The evolution of therapeutic recreation.

During the past five decades, the profession of therapeutic recreation has evolved into a dynamic discipline with untold potential for continued growth. This article provides an overview outlining some of the elements that currently influence and impact the delivery of therapeutic recreation services. This paradigm is offered in two parts: those elements external to the discipline that influence practice and, perhaps more importantly, those factors that are internal to the discipline that must be addressed if therapeutic recreations is to continue its evolution as a competitive health and human service discipline. Although external elements continue to influence the nature of our practice, it is the internal factors that will hold the greatest impact on the future of the profession.

The Changing Nature of the Populations We Serve

The nature of the populations served by therapeutic recreation specialists has continued to change as the population demographics of the nation have evolved. In today's health care and social service environments, including community, hospital, rehabilitation, and residential settings, the face of the consumer has grown older. In the Untied States, the percentage of the population ages 65 or older has and will continue to increase dramatically. Today, persons 65 years of age or older represent nearly 13 percent of our population. By the year 2025, this segment of the collective will represent almost 25 percent of the population (Godbey, 1997). This "aging of the population" has and will continue to place unprecedented demands on every facet of the social and health care-delivery system.

In addition, North American culture will continue to diversify, increasingly influencing therapeutic recreation practice well into the future. Although ethnic diversity may be more fully realized in specific regions of the country, the profession must be poised to address the multicultural nature of a global environment. It is projected that in the United States, Hispanic, African-American, and Asian populations will increase from 1995 levels of 10 percent, 12 percent, and three percent to represent 16 percent, 13 percent, and six percent, respectively, by the year 2020 (Godbey, 1997). This demographic transformation will demand that therapeutic recreation professionals become more culturally sensitive both in practice and life interactions, that the profession increase its efforts to attract and incorporate persons of varied ethnic backgrounds, and that professional preparation programs include content to the multicultural nature of service delivery (Lee & Skalko, 1997). The evolving characteristics of the population will influence the nature of our practice, the populations served, the settings in which services are delivered, the elements of our professional preparation efforts, and the emphasis therapeutic recreation places on advocacy and public policy efforts.

The Dynamics of a Changing Industry

In a rapidly evolving health care industry, inordinate challenges have been created for all medical and allied health professions, including therapeutic recreation. Medical progress and cost containment have resulted in reduced hospital stays, increased outpatient services, and home health care practices.

Progress in medical and health care practices has been realized in the expansion of outpatient treatment services. Medical advancements of the past two decades have resulted in a dramatic decrease in the need for inpatient hospitalization and the utilization of outpatient alternatives. This transition has influenced both the nature of our work and the settings in which therapeutic recreation delivers its services.

Coupled with the progress in medical and health care practices, the financial structure of the health care system has been transformed. Within the last 30 years, the system has evolved from a retrospective payment system to a prospective payment system to a capitated system of financing. This changing nature of health care financing has revolutionized the industry. Cost-effective, time-efficient, quality services have become the standard of the industry. These factors have influenced the number and mix of health care providers, the types of services provided the consumer, and the settings in which services are offered. The ever-changing system is demanding multiskilled professionals who are prepared to produce meaningful outcomes in as cost-effective a manner as possible.

Although not fully developed, the new health care system will increasingly focus on illness/disease and disability prevention and less costly alternative health care in lieu of immediate, traditional medical treatment. It will be the health care system's ability to reduce medical needs and to keep people out of the hospital that will produce meaningful returns in the future. Therapeutic recreation can benefit from this shifting focus if the practitioner is prepared to respond to the resulting challenge and can produce the desired outcomes for improved health can quality of life.

Changing Nature of the Workplace

With the evolving health care industry come modifications across the entire health and social service system. The therapeutic recreation profession and individual practitioner must posses a broader perspective of care for all persons. Specific health care and social service interventions will not be the purview of a designated discipline but will instead fall of the individual practitioner who can meet the demands of the consumer. The industry will look for multiskilled individuals who can address the diverse needs to consumer groups. This will have significant implications for settings in which therapeutic recreation specialists operate.

In the future, the individual therapeutic recreation professional will select from a range of settings in which our profession will operate. Therapeutic recreation specialists will market their skills and talents for producing meaningful outcomes across delivery settings. Not only will therapeutic recreation specialists provide services in hospital, rehabilitation, and community recreation settings (a function of best candidate versus professional mission), but therapeutic recreation professionals will increasingly capture service-delivery roles in home health, homeless care, domestic abuse, substance abuse, at-risk youth services, transplant units, adult day services, partial hospitalization, retirement services, and care for the frail elderly. This diversification of settings will be consistent with the changes occurring throughout the health care industry in which agencies are placing more emphasis on maintaining effective professionals versus specific disciplines. It will be the well-prepared professional's entrepreneurial spirit that will expand the range of settings in which therapeutic recreation professionals work, not the efforts of the professional organizations.

Legislation and Advocacy

There has been monumental progress made with regard to public policy for the general population, including older adults and persons with disabilities. The passage of the Social Security Act, the Rehabilitation Act and subsequent amendments, the Education for All Handicapped Children Act and the Individuals with Disabilities Education Act (IDEA), and the Americans with Disabilities Act (ADA, P.L. 101-336) has presented landmark legislation transforming the profession. Although therapeutic recreation has been specifically included in several of these pieces of legislation, advocacy efforts for continued inclusion, opening access to therapeutic recreation for the consumer, and fulfilling the intent of these legislative acts must remain at the forefront of our agenda.

The Rehabilitation Act of 1973 was a monumental milestone with regard to the rights of persons with disabilities to access programs and services receiving federal financial assistance. The intent of this legislation has been furthered by the passage of the ADA. In fact, the right to access all recreation services by persons with disabilities has significant implications for the practice of therapeutic recreation and the parks and recreation field. The ADA protects the rights of every American to access recreation and leisure opportunities and resources. No longer is the provision of recreation services to persons with disabilities synonymous with therapeutic recreation. These charges are the responsibility of the parks and recreation segment of leisure services. To place persons with disabilities into "therapeutic recreation" programs because they posses a disability is contradictory to the intent of the law.

With the move to decentralize Medicare and Medicaid and other federal programs, the therapeutic recreation field is being challenged to bring public policy efforts to the state level. While therapeutic recreation has made advances in establishing its role as a value-laden health care and quality-of-life service, the continued progress of the profession toward ensuring that the consumer is guaranteed access to our services will be affected by our success in this grassroots legislative process.

Although progress has been realized, as a collective, our profession has not been effective in the public policy arena. Therapeutic recreation professional organizations, practitioners, and recipients must pool resources and energies at the local, state, and national levels in order to influence public policy language. The inclusion of therapeutic recreation services in the verbiage of legislative bills and regulatory guidelines will be among the primary means by which the profession can better ensure consumers access to our services.

Emphasis on Outcomes of Service and Efficacy Research

The changing nature of the environment where therapeutic recreation is employed has resulted in increased pressure to demonstrate effective and cost-efficient levels of therapeutic recreation service. As an outgrowth of the cost-conscious, consumer-driven service industry, therapeutic recreation has been called upon to demonstrate its contribution to the overall health and well-being of the people it has served. Whether the endpoint of therapeutic recreation service is the involvement in leisure services or the achievement of an independent functioning lifestyle, therapeutic recreation professionals are expected to provide programs and interventions that have proven effective and satisfying to consumers.

The need for demonstrated outcomes from therapeutic recreation has been recognized for years. But today, a new and more stringent imperative can be heard. The collaborative efforts of health care regulatory and accrediting bodies, such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), CARF-The Rehabilitation Accreditation Commission, and the Health Care Financing Administration (HCFA), coupled with the demands of insurance providers, have resulted in an atmosphere of restrictive funding for those services that fail to demonstrate effective levels of care. As a result, there is a need for both the understanding and establishment of functional assessments, program protocols, critical/clinical pathways, and quality improvement strategies within therapeutic recreation practice. Establishing common and uniform outcomes of therapeutic recreation services is critical. Such efforts can be accomplished through an immediate and sincere effort to implement efficacy research in order to safeguard a contributing role in the broad arena of health care services.

Professional Preparation

Among the many challenges that besiege a profession lies the critical issue of how to best prepare students for entry-level practice and how to assist veteran professionals in maintaining and improving their current levels of competence. Much has changed in the delivery of therapeutic recreation during the past 20 years, and many professionals are concerned that the educational process has not kept pace. While some professionals call for increased emphasis on specific techniques and specialization in the therapeutic recreation educational process (Austin, 1997; Brasile, 1992; Skalko & Goldenberg, 1995), others maintain a rather conservative "back-to-basics" approach in an effort to streamline the educational process. This latter approach has gained widespread support. More specifically, the findings of the PEW Health Professions Commission (1995) have called for less specialization and an increase in cross-discipline training and interdisciplinary core curricula among allied health professions.

Given the expanding nature and volume of professional competencies that we expect our novice professionals to possess, there appears to be an urgent need for a thorough analysis of course offerings, content design, and departmental alignment of therapeutic recreation curricula (Skalko & Goldenberg, 1995).

Continuing Professional Competency

Responding to mandatory continuing education requirements, professional organizations have begun to assist individuals through the sponsorship of expanded and unique continuing education unit (CEU) opportunities. The impact of this requirement has been substantial with respect to the number of continuing education programs and workshops being offered at the state and national levels. Given the nature of change in therapeutic recreation today, continuing education is viewed as the primary vehicle for addressing practitioners' learning needs. Many diverse and interesting topics representing a wide spectrum of innovative ideas and concepts involving practice and management techniques are being addressed within the continuing education framework.

As individuals advance within their careers, it is logical that they pursue additional high-level competency training. This notion is supported in part by data from the NCTRC (1997), which indicates that less than five percent of certified therapeutic recreation specialists applying for re-certification do so by completing the national entry-level exam.

The acknowledgment that experienced professionals in therapeutic recreation are a talented and competent group is an important step toward developing valid measures for advanced professional competency. Certification and recognition of competency beyond the entry level of practice is not only viewed as important but as a necessity for inclusion in today's health care environment. Looking toward the future, many promising opportunities surrounding the process of professional development appear possible, including therapeutic recreation specialization certification, advanced or master-level competency certification, and cross-discipline recognition.

Conclusion

Today, the practice of therapeutic recreation is in a state of flux, mired in a process of evolving professional concerns centered around the issues of social and economic change, financial support, and quality of service. To best safeguard consumer outcomes and ensure a vital role for therapeutic recreation services, the following recommendations are offered:

* Sponsor a national forum on strategic forecasting for the purpose of identifying opportunities for therapeutic recreation.

* Establish a national clearinghouse for efficacy research in therapeutic recreation for the purpose of identifying sources for funding, opportunities for collaborative studies, and dissemination of established findings.

* Call for national organizations to continue to address educational reform.

* Establish alternative methods for advanced-level competency certification in therapeutic recreation.

* Expand the network of continuing education opportunities for practitioners at the local, state, regional, and national levels.

Accelerated change has become a constant in modern life. It is only through active planning and decision-making that we are able to turn potential adversity into opportunities for success. Let's begin to initiate the necessary steps to ensure a bright and productive future for the profession of therapeutic recreation.

References

Austin, D. (1997). Recreation therapy education: A call for reform. In D.M. Compton (ed.), Issues in Therapeutic Recreation: Toward a New Millennium, (pp. 193-210). Champaign, IL: Sagamore.

Brasile, F. M. (1992). Professional preparation: Reported needs for a profession in transition. Annual in Therapeutic Recreation, 3, 58-71.

Goodbey, G. (1997). Leisure and leisure services in the 21st century. State College, PA: Venture.

Lee, Y. & Skalko, T.K. (1996, May). Multicultural sensitivity: An innovative mind-set in therapeutic recreation practice. Parks and Recreation, 31 (5), 50-53.

National Council for Therapeutic Recreation Certification (1997). Candidate bulletin. Spring Valley, NY: NCTRC.

Pew Health Professions Commission. (1995). Critical challenges: Revitalizing the health professions for the twenty-first century. San Francisco: Center for the Health Professions.

Skalko, T.K. & Goldenberg, R. (1995, March/April). Recreational therapy/therapeutic recreation: A call for reform. American Therapeutic Recreation Association Newsletter, 11 (2), 11.