives.

Much has been written about the graying of America, as well as of many Western nations. In the United States one in eight Americans is over the age of sixty-five. One common misconception is that being old means moving to a nursing home. In fact, 70% of seniors spend the rest of their lives where they were living at the age of sixty-five (McGuire, Boyd & Tedrick, 1999). Only four percent of those over sixty-five live in long-term care facilities (McGuire, et al., 1999). This figure has been constant for at least twenty years.

A national survey conducted by the American Association of Retired Persons in 1995 found that 86% of older adults want to stay where they are as they grow older. When 50% of the residents of a building or neighborhood, which was not originally designed for adults who are sixty years of age or older, that community can be designated a "naturally occurring retirement community" or NORC. As of 1992, 27% of older people were living in NORCs (Lanspery, 1995). This is a significant number which will only increase because older adults prefer supportive, age-integrated housing in a familiar, safe and convenient neighborhood. Many retirees who relocated to warm climates are returning to the areas where they lived most of their adult lives. This has important implications for therapeutic recreation professionals as the NORC represents a nontraditional setting for therapeutic recreation services.

Since these communities weren't built with the needs of an older population in mind, they have rarely offered the social, health and support services that older adults need. NORCs are high risk sites for unmet health needs of residents who are frail and elderly. Once the community becomes aware of these needs it can organize into a group to contract for services and hire staff. Frequently, residents recognize there are problems when a fellow resident hasn't been seen outside in a while, or asks neighbors for frequent favors. These are signs of unfulfilled needs for assistance and support. Usually a social worker and a nurse are among the staff hired to provide specialized social services and some health care. Some of these groups also offer social and recreational programs in a community room, such as lectures, classes, exercise programs, gardening and the arts. One feature of the NORCs is self-government. The residents themselves serve on a board of directors, lead programs and serve as volunteers to assist frailer neighbors with transportation, visits and phone calls.

Despite these admirable efforts, older adults living alone or with one other person often become isolated due to worsening physical condition, depression and cognitive disturbances. The prevalence of mental disorders in persons who are elderly is about 30%, with 35% of the frail elderly considered to be suffering from depression and 40% over 80 years of age with dementia (Nathanson, 1996). Alcoholism often goes untreated in the aged. How best to reach these older adults who are often fearful of mental health treatment and/or unable to travel due to physical immobility is a challenge for the NORC staff. Therapeutic recreation in the home of the NORC residents is a logical and viable approach to addressing the physical, social, cognitive and emotional needs of an isolated population.

Although several in-home therapeutic recreation programs have been described in the therapeutic recreation literature (Bollin, Voelkel & Lapidos, 1998; Neumayer, Gattuso, Saw & Jelinek, 1998; Wilhite, 1997), implementing a program in a NORC facilitates the multidisciplinary team approach with nursing and social service providing referrals and on-site resources. There may be opportunities to plan group therapeutic recreation programs, organize trips and set up buddy systems among neighbors. The close proximity of the clients to other services and formal resources makes the NORC a natural setting for therapeutic recreation services. Current models of therapeutic recreation service emphasize preventing declines in health status and functional abilities in order to improve quality of life (Austin, 1996; Carter, Van Andel & Robb, 1995). When applied to the NORC, these models may produce outcomes of reduced isolation, delayed institutionalization, increased participation in the community, cognitive stimulation and greater life satisfaction.

Providing therapeutic recreation services in the home has distinct implications for carrying out the therapeutic recreation process. To carry out the first step, the assessment, the therapeutic recreation specialist must consider several factors that differ from the institutional setting. Trust must be established in an intimate setting, an individual's home. It is important that another professional or person who is known to the potential client introduce the therapeutic recreation specialist to the older adult in order to establish a sanctioned relationship. To develop trust, the therapeutic recreation specialist could share some of his or her own interests and background, as well as engage the individual in casual, social conversation. One of the most important benefits the therapeutic recreation specialist provides in the home setting is socialization. The clients enjoy the interaction with the therapeutic recreation specialist and the opportunity to discuss various topics. The assessment process is the beginning of the social interaction between the therapeutic recreation specialist and the older adult. On the other hand, the therapeutic recreation specialist will probably be alone in a closed environment with an individual who may have behavioral problems that could pose a threat or danger. Careful screening of the client and training for the therapeutic recreation specialist is vital. Once the therapeutic recreation specialist is ready to begin the formal assessment process, evaluation of interests, strengths and needs will be fairly standard. One factor to take into consideration is that the individual probably has not suffered the sudden loss, trauma or illness that often precipitates admission to an institution; but rather may be in a period of slow decline. Therefore, reasons for the discrepancy between current and past leisure interests and behaviors should be carefully noted. Changes such as loss of physical mobility or strength, loss of spouse, or decreasing vision or hearing may lead an older adult to discontinue a leisure interest.

Another aspect of the assessment phase that differs from the traditional is the environmental assessment. The home should be evaluated for any recreation-related equipment; games; supplies; electronic equipment such as radios, televisions, VCRs, stereos and computers; as well as pictures or objects that may indicate the individual's interests. As the program progresses, the therapeutic recreation specialist and the client may decide that they wish to obtain some new supplies or equipment, such as a cassette player, tapes of music, art supplies or books, for the client to utilize. The physical space and furnishings should also be evaluated. Are there adequate work spaces, comfortable areas, and appropriate lighting and ventilation for a variety of recreation activities? Programming may be limited by what feasibly can be utilized in the available space. A third factor important to the home setting is the social network of the client. Are there home care workers, meals on wheels deliveries or other friends or service providers who come to the home and may be a potential supporter of the therapeutic recreation service?

Once the assessment has been completed, utilizing interviews, observations and appropriate checklists and/or standardized instruments, planning begins that truly emphasizes the individual's interests and needs. The goals and selected interventions are very individualized. Initially, the client may be very specific about what she or he wants or needs from the program or, conversely, passive or vague. Planning must be dynamic, changing as the relationship between the therapeutic recreation specialist and the client grows, and the client is more willing to accept direction or becomes more assertive, as the case may be. The therapeutic recreation specialist is working one-on-one and may be able to get to know the client more fully than in a group situation. Some individuals may be more comfortable in this format, and more responsive to the undivided attention of the therapeutic recreation specialist. They may achieve outcomes more readily due to their intensive interaction with the therapeutic recreation specialist. As stated above, planning will be affected by the environment and what can realistically be obtained or utilized. Another consideration is that the programs occur primarily in the clients' homes, where they may be confronted with activities they can no longer accomplish. This requires sensitivity and knowledge of possible adaptations and modifications. Planning can be for long-term projects, such as arts and crafts or creative writing, or for a different activity each session, such as potting plants, music appreciation, or reminiscence with family photograph albums. Over the course of the in-home intervention, new needs, problems or issues may surface that could be addressed by a different intervention. Perhaps a client owns, or would like to obtain, a computer and connect to the Internet, use e-mail, and locate favorite web sites.

Implementing therapeutic recreation in the real-life home environment of the client can be very rewarding to the professional because behavioral changes and improvements occur in context (Bullock & Mahon, 1997) and can be immediately applied. Being in their own home gives clients a sense of control over their participation and they feel safe and comfortable in expressing their choices. When the therapeutic recreation specialist arrives for a session, it generally begins with casual conversation. Then the activity participation can occur in a comfortable and appropriate setting, such as painting or indoor gardening in the kitchen, or music or reminiscence in the living room. However, when the client is ill, has an appointment, or just is not in the mood, there may be no active participation in the therapeutic recreation program. This differs from the institutional setting where there are always participants available. In the home the client, at times, may only feel like engaging in conversation. This should be seen as an opportunity to develop the relationship and provide social and emotional benefits to the client. The therapeutic recreation specialist may also be able to utilize facilities in the NORC, such as common areas, the outdoors or nearby senior centers and libraries, as long as the client is capable and needed transportation is available. Lack of transportation has been cited as one of the biggest barriers to leisure participation by older adults (McGuire, et al., 1999).

Evaluation, the last step in the therapeutic recreation process, should include clients evaluating their own progress and setting their own goals. Formative evaluation should incorporate client satisfaction with the selected interventions and activities as well as their opinions of their progress and the overall program and its impact on their life. As the therapeutic relationship grows and progresses, client improvement may call for new approaches as well as uncover latent interests and needs. The effectiveness of the program needs to be determined from a professional standpoint. Discharge planning, as part of summative evaluation, differs from the traditional setting as the client is remaining in the same residence. Discharge planning could include linkages with other agencies, recreation resources, neighbors and additional NORC services; as well as plans to obtain recreation equipment, supplies or resources. One concern in this setting is that, if the therapeutic recreation services are completed with an individual client, will the client continue to need supports to maintain the progress that has been made? This raises the question of time-limited vs. ongoing intervention. It is recommended that the therapeutic recreation specialist attempt to organize group programs and friendship development to keep clients involved and active as much as possible. For example, two neighbors who were not well-acquainted may share a common interest and be brought together.

Providing therapeutic recreation services in the NORC presents an exciting and challenging opportunity for the therapeutic recreation profession to be involved with an emerging and fast growing phenomenon. Not only can the therapeutic recreation specialist experience the satisfaction of providing individualized services which may have the potential to produce greater and longer-lasting benefits, the therapeutic recreation specialist may also impact a community through organizing group programming and establishing linkages. They can serve as a valuable resource to the NORC staff by being in the unique position of entering an individual's home to participate with them in pleasant activities, not to address often discouraging health and social service concerns. The therapeutic recreation specialist can report significant observations of health, behavioral and social issues to the NORC staff, which may then pursue further action. The NORC can also be a setting that links therapeutic recreation with community recreation and leisure services. The local parks and recreation department can collaborate with the therapeutic recreation specialist to provide programs at the NORC site or transportation to department programs. Recreation programming is now available to home-based participants via conference calls and the Internet. Collaboration among local agencies that provide services can further the opportunities for NORC residents.

The Naturally Occurring Retirement Community is an emerging and nontraditional setting for the delivery of therapeutic recreation services creatively and collaboratively. In-home therapeutic recreation, delivered by professionals who successfully implement the therapeutic recreation process and utilize the resources of the community, can affirm the values of home, self-determination, quality of life and meaningful recreation for older adults. therapeutic recreation professionals are encouraged to develop services for these growing and vital communities.

References

Austin, D. (1997). Therapeutic recreation: Processes and Techniques, (3rd ed.). Champaign, IL: Sagamore Publishing.

Bollin, S., Voelkl, J. & Lapidos, C. (1998). The at-home independence program: A recreation program implemented by a volunteer. Therapeutic Recreation Journal, 32 (1), 54-61.

Bullock, C. & Mahon, M. (1997). Introduction to recreation services for people with disabilities: A person-centered approach. Champaign, IL: Sagamore Publishing.

Carter, M., VanAndel, G. & Robb, G. (1995). Therapeutic recreation: A practical approach. Prospect Heights, IL: Waveland Press.

Lanspery, S. (1995). AAAs and "naturally occurring retirement communities (NORCs). The Supportive Housing Connection. National Resource and Policy Center on Housing and Long-term Care. Retrieved January 3, 2000 from the World Wide Web: http://www. pr.aos.dhhs.gov/Housing/norcs.html

McGuire, F., Boyd, R., & Tedrick, R. (1999). Leisure and aging: Ulyssean living in later life, (2nd ed.). Champaign, IL: Sagamore Publishing.

Nathanson, M. (1996). A proposal for mental health delivery to naturally occurring retirement communities. Psychiatry On-Line. Retrieved March 5, 2000 from the World Wide Web: http://www.pol-it.org/norc.htm.

Neumayer, R., Gattuso, S., Saw, C. & Jelinek, H. (1998). Programming home-based activities for people with dementia: Benefits and constraints. Journal of Leisurability, 25 (4), 29-39.

Wilhite, B. (1987). REACH out through home delivered recreation services. Therapeutic Recreation Journal, 21 (2), 29-38.

Robin Kunstler, Re.D., CTRS, is associate professor and program director of recreation education, Department of Health Services, Lehman College of the City University of New York. She designed and directed a therapeutic recreation pilot program in a NORC. Check out her article, "New Options for Therapeutic Recreation in the Naturally Occurring Retirement Community".