TR Process

Assessment

Name the assessment(s) used at your agency. If your agency does not use an assessment, identify an assessment that maybe appropriate for the agency.

The assessments used at the Lewinsville Adult Day Health Care Center (ADHC) are the Therapeutic Recreation Assessment, Social History and 20 Questions.

Include whether the assessment is standardized or an “in-house” tool. 

The RT assessment was created by the Fairfax County ADHC Therapeutic Recreation Team. The Social History Assessment was created “in-house” by the staff at the ADHC which is updated periodically by the Recreation Therapy Team. The 20 Questions Assessment was taken from the Person-Centered Care in Practice book and the ADHC Recreation Therapists added the “Program Idea” section.

Describe the on-boarding process- registration, admission, etc.

The ADHC is for anyone 18+ who requires supervision during the day due to dementia, Alzheimer’s, Parkinson’s, or cognitive and/or physical impairments. They must be able to feed themselves and transfer with the assistance of no more than one person.

To enroll in ADHC you must schedule an admission meeting at one of the four locations (in Alexandria, Herndon, McLean and Mount Vernon). The Center Nurse Coordinator will assess the participant and discuss their needs and abilities and then create a treatment plan based on that discussion.

The participant is required to have completed a Physical Exam and a Tuberculosis Screening prior to their admissions meeting and these documents must be updated within 30 days of the participants first day at the center.

The participant will pay for services based on the agencies’ sliding fee scale which is determined on the participant’s income and two percent of their assets. Transportation fees are also based on income. For this reason, a copy of the participant’s tax return, latest bank statement or other relevant income information (i.e. social security income, pension, money markets, trust funds, etc.) should be brought to the admissions meeting. Other documents families should bring to the meeting include: insurance cards, advanced directives, living will, Durable Do Not Resuscitate, legal guardian paperwork and medication details.

The participant is given a 30-day trial to determine if ADHC is the right fit for their needs. They are required to attend at least two days each week.

They must be assessed by the Recreation Therapist within the first 30 days of coming to the facility. Participants are then reassessed annually or as needed if significant health concerns arise.

Identify other documents or resources that assist in the assessment process (past records, families, other providers).

Other resources used to assist in the assessment process include reviewing medical records and talking to the family and caregivers (they complete the Social History for participants.) The Program Assistants complete the 20 questions with the participant, and share the information with the team.

Other- list any other aspect of the assessment process or details you deem important to include here.

The participants must be assessed within one month of coming to the ADHC and be reassessed annually or in the case of any significant health status change.

Plan

Describe the planning process at your agency. Be sure to identify the role of the assessment in planning.

Every month a calendar is created in a collaborative effort of staff and participant feedback. The calendar is due by the 25^th of every month. Often, the calendar of the year before is evaluated on what worked, what may need to be adapted for the new group of participants and what needs to be added. The bigger special events such as field trips and entertainers may be advertised in the monthly newsletter created by the ADHC.

Assessments are taken into consideration when planning different intervention programs because they must be suitable for participants and their abilities. For example, a higher cognitively functioning group would not be participating in a program meant for lower cognitive functioning individuals and vice versa. The 20 Questions Assessment is useful when planning activities so that programs can revolve around the specific interests of participants and can create greater engagement. Reviewing assessments can also be helpful when doing 1:1 therapy, as by reviewing a participant’s interests it is easier to help them when they experience sundowning, agitation or confusion.

The Senior Program Assistant is responsible for assigning who facilitates an activity. It is important for the facilitator to be enthusiastic and comfortable about the program they are facilitating in order to achieve the best outcome for the participants.

Identify any documents used in the planning process.

The documents used in the planning process are the Therapeutic Recreation Assessment, Social History, 20 Questions Assessment and a Health Evaluation.

Describe other departments, sources, allied professionals that are involved in the planning process.

The Recreation Therapist, Senior Program Assistant, Program Assistants, Center Nurse and the Center Nurse Coordinator are all involved in the planning process. Occasionally, a Physical Therapist, Speech Therapist or Occupational Therapist will offer their suggestions and expertise.  Dietitians ensure the meals offered provide proper nutrition for the participants. These allied health professionals could also suggest ideas to the staff occasionally that can help in the planning process.

Describe how activities/interventions/programs are selected. Give examples.

Programs are based on participant needs and abilities. Most programs focus on socialization, cognitive stimulation, improving or enhancing emotional functioning, improving or enhancing gross and/or fine motor functioning, initiating leisure activities and increasing sensory stimulation.

For a participant who may need cognitive stimulation, a program such as “Outburst Family Feud” may be an appropriate program to participate in. This program focuses on memory recall (answering the questions), mathematics (keeping score), socialization (working with your team), fine motor function (hitting the buzzer) and gross motor function (walking up to buzzer).

For a participant who may need sensory stimulation, a cooking program can provide an opportunity for them to use all the different senses. Tasting the food, touching the ingredients smelling the finished product, looking at everyone’s completed recipe, and hearing the noises of the cooking tools.

Participants who may need to improve or maintain their gross and/or fine motor function can participate in the Pet Therapy program. Walking the dog allows for participants to work on gross motor skills and brushing them allows them to work on their fine-motor skills by grabbing the brush with their hands. With Pet Therapy, there are many opportunities to work on motor skills as well as socialization.

Provide a monthly and weekly schedule of programming/activities at the agency/setting.

Calendar from January 2020:

Calendar from September 2012:

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Implementation

Describe the implementation procedure. Give an example.

When beginning the implementation process, safety must be taken into consideration. Staff should maintain an overall 6:1 ratio at all times while implementing programs.

The facilitator will introduce themselves, the title of the program, and state the purpose of the activity. Next, they will give clear and simple directions to make sure everyone understands what they are doing. After, they will demonstrate the activity by showing what is expected, giving examples or even asking participants to talk about how the activity was done the last time.

If memory recall was a main focus in the activity, it can be used throughout the introduction process. For example, if the activity was Outburst Family Feud, asking questions like “What’s my name?” or “Can anyone explain how we played Outburst Family Feud last time?” can be used to assess memory recall, it can also increase orientation and alertness. The participants become aware of where they are, who is talking to them and what they are playing.

Identify how implementations are documented. Explain what information is required in this documentation.

Implementations are documented when creating the calendar of the month and selecting who is facilitating what activity. For special events such as festivals that require multiple stations, there is an activity plan created that is reviewed by the staff that is participating prior to the event.

Safety information is a requirement in the activity plans. Adaptions, modifications and accommodations are also required for the activity. The activity plan must include when and where the program will be held, the set-up of the activity area (ex: lighting may need to be adjusted if using the SMART Board or projector), appropriate outfits to wear during the activity, adjusting placement of participants (ex: individuals who have difficulty hearing may be seated in the front) and the clean-up.

Evaluation

Describe how the client’s progress is evaluated. Be sure to mention all documents used to evaluate client progress.

Participants are reassessed annually. Their progress is updated in the Therapeutic Recreation Assessment under each heading (i.e. physical functioning, cognitive functioning, and social/emotional functioning), there is also a section for comments where progress or general notes can be written.  The treatment plan is also updated. Another reason the assessment may be updated is in the case of significant medical concerns arising, such as being hospitalized.

Describe how the program’s progress is evaluated. Be sure to mention all documents used to evaluate programming and how programming improvement is made.

Participant feedback is important for evaluating programs. The Participant Council is a group that meets monthly to discuss new topics or ideas about activities. Staff input is also considered when evaluating programming as they can suggest their ideas or topics to implement in an activity. There is also an Annual Caregiver Satisfaction Survey that gets sent to the participants and their caregivers.  It is a generalized survey that includes a section dedicated to Recreation Therapy programs where comments or concerns can be written. The Staff then review the survey and identify where they may need to improve.

Describe how the therapist’s skills are evaluated. Be sure to mention all documents associated with this process. Describe how the therapist uses feedback to improve their skills.

When you first start as a Recreation Therapist at the ADHC you are evaluated within the first six months by the Center Nurse Coordinator and then formally evaluated every year. Informal feedback from participants, caregivers, and staff is also taken into consideration. After receiving feedback, the Recreation Therapist identifies what needs to be improved upon and what they could do to make improvements. The Recreation Therapist can take a course, training, attend conferences, learn new technology skills, or even implement a new approach to revamp their current programs. For example, adding smaller groups if that is what is desired by the participants, talking to other Recreation Therapists to see what has worked for them, or trying new trends and ideas for interventions.

Program Outline

Programming- create an outline of all RT programming offered at your assigned agency/setting

Arts and crafts (ceramics, collage, woodworking, painting) – COGNITIVE, SOCIAL, FINE MOTOR, SENSORY STIMULATION * FOUR times a month

Cognitive Activities (crossword puzzles, table games, trivia, reminiscing) – COGNITIVE, SOCIAL *ONCE a day

Community Service (biscuits for dog shelter, holiday food baskets, book buddies) – SOCIAL, COGNITIVE, PHYSICAL, EMOTIONAL *FOUR times per year

Community Trips (picnics, museums, shows, lunch, sightseeing) – SOCIAL, GROSS & FINE MOTOR, COGNITIVE *MINIMUM of 12 per year

Discussion Groups (book clubs, men/women’s group, participant council, coffee club) – SOCIAL, COGNITIVE, EMOTIONAL *TWICE a week

Health and Beauty (make-up, nail care, support groups, beauty shop) – SOCIAL, EMOTIONAL, SENSORY STIMULATION *ONCE a week

Intergenerational programs (scout groups, preschool visits, teen volunteers) – SOCIAL, COGNITIVE, PHYSICAL, EMOTIONAL *ONCE a month

Music/ Entertainment (sing-a-long, storytelling, concerts, dancers, comedians) – SENSORY STIMULATION, SOCIAL, COGNITIVE, EMOTIONAL *according to budgetary guideline

Nature (gardening, zoo on wheels, wild bird center, nature discussion) – SENSORY STIMULATION, EMOTIONAL, COGNITIVE, GROSS & FINE MOTOR *ONCE a month

Special Events (holidays, birthdays, Annual ADHC dance, carnival day, fall festival) – SOCIAL, COGNITIVE, SENSORY STIMULATION *ONCE a month

Adapted Sports/Games (volleyball, golf, soccer, bowling, basketball, tossing games) – PHYSICAL (FINE AND GROSS), COGNITIVE, SOCIAL, SENSORY STIMULATION *ONCE a day

Fitness (yoga, Tai Chi, walking, aquatic therapy, chair dancing)– PHYSICAL, SOCIAL, COGNITIVE, SENSORY STIMULATION *TWICE a day

Additional Therapeutic Programs (art therapy, sensory therapy, music therapy, pet therapy, creative movement, culinary therapy) – PHYSICAL, SOCIAL, EMOTIONAL, COGNITIVE, SENSORY STIMULATION *FOUR times per month  

Interactive Whiteboard (videos/music, cognitive activities, PowerPoints.)– COGNITIVE, SOCIAL, SENSORY STIMULATION * TWO times a month

Interventions/activities (no more than 10)- list all the activities/interventions, with a brief description and the expected outcomes. Include the duration and frequency of the activity within the program. Identify whether each intervention/activity is evidence-based.  

1. Arts and Crafts – Peanut Butter Pinecone Feeders:

This program consisted of small group of about four participants. After collecting pinecones, participant would spread peanut butter around the pinecone with plastic knives and then dip it into a bowl of bird feed. They would then tie a string around their pinecone and go outside to hang it up on a tree. The expected outcomes were to work on fine-motor skills by applying the peanut butter and bird feed onto the pinecone as well as engage in fitness walking to find pinecones and hang them outside. The activity takes about 30 minutes to complete and is done twice a year in the colder months. A safety consideration was assessing participants who may be a fall risk since there may have been snowfall on the ground.

2. Cognitive Activity – You Be the Judge:

The program consisted of a group of six to eight participants. The Recreation Therapist would pull a few stories from the book “You Be the Judge” and give participants the option to choose which story they would like to hear that day. Once the group chose the desired story, the Recreation Therapist would give each participant a copy of the story, gave them an opportunity to read it for themselves and then read it aloud so they could follow along. Participants were also asked if they wanted to read the story aloud while everyone followed along. The story was usually read two to three times so that everyone had an opportunity to listen and take notes if needed. After listening to the story, the participants were asked questions regarding what they just heard such as “Do you think they’re guilty?” “Who do you think is guilty?” and more. This was a time to share opinions, hear other opinions and having a meaningful discussion. Everyone got a chance to give their opinion. At the end of the program the Recreation Therapist would have a discussion to draw a conclusion about everyone’s opinion, what was said, who agrees, who disagrees or if anyone had any remaining questions. The expected outcomes were to have participants actively listen and pay close attention to the details of the story (cognition) as well as engage in discussion with one another (socialization). This program runs for about 30-45 minutes and was facilitated once or twice a month before lunch.

3. Intergenerational – World Health Day Fair:

This program consisted of three even teams of older adults and children. There were three activity stations. Each team started at a different station and each station would be given 20 minutes to complete their activity.

The first station was the Healthyland Board Game. The group was split into two teams and were instructed to roll the dice to determine how many spots they could move forward. The board game was designed similarly to Candy Land, except every time they landed on a square, they would be asked a health-related question. Each color square would represent a different style of question they would be asked (i.e. if they landed on a blue square they would be asked a true or false question, if it was yellow it would be fill in the blank, etc.) If the team got the answer wrong, the next team would take their turn. The team who reached the last square (Happy Home) or was closest to it by the end of the rotation would win.  The expected outcome of this activity was to come up with correct answers for each question and work together with their team to answer the questions (cognition and socialization).

The second station was the “Wellness Words” Word Search. The entire team was given 15 health related questions and asked to answer them by creating a list of the words. Then the words they identified would be the words they were searching for in the enlarged word find. The team worked together to find as many possible words before moving onto the next station. The expected outcome of this activity was to answer each question correctly, look for the words, and work with their team to complete the puzzle (cognition and socialization).

The third station was the Safety Survival Scavenger Hunt. At this station the participants were given a poster that listed all the items to find around the room, all related to things you would find in a first aid kit. Some of the items were only in picture form for the safety of the participants (i.e. scissors, tweezers, etc.) After all the items were found, the nurse would explain the purpose of each item and review what can be found in a disaster relief plan kit at home.  The expected outcomes of this activity were to successfully find all the items by working with their team and to learn about first aid kit supplies. (cognition, physical, socialization)

This event was hosted annually during Public Health Week in April and would consist of the same set up of three different activity stations.

4. Sports/Games- Ring Toss:

The activity can be done with six to eight participants. The Recreation Therapist determines how far the throwing line is from the cornhole based off the needs and abilities of the participants, ranging anywhere from 5-12 feet. The board has the point value displayed under each peg and the higher the peg, the higher the point value. Participants are then handed the rings and they can begin tossing them at the board. At the end, all of the points are tallied and the winner is the one with the highest points accumulated throughout the game. All the other participants who played are also recognized and cheered for! The activity is an hour long and is played once a month. The expected outcomes for the participants are to work on fine-motor skills by grabbing the rings and gross-motor skills by tossing the rings. They also are socializing with other participants during the game.

5. Cooking – Cherry Bake Off Cooking Contest:

This program consisted of five teams each comprised of one staff member and one or two participants. They were instructed to use the main ingredient (cherries) in all their recipes. The staff and participants worked with their teams to make their recipes.  After they finished making their recipe, they presented it to a panel of judges that consisted of a mix of staff, participants and volunteers. After the judges tasted each team’s recipe, each team was awarded a certificate based on the category in which they won (i.e. best appearance, best aroma, best overall, best taste and most original). After the judging was finished, the ADHC would also provide a cherry themed snack to all participants. The expected outcomes of this activity were to use fine-motor skills when preparing their recipe (i.e. stirring, mixing), reading and successfully putting together a recipe which focused on cognitive skills and work together with their team to accomplish their meal which focused on socializing. The cooking contests were hosted four times a year, each time using a different main ingredient (i.e. edible flowers, pumpkin, spam, strawberries, etc.)

*None of the activities are Evidence-Based.

TR Process Delivery Flow Chart

SWOT Analysis- conduct a SWOT analysis of your agency. It should be based upon all the information gathered thus far to include the agency summary, market scan, population summary and program analysis. The SWOT analysis should be used to help identify a course project for you to pursue for the remainder of the internship.

Strengths- what are the strengths of the RT program?

There are a variety of programs that are offered to the diverse population that meet their needs, abilities and interests. There is a large day room, library, dining room, and craft room where activities can be conducted.  There is funding for trips and outings, board games, art supplies and equipment.

Weaknesses- what are the weak areas of the RT program?

A weakness would be when there are staffing shortages since there must be a 6:1 ratio at all times, and facilitators available to lead the activities. Another weakness is not having enough funding for new programs that interest participants.

Opportunities- what are potential opportunities to expand, obtain resources, or broaden the market?

More ADHCs in Northern Virginia would be a possible expansion opportunity, though more funding would be needed to expand.

Threats- are there areas that threaten the existence of the program? This may include non-compliance with regulatory bodies, lack of funding, or loss of resources.

Due budget cuts over the years, the closing of two ADHC facilities in Northern Virginia is a threat to the existence of the program. The openings of other day care centers as well as in-home health care are also threats since there are more options for the caregivers to consider.

RUBRIC: