Therapeutic recreation professionals have spent an incredible amount of time and energy on developing various standards and guidelines for improving practice at both the national and state levels. Most of the time, though, little in known about the use and usefulness of the standards because we fail to adequately research and understand the difficulties of implementing these standards in practice.

In 1982, the Community Referral Committee developed the Illinois Therapeutic Recreation Section (ITRS) Therapeutic Recreation Discharge/Referral Process — Standards and Guidelines document. Since its initial development, the standards and guidelines have undergone several revisions. They have also experienced periodic shifts in acceptance and use by practitioners. In late 1989, a research project was funded in part by ITRS to determine the current status and use of the standards.

After a review of past information provided by the committee, an instrument was developed and pilot tested by the research team, and it addressed demographic questions, general questions about the implementation of the discharge/referral process and specific questions concerning the adherence to the standards and guidelines. The revised survey was mailed to a sample of 98 therapeutic recreation professionals in the state for their responses.

Of the 98 questionnaires that were mailed, 65 (66.33 percent) were returned after one follow-up letter. These returned surveys represented 35 clinical agencies, 26 community-based agencies, and three agencies in the "other" category, with one non-respondent to this question. Of the 65 respondents, the majority were from the Northern region of the stale.

Population groups served

The most prevalent service groups for all respondents included individuals with mental illnesses, emotional disturbances/behavior disorders and orthopedic impairments. However, when the respondents are divided into clinical and community settings, some interesting differences are noted. Clinical agencies most often served individuals with mental illnesses, aging, emotional disturbances/behavior disorders, orthopedic impairments and substance abusers. Community agencies most often served individuals with mental retardation, mental illnesses, and orthopedic impairments. While clinical agencies primarily served individuals with mental illnesses, the community group primarily served individuals with mental retardation. Both types of agencies typically served over 250 individuals annually.

Number of therapeutic recreation staff

Regarding the total number of therapeutic recreation staff employed, there was a wide variation among responding agencies. Almost half of both types of agencies employed only one or two therapeutic recreation personnel (31 or 47.69 percent), but only three clinical agencies employed 12 or more staff while seven community agencies employed that number.

Awareness and use of ITRS Discharge/Referral Standards

The next series of questions examined the agencies' awareness and use of the ITRS Discharge/Referral Standards. Frequencies and percentages of responses equal more than 100 percent because respondents could select all options which applied. The four most common reasons for all agencies for not using the standards were: "Standards do not fit agency's needs;" "Was unaware of the Standards;" "Not required to use;" and "Not sure how to start the process." Clinical personnel were less likely to know how to start the discharge/referral procedure, and community staff stated they were not required to use the standards.

In summary, while 50 of the 65 responding agencies knew about the standards and 45 reported having a copy, only 25 currently used the standards. Of those who used them, the majority had done so from one to three years. Two of the four main reasons given for not using the standards related to unawareness of the standards or the discharge/referral process, and the other two related to not being mandated to use the standards. Reasons for not using the standards varied among the two types of settings. Eighteen agencies requested further information about the standards.

Adherence to and use of the discharge/referral standards

Both clinical and community agencies were asked about their use of the standards and guidelines. Seven of the clinical agencies reported an increase in the number of referrals they had sent in recent years, however, most also reported that few clients actually followed through and participated in the community-based programs. Similar information was found with the community agencies, with 13 responding that referrals had increased in the last two years, but few clients registered and attended programs. One discrepancy found between the two types of agencies' responses was the types of programs available to clients. Clinical respondents reported that there were not enough or inadequate community programs for client referrals.

Agency respondents were also asked about their adherence to the ITRS Standards. Clinical agencies have five standards and community agencies have a different set of 10 standards to follow. While the ability to generalize from such a small sample is weak, for the most part, community agencies followed the guidelines more closely that did the community agencies. The clinical agencies were most likely to do follow-up services. Community staff were best able to make determinations of appropriate programs for referred clients and suggest alternative programs if non-existed within the agency. They were least successful at providing in-service staff training concerning disability information and utilizing consumer service evaluations.

Several conclusions can be made from the data discussed here. While they are discussed more fully in the final research report, they are simply listed here due to space limitations.

Clinical and community therapeutic recreation agencies may be serving distinctly different types of population groups (e.g., individuals with mental illnesses in clinical settings versus individuals with mental retardation in community settings).

While the number of client referrals being made by clinical staff arc increasing, few clients actually participate in the community-based therapeutic recreation programs to which they are referred.

Fewer therapeutic recreation staff are employed per agency in clinical settings, although the number of clients served is comparable with community-based programs.

Those agencies which used the discharge/referral standards did so with some .consistency and regularity. There seemed to be a "core" group of regular, committed users and a "fringe" group which have a lesser commitment.

Based on the results and conclusions, six recommendations were made to the ITRS Discharge/Referral Committee. These include:

1. Maintain and/or increase education efforts to therapeutic recreation practitioners and students.
2. Review the current standards documentation to determine if the process may be made more "user friendly."
3. Re-institute the "liaison" concept to assist in creating a grassroots support for the discharge/referral system.
4. Reward those who use the system well.
5. Conduct further research to examine issues uncovered by the present study, especially the differences in populations served and the number of staff and time usage.
6. Consider creating a directory of therapeutic recreation services for people with disabilities on a statewide basis.

At the present time, the ITRS Discharge/Referral Committee is reviewing the results of this study and developing plans to improve the system. The committee would welcome any input and comments from ITRS members. The complete research report is available through ITRS at the IPRA office.

About the Author
Norma J. Stumbo, Ph.D., CTRS, is an Associate Professor and Coordinator of Therapeutic Recreation at Illinois State University where she has been employed for seven years. Most of her research publications and presentations are targeted to applying research findings to the improvement of practice.