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Center for the Future of the Health Professions Oct. 2021 digest

This month, The Center for the Future of the Health Professions is posting another monthly op-ed column for 2021. Our columns represent strong, informed, and focused opinions on issues that affect the future of the health professions. As mentioned in the past, the center was developed to provide state, local, and national policymakers and health system stakeholders with accurate, reliable, and comprehensive data and research about the healthcare workforce, so they can effectively plan for a sustainable future and make the best use of available resources.

This month features a discussion around the occupational therapy (OT) profession in the U.S. Despite its long history in western medicine and healthcare, it is not a well-understood profession, even among interprofessional healthcare teams. This article will discuss the profession, why it is important to the occupational health of U.S. citizens, and where it is going. The author, Jyothi Gupta, PhD, chair and professor, department of occupational therapy, A.T. Still University (ATSU) in Mesa, AZ has extensive experience in academia and higher education in occupational therapy. She has expertise in successful accreditation, curriculum development, program development, faculty mentoring, and managing complex programmatic issues. She is also the coauthor of Understanding Policy Influences on Health and Occupation Through the Use of the Life Course Health Development (LCHD) Framework in the American Journal of Occupational Therapy (2020) and coauthor of the textbook Culture and Occupation: Effectiveness for Occupational Therapy Practice, Education, and Research (2016) by AOTA press.

Occupational therapy (OT) in the U.S. celebrated its centennial in 2017. Despite its long history in western medicine and healthcare, it is not a well-understood profession, even among interprofessional healthcare teams. Many reasons may be attributed to this lack of clarity as to what OT has to offer. Perhaps the word occupation makes people think it is ‘work’ therapy, and therapists help people get employment. This is understandable since the term ‘occupation’ commonly denotes a job or a profession. The Merriam-Webster dictionary also defines occupation as an activity in which one engages. The profession’s use of the term occupation refers to how we ‘occupy’ our time; in short, everything we do in our daily lives, such as self-care, domestic life, interpersonal interactions and relationships, and major life areas such as work and education (AOTA, 2020a). Secondly, given the broad scope of practice in diverse settings, the profession’s scope is often defined by practice that pertains to a specific location. For example, in most hospital settings, practice is focused on activities of daily living (ADLs), so much so that this practice focus defines OT. Essentially, occupational therapists (OTs) assist people with injuries and disabilities to adapt and function in their environment and maintain their quality of life through participating in meaningful and purposeful activities (AOTA, 2020a).

The fundamental belief of the profession is that everyday living and the multitude of occupations we engage in across our life span influences our health and quality of life. The philosophy and outcomes of OT are well aligned with the World Health Organization’s view of health as not merely the absence of a disease but the ability to participate in life activities (WHO). Occupation is, therefore, a health determinant, and the environment determines the access and opportunities to health-promoting occupations.

The profession’s broad scope of practice encompasses physical, mental, and behavioral health concerns. OTs practice in many diverse contexts through healthcare and education are the primary settings. According to the 2019 AOTA Workforce survey, the most common primary work setting for OTs is hospitals: 46% of OTs work in urban areas, 39% work in suburban areas, and the remaining 15% work in rural areas. The most common secondary work setting is skilled nursing facilities. Pediatric OTs practice 15% in the school system and 4% in early intervention programs. Historically, OT started to provide WWII veterans with activities to ‘occupy’ their time in mental institutions. It is unfortunate that today, despite the overwhelming need, only 2% of OTs in the U.S. work mental health (AOTA, 2020b).

OT education at ATSU

The OT department at ATSU’s Mesa, Arizona, campus was the first OT program in Arizona (1995) and offered the master of science in occupational therapy degree. At present, it is the only department in the state that provides the two entry-level degree options of a master’s degree and a clinical doctorate (OTD). It is also the only doctoral program in the country with an embedded public health certificate within the OTD curriculum. This motivation is to align the curriculum with the university’s mission, the compatibility between public health and OT, and the contribution ATSU graduates can make for population health, systems changes, and advocacy. The progressive curriculum at ATSU prepares graduates for current practice and introduces them to novel systems and community contexts where OT can make a substantial impact. Some examples of systems that can benefit from OT will be discussed below. The barrier to practice in these areas is payment for services.

Primary care settings

Efforts to contain healthcare costs and improve quality of care have changed reimbursement based on fee-for-service to health outcomes and care quality. Achieving the quadruple aim of improving population health, cost, the patient experience, and provider/care-team well-being require interdisciplinary care teams with the skills and knowledge to meet the wide variety of needs in primary care settings. Unfortunately, primary care providers do not yet fully understand OT’s contributions to achieving better health outcomes and improving quality of life for all (Tshuma, Gupta, Dahl-Popolizio, and Vohra; Beyond Flexner, 2020). Promoting daily life functioning with physical, cognitive, and behavioral impairments; lifestyle wellness and prevention; end of life preparation; behavioral health interventions, and chronic disease management are just a few examples. A 2016 study by health policy researchers demonstrated that increased healthcare spending was correlated with reduced hospital readmissions post-discharge with occupational therapy interventions (Rogers, Bai, Lavin, & Anderson, 2016). OT was the only profession to show positive outcomes. OTs are a cost-effective solution to enhancing health and quality of life for people with disabilities, chronic disease conditions, or age-related decline in functioning by keeping them safe in their homes. In the U.S., annual medical costs for non-fatal fall injuries are nearly $50 billion, and $754 million is spent on fatal falls (Florence et al., 2018). There is evidence that occupational therapy interventions save money by reducing the rate and risk of falls (Gillespie et al., 2012; Haines et al., 2004). OTs at community health centers can help with health promotion, prevention, and healthy lifestyle behavioral changes for their clients. This is yet a new opportunity.

Criminal justice system

The U.S. has the highest incarceration rate, and according to the Bureau of Justice estimates, the costs are more than $80 billion annually (Sawyer & Wagner, 2020). The OT profession has been slow to delineate the role of occupational therapy within criminal justice settings (Munoz, Moreton, & Sitterly, 2016). Occupational therapy can help correctional facilities, policymakers, halfway houses by developing programs for community reintegration and rehabilitating juvenile offenders to resume life occupations that will set them on a socially approved life trajectory.

OT during COVID-19

The pandemic propelled telehealth to the forefront, and like all other health professions, OTs were required to provide virtual services. Not all services can be provided in a virtual environment, more so for the pediatric population. The apparent benefit of telehealth is that OT services can reach people in remote areas. There is evidence that telehealth can be effective for remote home visits under particular contexts (Read et al., 2020). While telehealth will continue, reimbursement for virtual OT services and consumer preference may be the deciding factors.

According to the Bureau of Labor Statistics (BLS), the profession’s future looks optimistic, which projects OT to grow by 17% from 2020-30 (BLS, 2021). Despite the projected job growth rate, the profession also faces several threats. With the rising costs of healthcare and increasing demands of accountability by consumers of healthcare, the greatest challenge for the profession is inadequate research evidence. The profession lacks the research capacity and must prioritize building the next generation of researchers.  One potential is for entry-level OTD graduates to be scholar-practitioners and perform quality assurance in their places of work to produce evidence for the effectiveness of the services they provide. A secondary challenge is the acute shortage of qualified faculty. The profession must also differentiate outcomes of graduates who are master’s prepared and those with an entry-level doctorate. Factors that may impact faculty capacity building are the high cost of OT education, lack of understanding of the entry-level versus post-professional doctorates and their outcomes, and a lack of accessible PhD programs in rehabilitation sciences or related disciplines for working professionals. This can be seen as an opportunity to develop MS-PhD or OTD-PhD bridge programs to prepare the future generation of academics and researchers.

References:

American Occupational Therapy Association. (2020a). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001

American Association of Occupational therapy (2020b). 2019 workforce & salary survey.

Bureau of Labor Statistics (n.d.). Occupational Therapy Handbook. Retrieved from https://www.bls.gov/ooh/healthcare/occupational-therapists.htm

Florence, C. S, Bergen, G., Atherly, A., Burns, E. R., Stevens, J. A., & Drake, C. (2018 ) Medical Costs of Fatal and Nonfatal Falls in Older Adults. Journal of the American Geriatrics Society, 66 (4), 693-698. DOI:10.1111/jgs.15304 external icon

Gillespie, L. D., Robertson, M. C., Gillespie, W. J., Sherrington, C., Gates, S., Clemson, L. M., & Lamb, S. E. (2012). Interventions for preventing falls in older people living in the community. Cochrane Database of Systematic Reviews, http://dx.doi.org/10.1002/14651858.CD007146.pub3

Haines, T. P., Bennell, K. L., Osborne, R. H., & Hill, K. D. (2004). Effectiveness of targeted falls prevention programme in subacute hospital setting: Randomized controlled trial. British Medical Journal, 328, 1–6. http://dx.doi.org/10.1136/bmj.328.7441.676

Merriam-Webster. (n.d.). Occupation. In Merriam-Webster.com dictionary. Retrieved September 23, 2021, from https://www.merriam-webster.com/dictionary/occupation

Muñoz, J. P, Moreton, E. M,  Sitterly, A. M (2016). The Scope of Practice of Occupational Therapy in US Criminal Justice Settings. Occup Ther Int, 23(3):241-54.

Read, J., Jones, N., Fegan, C., Cudd P., Simpson, E., Mazumdar, S.,  Fabi, & Ciravegna, F. (2020). Remote Home Visit: Exploring the feasibility, acceptability, and potential benefits of using digital technology to undertake occupational therapy home assessments. British Journal of Occupational Therapy, 83(10) 648–658.

Rogers, A. T., Bai, G., Lavin, R. A., & Anderson, G. F. (2017). Higher hospital spending on occupational therapy is associated with lower readmission rates. Medical Care Research and Review, 74(6), 668-686.

Sawyer, W., & Wagner, P. (2020). Mass incarceration: The whole pie. Retrieved from https://www.prisonpolicy.org/reports/pie2020.html

Tshuma, L., Gupta, J., S., Dahl-Popolizio, and Vohra,R. (2020). Better together: Occupational therapy on integrative behavioral health teams. Presented at Beyond Flexner, Virtual conference.

World Health Organization. (2006). Constitution of the World Health Organization (45th ed.). Retrieved from https://www.who.int/governance/eb/who_constitution_en.pdf

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