Linda L. Buettner 1
1 Linda L. Buettner, CTRS, Ph.D. is
an assistant professor at Decker School of Nursing, Binghamton University and
Coordinator of the Gerontology Treatment Network for the American Therapeutic
The purpose of this paper is to increase awareness
of therapeutic recreation as a treatment option for nursing home residents.
It addresses recent regulations and documentation changes that have occurred
under the prospective payment system, and summarizes efficacy research documenting
the possible health outcomes of recreation therapy.
KEY WORDS: recreation therapy, nursing
homes, regulations, benefits
Therapeutic Recreation in the
Reinventing a Good Thing
For years certified therapeutic recreation specialists
(CTRS) have worked in psychiatric, acute care, and rehabilitation settings with
older adults. In psychiatric hospitals recreation therapists provide therapeutic
interventions to treat various forms of depression, the psychiatric symptoms
of dementia, and chronic schizophrenia. In acute care and rehabilitation hospitals
older individuals are provided with programs and therapy sessions to assist
in the recovery of functional losses from cardiovascular accidents and illnesses,
fractures, and surgery. The goal of the therapeutic recreation programs in these
settings is to help older clients cope with additional free time, symptoms of
disease or illness, loss of function, and to bring these individuals opportunities
for reintegration into the community. Many of these same types of clients are
now cared for in the nursing home setting on subacute rehabilitation units,
special care units, and on traditional skilled nursing units.
The patient population, the organizational structure,
and the rules and regulations in long term care have all dramatically changed
during the past decade. The interdisciplinary staff who work at nursing homes
are now expected to care for very complex older adults with a myriad of mental
and physical health problems. For some residents the goal is to "go home"
and for other residents goals might include "reducing aggression, improving
comfort levels, or improving ADL function". Whatever the goals, nurses
in long term care settings are instrumental in advocating for the services,
medications, and therapies provided to meet the needs of the residents in their
care. Unfortunately, few nursing education programs or textbooks accurately
describe therapeutic recreation services for long term care settings. Therefore,
interventions from the field of therapeutic recreation have not been well understood
or requested in this rapidly changing healthcare environment. The purpose of
this article is to provide nurses with the knowledge, definitions, and language
they need to request recreation therapy services for the residents in their
What is a CTRS ?
A CTRS is often referred to as a recreation therapist.
Requirements for certification include
a minimum of a four year degree, an extensive internship
under a certified therapist, and passing the national certification exam. After
passing the national certification exam, the therapist is allowed to use the
initials, CTRS after his or her name. Every CTRS has continuing education and
practice requirements for re-certification, which occurs every five years. Recreation
therapy is a "therapy ordered by a physician (a nurse practitioner or physician’s
assistant) to restore, remediate, or rehabilitate in order to improve functioning
and independence as well as reduce or eliminate the effects of illness or disability"
(ATRA, 1997). In long term care, recreation therapists offer outcome-based therapeutic
programs in small groups or one-to-one sessions for older adults with a variety
of mental and physical conditions.
Impact of Regulations on Recreation Therapy
Historically, in terms of regulations, the nursing
home reform section of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87)
caused sweeping changes in the regulation of the nursing home industry (Martin
& Smith, 1993). This legislation was developed to assure that nursing facilities
provide an improved quality of care to residents. It changed the model of care
from a medical emphasis to quality of life for the residents. Much of the focus
of OBRA ‘87 was to restore dignity and self-determination to residents of nursing
homes. Activities are included as a component of quality life in nursing homes,
and facilities must now provide for an "ongoing program of activities designed
to meet, in accordance with the comprehensive assessment, the interests, and
the physical, mental, and psychosocial well-being of each resident" (Department
of Health and Human Services, 1989a, pp. 5363-5364). This statement caused nursing
home activities departments to diversify and provide two types of programs;
1) diversional or entertainment-based large group activities, and 2) small group
and individualized outcome-based therapeutic interventions (Buettner & Martin,
The Minimum Data Set (MDS) was mandated by the
Omnibus Reconciliation Act (OBRA) of 1987 to ensure that all nursing home residents
were assessed, provided with services, and monitored on a regular basis. The
MDS has undergone several changes in the past few years, with the last one occurring
in the summer of 1998. As of July 1, 1998 the Prospective Payment System began
and Section T. was added to the MDS, which requires the reporting of Recreational
Therapy treatment services under Section T. 1a. HCFA is currently collecting
statistical data on the use of recreation therapy through Section T. 1a. to
evaluate for future reimbursement rates. The MDS documents the number of days
and total minutes of recreation therapy administered during the past seven days.
Recreation Therapy is considered a rehabilitation treatment option, and must
be provided by a qualified provider (a certified therapeutic recreation specialist
or a certified therapeutic recreation assistant under the supervision of a therapist).
The scope of intensity, duration, and service provided must be within the physician
or nurse practitioner’s prescription. If recreation therapy is ordered, it is
considered medically necessary and appropriate, and therefore, the facilities’
obligation to provide the service for their residents. If the facility does
not employ a certified therapeutic recreation specialist, the facility is required
to contract for this service(Belfy, 1998).
Referrals and Orders
Many nursing homes already have a therapy referral
process in place, and have added recreation therapy to the referral form used
by physical therapy, occupational therapy, and speech therapy. Other facilities
have created a separate recreation therapy referral form to help educate nursing
home staff about the service. Figure 1. provides an example of a recreation
therapy referral form that was developed by this author. Once the referral for
recreation therapy is made an assessment should be completed by the CTRS. On
many subacute units a standard order is provided for each new resident "to
evaluate for recreation therapy services". Residents from other units may
also be appropriate for recreation therapy, and the referral should be done
on a case-by-case basis.
Who can benefit from recreation therapy?
Recreation therapy interventions address the areas
of restoration of function, health maintenance, reduction of health risk factors,
and psychosocial competence (ATRA, 1999).
Interventions include fitness, exercise, and movement
activities; sensory and cognitive stimulation programs; activities to promote
social interaction skills, choice, and self-expression; various programs to
improve activities of daily living and functioning in the community; and therapy
programs to reduce behavioral and psychiatric symptoms.
Research studies have been completed in rehabilitation,
psychiatric, and nursing home settings and have demonstrated that older individuals
with a variety of conditions benefit from therapeutic recreation services. Frail
older adults who received exercise programs experienced significantly increased
cardiovascular fitness, decreased blood pressure, and increased flexibility,
strength, and improved ambulatory skills (Buettner, 1988; Buettner & Ferrario,
1998; Davis, Shepard, & Jackson, 1981; Green, 1989; Keller, 1991; Yoder,
Nelson, & Smith, 1989). Interdisciplinary therapy programs and exercise-based
activities lead to improved opportunities for re-integration into the community
(Buettner, Kernan, & Carroll, 1990).
Nursing home residents with cognitive impairments
who received recreation therapy programs demonstrated improved behaviors, increased
activity and alertness levels, used fewer psychotropic medications, and experienced
fewer falls (Buettner, 1999; Buettner & Ferrario, 1998; Buettner & Waikavitz,
1998; Osgood, Meyers, & Orchowsky, 1990; Peniston, 1991; Schwab, Roder,
& Doan, 1985). In addition, several studies have demonstrated these improvements
impacted positively on the mental functioning of the residents (Buettner &
Ferrario, 1998; Osgood et al, 1990; Peniston, 1991).
Frail older adults in both psychiatric hospitals
and nursing homes who participated in social, expressive, artistic, or nature-based
recreation therapy programs demonstrated decreased loneliness and increased
affiliation with others (Buettner & Kennison, 199 ; Cutler & Riddick,
1985). Involvement in therapeutic recreation programs increased involvement
with families and improved visit satisfaction (Buettner, 1999; Fink & Bedall-Fink,
1986). Studies have also demonstrated significantly improved verbal interaction,
improved morale and life satisfaction, decreased levels of depression, enhanced
perception of personal control and competence (Katz, Adler, & Mazzella,
1985; McGuire, 1984; Shary & Iso-Ahola, 1989; Skalko, 1990; Wassman &
Summary and Conclusion
It is clear that recreation therapy, can have
a major positive impact on the lives of older adults with a assortment of health
conditions in a variety of settings. As the types of residents in nursing homes
change, the programs and types of activities provided must also change. Individualized
outcome-based activities need to be provided to supplement the nursing home’s
general activity calendar. Activity programs must become smaller, and specifically
developed to meet the identified needs of the residents. More emphasis must
be placed on education and rehabilitation of residents. For those residents
with a dementia diagnosis, specialized small group programs should provide just
the right amount of challenge and stimulation to help maintain function and
alleviate difficult behaviors. Facilities with short-term rehabilitation units
should offer off-hours therapeutic programs so that residents who are focused
on going home will learn how to adapt recreational interests for their new situation.
Whether medicare reimbursable or not, all nursing home residents deserve treatment
for the symptoms of depression, programs to prevent falls and injuries, and
therapeutic activities to maintain or improve function.
Over the years there has been strong evidence that
recreation therapy interventions make a tremendous difference in the outcomes
of older adults in other healthcare settings. Making these types of programs
work in nursing homes now takes interdisciplinary teamwork, and well-informed
highly trained staff. When nurses advocate for this type of therapeutic programming
the resident is the real winner. Perhaps there is no need to "reinvent
a good thing" but simply move it into a new arena.
Belfy, M. (1999/Winter). Reasons for inclusion
of recreation therapy in skilled nursing units,
ATRA Newsletter, .
Buettner, L. (1988) Utilizing developmental
theory and adaptive equipment with regressed geriatric patients in therapeutic
recreation. Therapeutic Recreation Journal, 22(3),72-79.
Buettner, L. (1995). Therapeutic recreation as
an intervention for agitation in persons with dementia: A case study of Mrs.
M. Therapeutic Recreation Journal, 29, 63-69.
Buettner, L. (1999). Simple pleasures: A multilevel
sensori-motor intervention for nursing home residents with dementia. American
Journal of Alzheimer’s Disease, 14, 41-53. Buettner, L., Kernan,
B., & Carroll, G. (1990). Therapeutic recreation for frail elders:
A new approach. (Eds. Hitzhuzen, J. & Thomas,
L.) Global Therapeutic Recreation I: Selected Papers from the First
International Symposium, 1, 82-88.
Buettner, L. & Ferrario, J. (1998). Therapeutic
recreation as an intervention for nursing home residents with dementia and agitation:
An efficacy study, Annuals of Therapeutic Recreation, Vol.7, 1,
Buettner, L. & Martin, S. (1995). Therapeutic
recreation in the nursing home. State College, PA: Venture Publishing.
Buettner, L., & Waitkavitz, J. (1998). Preventing
falls in long term care: A model therapeutic recreation program (Editors Hitzhuzen,
J. & Thomas, L.) Global Therapeutic Recreation V, 5, .
Cutler R. & Dugan-Jendzejec, M. (1988). Health
related impacts of a music program on nursing home residents. In F. Humphrey
and J. Humphrey (Eds.), Recreation: Current selected research (pp. 155-166).
New York, NY: AMS Press.
Davis, G., Shephard, R., & Jackson, R. (1981).
Cardiorespiratory fitness and muscular strength in the lower limb disabled. Canadian Journal of Applied Sport Sciences, 6, 159-177.
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Care Financing Administration. (1989a). Rules and regulations. Federal Register, 54, (21), 5316-5373.
Fink, J. & Bedall-Fink, T. (1986). Implementation
and rationale of family leisure programs for an inpatient psychiatric hospital. Trends III: Therapeutic recreation expressions and new dimensions (3rd
Green, J. (1989). Effects of a water aerobics
program on blood pressure, percentage body fat, weight, and resting pulse rate
of senior citizens. Journal of Applied Gerontology, 8 (1), 132-138.
Katz, J., Adler, J., Mazzarella, N., & Inck,
L. (1985). Psychological consequences of an exercise program for a paraplegic
man: A case study. Rehabilitation Psychology, 30(1), 53-58.
Keller, J. (1991). "The impact of a water
aerobics program on older adults." Unpublished Manuscript.
Martin, S. & Smith, R. (1993). OBRA Legislation
and recreational activities: Enhancing personal control in nursing homes, Activities,
Adaptation, & Aging, 17, (3), 1-14.
McGuire, F. (1984). Improving quality of life
for residents of long term care facilities through video games. Activities,
Adaptation, and Aging, 6, 1-8.
Osgood, N., Meyers, B., & Orchowsky, S. (1990).
The impact of creative dance and movement training on the life satisfaction
of older adults. Journal of Applied Gerontology, 9, 255-265.
Peniston, L. (1991, September). The effects of
a microcomputer training program on short-term memory in elderly individuals.
A paper presented at the Benefits of Therapeutic Recreation in Rehabilitation
Conference, Lafayette Hill, PA.
Shary, J. & Iso-Ahola, S. (1989). Effects
of control relevant intervention on nursing home residents perceived competence
and self esteem. Therapeutic Recreation Journal, 23(1),7-16.
Skalko, T. (1990). Discretionary time use and
the chronically mentally ill. Therapeutic Recreation Annual, 1,
Wassman, K. & Iso-Ahola, S. (1985). Hidden
disabilities: A new enterprise for therapeutic recreation. Therapeutic Recreation
Yoder, R., Nelson, D., & Smith, D. (1989).
Added purpose versus rote exercise in female nursing home residents. American
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Therapeutic Recreation Referral
"Therapeutic recreation is the provision of
treatment services and recreation services to persons with illnesses or disabling
conditions. The primary purpose of treatment services which is often referred
to as recreation therapy, is to restore, remediate, or rehabilitate in order
to improve functioning and independence as well as to reduce or eliminate the
effects of illness or disability. The primary purpose of recreation therapy
services is to provide recreation resources and opportunities in order to improve
health and well-being. Therapeutic recreation is provided by professionals who
are trained and certified (CTRS) to provide therapeutic recreation". ATRA
Reason for referral:____________________________________________________________
Possible areas for referral to recreation therapy:
- Reduction of symptom levels of chronic or degenerative
disorders(reduced arthritic symptoms, improved bone and muscle strength, reduced
pain, enhanced functioning).
- Improvement in physical health (physical functioning,
endurance, range of motion, strength, community reintegration).
- Reduction in health risk factors (risk for falls,
decreased body weight, decreased mobility, decrease blood pressure).
- Improve cognitive functioning (memory, attention
span, alertness level, problem solving, psychosocial skills).
- Reduction of anxiety, stress, depression, or
- End of life well-being (relief from distressing
symptoms through integration of psychological and spiritual care, help residents
live as actively as possible until death)
Priority of problem areas to be addressed:
Referral made by:________________________________________________________
- - - - - - - - - - - - - - - - - - - - - - - -
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Recreation Therapy assessment completed by:__________________________Date:_____
Nurse Practitioner or M.D. notified and Orders
Figure 2. Sample Orders
RT: Evaluation for therapeutic programming to improve
(leisure skills, community skills, strength, endurance, range of motion, behavioral
symptoms, safety in community, mobility, risk of falls, mood, social skills,
adaptation to loss of___________, use of adapted equipment, etc.).
RT: Exercise for function program 30 minutes q
day 5 x q week for four weeks for increased endurance and strength.
RT: Community reintegration program 30 minutes
q day 5 x q week for 4 weeks for improved IADL functioning.
RT: Therapeutic cooking program 15 minutes q day
5 x q week for improved IADL functioning.
RT: Sensory stimulation program 15 minutes q day
5 x q week for improved cognitive functioning.
RT: Air mat therapy 20 minutes q day 5x q week
for reduction of agitation.
RT: Wheelchair biking program 60 minutes q day
5x q week for reduction of symptoms of depression.
RT: Outdoor therapeutic walking program 30 minutes
q day 5x q week for eight weeks for improved sleep.
RT: Aquatics therapy 30 minutes q day 5 x q week
for 4 weeks for improved mobility.
RT: Relaxation therapy 20 minutes q day 5 x q week
for 4 weeks to reduce anxiety symptoms.
RT: Falls prevention group 30 minutes q day 5 x
q week for 10 weeks for falls reduction.
Article reprinted with permission of the author. All rights reserved.