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Is rehab killing recreation?

Just plain fun isn't what it used to be

THE NEW ACTIVITY DIRECTOR TOSSED A HUGE BAIL BACK AND FORTH TO THE CIRCLE OF RESIDENTS SURROUNDING HER. IT COULD HAVE BEEN ALMOST ANY NURSING HOME IN THE PAST 30 YEARS--UNTIL YOU LISTENED. THE USUAL LIGHT BANTER WAS MISSING. RESIDENTS SILENTLY ABSORBED THE LECTURES SHE FLUNG WITH EACH THROW. "THIS IS STRETCHING YOUR MUSCLES," SHE ADMONISHED. "THIS IS GOOD FOR YOU. THIS ISN'T SUPPOSED TO BE FUN. IT'S THERAPEUTIC."

Recreation, arts, and other leisure pursuits are being reevaluated in long term care facilities, as providers look for ways to cut costs and increase revenues and various activities professionals fight for legitimacy.

To convince administrators to loosen purse strings tightened under the PPS, practitioners point to news reports heralding music, art, drama, and therapeutic recreation in settings from social day care centers and assisted living communities to subacute care units. They talk about how these activities can improve motor skills, balance, and coordination; promote decision making, sequencing, and reality orientation; enhance interaction, socialization, and communication; and reduce a wide range of ills, from falls to aggression.

While some of these claims are justified, others are probably exaggerated. But one thing is certain: Just plain fun isn't what it used to be.

"With facilities now looking to get reimbursement any way they can, activities and quality of life are getting the short end of the stick," cautions certified activity consultant Catherine R. Selman, executive director of the National Association of Activity Professionals in Jackson, Mississippi. And turning activities into a form of therapy is not the answer. "You can only do therapy with one to three people at a time," Selman points out. "If there's 120 people, what happens to the 117 others? There's nobody there to provide day-to-day activity."

Recent discussions with experts and practitioners yielded consensus in four areas. First, there's a place in long term care for every recreational specialty. Second, specialists tend to over-sell their capabilities. Third, some specialists aren't suited, by temperament or education, for long term care. And fourth, administrators frequently can't tell the difference between the people who know what they're doing and those who don't--and no wonder.

The importance of leisure

Thankfully, the era of bingo, birthday parties, and crafts is nearly over. Facility managers have greatly expanded the recreational choices available to residents in the decade since the Nursing Home Reform Act of OBRA '87 put added emphasis on daily activities. This is partly in response to consumer demand, but it's also a result of heightened surveyor expectations--especially over the last couple of years, when surveyors have been looking harder at practices affecting "quality of life" and issuing more citations under tag F248, which calls for activities that meet residents' needs and interests.

The surveyors have a point: Fun matters. Leisure activities do more than restore and rejuvenate; they help define who we are. They're particularly important for long term care residents who are relieved of jobs, positions in the community, family roles, and other responsibilities.

Concentrating on the therapeutic aspects of activities to the exclusion of their leisure benefits may violate not only the spirit but the letter of tag F248. "By law, you must replicate what [residents] could do in the community, whether that's church, creative writing, or playing violin," says Sheryl Ludeke-Smith, MA, CTRS, corporate director of Alzheimer's Care and Quality of Life Services for Beverly Enterprises. "Basically, it's a respite from concentrating on your diagnosis, medical ills, and physical problems to concentrate on the person you are."

And it's never too late to take up a new hobby. Resident Rose Collins, 82, says she never "did art" until given the opportunity at Montefiore, a 240-bed nursing facility in Beechwood, Ohio. Now she checks the calendar and goes to classes and museum outings regularly. "The days go real fast because I'm busy," she says. "I feel proud of myself to be doing it at my age."

Performing arts such as music and drama offer residents special opportunities for camaraderie. Music therapist and consultant Donna Douglass is founder of Project Arts, Inc., a visual and performing arts organization for seniors with serious mental illness. Her nursing home productions have included wheelchair folk dances, a soft-shoe number for post-stroke patients, and musicals. Besides increasing residents' energy and self-esteem, she says, participation can provide the fun that's often absent in their lives.

For Rose Collins, that's the most important thing about her art program. "I never thought of it as helping me," she says. "I'm doing it to have fun."

Turf wars

Leisure activities can lead to clinical improvements. Research indicates, for instance, that music therapy can enhance social and cognitive functions, decrease anxiety, and help caregivers manage difficult behaviors in people with Alzheimer's. Art therapy can improve eye-hand coordination and fine motor skills. But such results can be achieved only by people who are trained to work with the elderly and disabled, and many art, music and drama therapists lack that training.

At the American Music Therapy Association's Midwestern conference this spring, music therapist Corene Hurt-Thaut joined a physical therapist and an occupational therapist to demonstrate ways to achieve specific functional goals. (Music therapy is particularly effective in overcoming certain gait problems and cognitive deficits, as well as loss of speech.) In the first demonstration, to aid extension and weight shifting, a patient twisted hesitantly from side to side, touching the therapists' hands. Then she was given a mallet and asked to strike drums placed at the same positions.

A tentative stretch. Boom. Pause. Another stretch. Boom. Pause. Then, smiling triumphantly, she sped up and swung rhythmically. Boom. Boom! BOOM!

Excitement swept the audience. They could do this!

Hurt-Thaut, a researcher and director of music therapy and rehabilitation at the Poudre Valley Hospital in Fort Collins, Colorado, then introduced techniques tailored for post-CVA patients with aphasia. Remarkably, she explained, singing phrases such as "I want a cup of coffee," or "time for sleep," rather than saying them, can enable some stroke victims to communicate by bypassing damaged areas of the brain.

This time, the certified music therapists had questions:

"What's aphasia?"

"What's a CVA?"

Hurt-Thaut was disappointed by their lack of comprehension, but she wasn't surprised. Music drama and art therapy curriculums that emphasize artistic competence leave little room for the course work on physical and psychological development and illness that constitutes the basis of recreational therapy, she points out.

But therapists who work in long term care should be familiar with the medical conditions commonly found in long term care residents. This is particularly important if they're claiming to be able to treat those conditions--and many are doing just that.

In packed auditoriums at the music therapists' conference, speaker after speaker suggested that attendees market their services to administrators by packaging them as "restorative care," making them eligible for PPS and managed care coverage. Some speakers even suggested that music therapists could replace the higher-priced occupational therapists and physical therapists who are being squeezed by therapy caps.

In fact, recreational therapists may already be performing some functions formerly performed by OTs and PTs. Lora Serra, MA, CTRS, thinks her services are needed more urgently than ever by residents with Alzheimer's and other dementias. Hampered by reimbursement caps, physical and occupational therapists are doing less with these residents, says Serra, who is director of therapeutic recreation at the 448-bed Schulman and Schachne Institutes for Nursing and Rehabilitation at the Brookdale University Hospital and Medical Center in Brooklyn, New York.

Meanwhile, the various therapeutic arts disciplines are battling each other for recognition and reimbursement coverage. "The economics of long term care have created absolute chaos," says Gerald O'Morrow, EdD, CTRS, a therapeutic recreation professor at Radford University in Radford, Virginia. "There's a lot of turf wars between therapies. Anybody who thinks they can fill the void will try it."

There are even turf wars within specialties. Recently, the two national music therapy associations merged their memberships and created a third certification standard. Two national organizations represent recreational therapy specialists and associates (a paraprofessional level), although only one certifies them (associate level certification will be discontinued at the end of this year.) The two groups are forming a joint long term care task force to define their scope of practice--and to differentiate recreational therapists from the activities professionals, whom they often describe as paraprofessionals.

Who does what?

That question might be easier to answer if activity, arts, and recreational therapies had clear qualifications and duties. Unfortunately, that's not always the case.

* Activities specialists and activities professionals provide leisure recreation, which may be therapeutic as well as diversional, for groups and individuals. Activities may include parties, craft groups, gardening, field trips, community performances, classes, and one-to-one arts and recreation. The only educational background required is a college degree or a state-approved activities course. (Some states also offer an advanced course.) Activities professionals can earn national certification in nine tracks at three levels, based on on-the-job experience and academic achievements.

* Activity therapists, therapeutic recreation specialists, and recreation therapists provide diversional activities encouraging participation, leisure education, and counseling to help people regain abilities and relieve stress. They also perform therapeutic assessments and targeted interventions to improve cognitive, physical, social, and emotional functioning. They have a bachelor's or post-doctoral degree, usually in one of the sciences, health, or recreation. Thanks to that strong health grounding, they emphasize individual assessment, adaptations, and activities designed to complement other treatment goals. They can earn national certification through an exam.

* Music, art, and drama therapists use activities such as "receptive music listening" and art gallery tours as well as hands-on participation for recreation and/or rehabilitation. Academic backgrounds vary widely. They may be certified through professional organizations.

Although basic requirements tend not to be rigorous, providers in some states have pushed for tougher standards. In New Hampshire, for instance, noting that the 36-hour course mandated for activity department heads was less than the 100 hours required for CNAs, the New Hampshire Health Care Association's board of directors won Bureau of Health Facilities approval in the mid-1990s to require 90 hours of classroom training and 90 hours of practical experience at the employment site. In addition, the board recommends that facilities offer the advanced 180-hour course developed by the National Association of Activity Professionals.

What's more, specialists can always opt for higher training--and it's generally worth the investment. Serra went back to school for her master's degree in therapeutic recreation after working in activities for six years because she felt she lacked the medical knowledge to help residents. "I could use personality and charm with low-acuity residents, but I dreaded those who needed skilled nursing," she says. Her training "opened an incredible range of skills," she adds. "I learned what's happening in their bodies and minds, and how to create environments that help them function."

Finding the right mix

An effective activities department plays a vital role in bringing variety to daily life. "Hiring the right person for the activities, recreation, or life department is key to success of the facility," says Ludeke-Smith. "The key to facility morale is residents' enjoyment of life. If residents are unhappy, disgruntled or detached, it colors how everyone sees that facility. A good activities program makes it feel alive."

So how do you get there?

First, create the right mix of specialties. "Most activities professionals are wonderful programmers and much better program leaders than recreational therapists, who are better as department heads, providing assessments, care planning and specific therapeutic programs," says consultant Keith Savell, PhD, CTRS, executive director of Oakland, California-based Therapeutic Recreation Resources and chair of the NTRS joint task force for long term care.

Don't give recreational therapists so many responsibilities that they don't have time for one-to-one interventions or interdisciplinary team interactions. Hiring a second recreational staff member to provide support could save money in the long run, says Savell, a frequent expert witness who's seen a rise in activity-related complaints. Poor activities programs can increase citations not only for tag F248 but for behavioral management, clinical care, and quality of life issues, including residents' choices and whether or not the facility offers a life that's worth living.

Allow staff adequate time for recruiting, training and supervising the volunteers who provide companionship, programs, entertainment, and other services to residents.

Let bingo lovers play bingo, but make sure your program offers variety, including activities that are incorporated into normal daily life rather than group settings. "Solitary, private people shouldn't be shoved into directions that aren't meaningful, and facilities shouldn't be criticized or cited because a resident isn't trotted out to three programs per week," says consultant Carter Catlett Williams, CSW.

When hiring staff or consultant specialists, examine their qualifications, verify certifications, and discuss their educations. For example, someone who fulfilled extensive requirements for a degree in music or other arts probably had little time to cover anatomy, physiology, disease, psychology, and other health basics, much less gerontology. The only way to make sure applicants are comfortable in geriatric care is to observe their interactions with residents, particularly with those who aren't alert or oriented.

Activities professionals should be familiar with the culture, arts and interests of the people you serve. Music therapists whose idea of big band music is the Beatles are unlikely to provide programs appealing to residents starved for Glenn Miller. But recreational planners must get away from stereotypes like "little old lady" tea parties, warns consultant Herbert Shore, EdD, director of Shore and Associates Geriatric and Elderly Services in Dallas. "Today's residents expect facilities to have computers, classes, e-mail, and CDS."

Beware of activity and arts specialists who tend to overemphasize their own skills and interests, such as painting or singing. "As a result, you get a staff-centered calendar, rather than resident-centered programs," says Savell.

And don't overlook the importance of personality. Recreation specialists should be more interested in personal relationships than professional detachment. Given the time spent and the nature of their interaction, it's often easier for recreation specialists to develop meaningful social relationships with residents than it is for other staff. But this opportunity can be lost if they get too caught up in the therapeutic potential of their work.

"Calling something a treatment robs you of ownership of the activity," says consultant Williams. "Leave the terminology in reimbursement, not in the nursing home."

Wendy L. Bonifazi, RN, a contributing writer to Contemporary Long Term Care, is based in Fort Collins, Colorado.
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Author:Bonifazi, Wendy L.
Publication:Contemporary Long Term Care
Article Type:Brief Article
Geographic Code:1USA
Date:Oct 1, 1999
Words:2401
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