Abstract
In her presidential address at the American Occupational Therapy Association’s 2017 Annual Conference & Centennial Celebration, Amy Lamb honored occupational therapy’s past and embraced its future. Occupational therapy practitioners have the power to serve as change agents, demonstrating their value during everyday opportunities as they design the future of occupational therapy.
Amy J. Lamb, OTD, OT/L, FAOTA
The profession of occupational therapy is powerful! The use of occupation as a therapeutic medium has grown. Evidence supports the effectiveness of occupational therapy, which is a remarkable tribute to the profession’s founders. Their wisdom and vision has made an impact on generations of practitioners and those whom we serve for a century. Today, we honor our past and embrace our future. We embrace the ability within ourselves and our profession to be powerful in our everyday actions.
A Strong Foundation for Occupational Therapy
The Centennial served as a great excuse to dive into the occupational therapy archives. I found that some questions do stand the test of time, such as what one should wear at the national convention. In the 1940s, the American Occupational Therapy Association (AOTA; 1947) newsletter noted that for play, attendees should consider bringing cotton frocks, playsuits, and a swimsuit; for business, sport suits of lightweight wool gabardine; and for fun, a dressy suit and bonnet for teas, cocktails, and dinner. What to pack when traveling to attend our annual conference has certainly changed over the years. The question, however, is timeless, as demonstrated by the many conversations on social media in the past few weeks about what to wear in Philadelphia.
Clear Visions to Guide the Path for Occupational Therapy
Our profession has obviously changed beyond the differences in what AOTA members found fashionable 70 years ago. As I pored over the archives, it was easy to see how the profession has evolved over the past 100 years. What stood out were the clear visions of our occupational therapy leaders. These visions supported our frontline practitioners in not only creating real and meaningful change in society but also transforming the occupational therapy profession. Today, we celebrate not only the leaders of our past but also the practitioners in the field who worked to harness the everyday opportunities to create change, to make visions become a reality, and to truly transform the profession while transforming their clients’ lives.
Eleanor Clarke Slagle
Eleanor Clarke Slagle was a true pioneer in occupational therapy. In the opening ceremony, we paid tribute to Slagle and the impact her leadership had on the occupational therapy profession. What stands out to me about Eleanor is her confidence and strength. It is clear she was a force to be reckoned with. She was a strong woman at a time when women did not have the rights or opportunities that they have today. She clearly owned her power and was confident in what she knew to be right. As a female leader, I find her accomplishments to be an inspiration to each of us as we work to advance the profession she pioneered.
Wilma West
As I continued my archival journey through the first century of our profession, the strong leadership of Wilma West jumped right off the page. Much of her leadership was during the civil rights movement, a time of turbulence and change. Advocacy efforts led to the Civil Rights Act of 1964 (Pub. L. 88-352), Voting Rights Act of 1965 (Pub. L. 89-110), and amendments to the Social Security Act that established Medicare and Medicaid (Pub. L. 89-97). Simultaneously, leaders of the profession were moving occupational therapy to emphasize science and theory and prove the legitimacy of the profession as well as to examine paths of opportunity in these newly expanded areas of medical rehabilitation.
In 1967, Wilma West delivered the Eleanor Clarke Slagle lecture as the profession celebrated its 50th anniversary (West, 2011). She spoke about our collective professional responsibility of determining our future and of being active agents in determining what that future holds and in the reorganization of health and medical care in the United States. These conversations parallel many of today’s discussions surrounding the need to reduce health care costs, reduce disease and disability, increase access to care, and raise the health standards for all Americans.
Wilma clearly explicated that as a profession, occupational therapy must stop resisting change. She recognized that change is uncomfortable and that at times occupational therapy is slow to adjust to new developments, but she encouraged taking occasional risks. These risks were important steps in enlarging our role in serving people’s health needs. The profession responded, occupational therapy practitioners captured the vision and found opportunities in the new systems that were developing, and as a result occupational therapy as a profession advanced.
Elnora Gilfoyle
Fast forward to 1984, when Ellie Gilfoyle delivered her Eleanor Clarke Slagle lecture titled “Transformation of a Profession.” I find her words especially meaningful. She said, “Occupational therapy is in a period of transformation, a paradigm shift, which is a shift in thinking about old concepts. Paradigm shifts are similar to upward spirals that transform perceptions of the present into new perspectives” (p. 575).
Ellie spoke about the opportunities for transformation to occur within the profession and the policy changes that opened a door for occupational therapy in the educational system. Ellie was one of many who shared this vision of occupational therapy as an education-related service. AOTA supported this transformation with the development of Training Occupational Therapy Education Management in Schools (TOTEMS) to further educate and prepare the workforce to meet the needs of students in educational systems across the country. The message fueled occupational therapy practitioners across the country to take action and make this vision a reality.
A Centennial Vision Is Born
The decade of the 1990s and the first several years of the new millennium were fueled by discussions about the need to refocus on occupation, to recognize the impact of policy on practice, and to build the science and evidence for the profession. After organization-wide feedback and dialogue, the 2006 Vision Summit took place, at which participants from all parts of the profession, as well as external stakeholders, identified elements critical to a shared vision for occupational therapy. We all know it by now, don’t we? “We envision that occupational therapy is a powerful, widely recognized, science-driven, and evidence-based profession with a globally connected and diverse workforce meeting society’s occupational needs” (AOTA, 2006, p. 613).
It is interesting that the word that often sparked the most controversy in the Centennial Vision was powerful. As a profession, we were somewhat uncomfortable with the word power and what it might imply, as though power is negative. As with many things, power can be used in positive and negative ways. I turn back to our early pioneer, Eleanor Clarke Slagle. It is inspiring how she used her power so eloquently in the early days of our profession. I believe we have embraced our use of power, and we are no longer uncomfortable with it. Instead, it has proved pivotal in building occupational therapy’s capacity as a profession.
Perhaps one of the Centennial Vision’s best legacies is how it brought the volunteer leadership, membership, and staff together to work toward a common goal in our efforts to advance the profession. We have enjoyed great success and a coming together of the profession in the past 11 years.
It is vital to recognize that the Centennial Vision was a success, not only because of the leadership within the profession but also because of the students, practitioners, educators, and researchers who all came together to work toward this common vision. It was the ability to see the opportunities and take action that led to our success.
Moving Forward Into Our Second Century With Vision 2025
As we celebrate our 100th anniversary, the growth of our profession, and the success of the Centennial Vision, we must also recognize that this is a pivotal time for occupational therapy. As we see the growing societal needs around us, we must identify paths for the future and actions to move forward. Some of what brought us to this point may not be what is needed to take the profession of occupational therapy into the future.
We must continue to build on our knowledge and tools from the past to create an even stronger path for our future as we journey to 2025 with a clear vision: “Occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living” (AOTA, 2017c).
Transformation Ahead
This pivotal time means that once again, we are in a period of transformation. Many of us may find ourselves holding on to familiar ways as a means to cope with workplace chaos. The words of Ellie Gilfoyle are as true today as they were in 1984:
Through this transformation period, if occupational therapists operate within a closed system, we are doomed to regress. If we enlarge our awareness to include social, economic, and political factors; admit new information from a variety of sources; and take advantage of the capacity to integrate past and present perceptions and concepts, we will leap forward. (Gilfoyle, 1984, p. 576)
Last year, I asked each of you to revisit what brought you to the profession of occupational therapy and lean on that passion to be an influencer of change (Lamb, 2016). Today, we must harness our influence, be open to new ways of understanding, and drive the transformation that will push the profession of occupational therapy to make Vision 2025 a reality.
Why is transformation necessary in occupational therapy? Occupational therapy practitioners are feeling pressure and uncertainty as a result of rising productivity standards, changing payment models, increased administrative demands, and the need to demonstrate our value not only to clients but also to organizations. Burnout among our workforce threatens client centeredness and quality.
AOTA has heard you and is working to develop the tools you need as a practitioner to facilitate creating an environment that supports you to make decisions that are in the best interests of clients and their occupational needs. AOTA has published an expanded list of inappropriate and potentially unethical practices that affect occupational therapy in skilled nursing facilities (AOTA, 2017a). This informs members of the ways in which some providers may be taking advantage of occupational therapy professionals to maximize reimbursement. We are not stopping there; we are working to develop additional materials to support practitioners with advocacy efforts to challenge these questionable practices.
Focus on Occupation
Some of you may ask, “Why talk about this here?” I believe that to show the need for transformation, we must examine the reality for frontline practitioners. As a means to hit unrealistic productivity standards, the use of occupation as the therapeutic medium has been compromised. Quality has been compromised by environmental pressures. Evidence for this is found by looking at our coding data, which show that the top two intervention codes used by occupational therapy practitioners are those for therapeutic exercise and therapeutic activities. These codes are not the ones that most accurately reflect the distinct value of occupational therapy. This endangers the profession and our clients.
When occupational therapy interventions lack links to occupation, we give up our distinct value to the people, populations, and communities we serve. As health care and educational systems face decreased revenue, they look to invest their limited resources in services that provide the highest benefit for the lowest cost. It is about quality, not quantity. We must hold on to the core belief that quality occupational therapy practice is anchored in the meaningful, necessary, and familiar activities of everyday life. That is our distinct value, and to remain vital we must demonstrate this value every day.
Today, we acknowledge the challenges that exist. However, we cannot succumb to them. Instead, we move to action and find ways to transform. The opportunities to act are all around us, often hidden in the routine of our daily work. We find administrators in our organizations who are interested in advancing client-centered care and tell them how occupational therapy does this. We find physicians who want to keep clients out of the hospital and tell them how occupational therapy can help. We find teachers looking to provide all students with equal opportunities to learn and support them in integrating universal design to build accessible classrooms.
We see the needs in our local community and develop a private practice to help meet those needs. As faculty, we step outside of the classroom and partner with local agencies to show the distinct value of occupational therapy in traditional and nontraditional areas. As researchers, we find opportunities to demonstrate the impact of occupational therapy services on population outcomes. These actions are not reserved for the select few but are open to us all as we take advantage of the opportunities in our everyday work to drive meaningful transformation in our practice, education, and research.
Enhancing Quality
Quality initiatives provide an opportunity for transformation in occupational therapy. Many of us have found ourselves serving as advocates for loved ones, whether they were in need of health care services or additional supports for success in an educational environment. We are fortunate that our background has well prepared us to know what questions to ask, when to ask them, and whom to ask. We understand how to navigate these complex systems. We know that quality care is not a guarantee. We recognize that to ensure our loved ones receive the highest quality of services, we must be persistent in our advocacy efforts and do what is needed to ensure accountability and quality. As providers, occupational therapy professionals can make a difference.
Quality occupational therapy practice is client centered and anchored in meaningful occupation. It begins with putting the client first, seeing each client as the most important person in the room when you are with him or her, and showing that you care about what is meaningful to the client. I am proud that many of you share this perspective. We cannot lose sight of who our clients are and what they need to do, want to do, and have to do. Regardless of the pressures and chaos that may surround our daily work, the client must be at the center of occupational therapy.
Quality occupational therapy starts with the evaluation and providing clients with the right services for the right duration at the right time. Our new evaluation codes are helping to promote quality occupational therapy by using terminology consistent with the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014) and requiring an occupational profile to better understand the client’s needs. Finally, the evaluation code language shows others the full scope of occupational therapy practice and recognizes the importance of clinical decision making. Changes such as these are not easy to implement, and AOTA is here to help. In addition to webcasts that walk you through the ins and outs of the new evaluation codes and process, AOTA (2017b) also developed the Occupational Profile Template to support you in better understanding the needs of your client in the evaluation process.
The new evaluation codes reference the development of the plan of care as the final step in evaluation. Here we can show the specialized skills that occupational therapy uses to achieve desired outcomes. This means that the interventions we use daily must be focused on occupation, on facilitating participation and engagement in the meaningful, necessary, and familiar activities of everyday life. This is what sets occupational therapy practitioners apart from other interprofessional team members, and we must not let go of it. Instead, we must articulate this distinct value, demonstrate it in our practice daily, and capture it in our documentation. It is for this reason that occupation is at the heart of AOTA’s quality agenda and clients and their occupational needs are at the center of occupational therapy.
Quality in Practice
AOTA member Izel Obermeyer is celebrating her 30th year as an occupational therapist. She is Director of the Assistive Technology Program at Westchester Institute for Human Development (WIHD) in Valhalla, New York, where she showcases the power of client-centered occupation-based practice. Occupation is the foundation of Izel’s work in the Assistive Technology Program. Therapists in the program are less concerned about the label the client comes in with. Instead, their approach is “You tell us what you would like to do, what you are struggling with, or what is preventing you from doing the activities you want to do, and we will find the technology to help you accomplish that.” The quality lies in being truly client centered, with the focus being on performance of activities of choice or occupation.
The institute has been involved in smart technology initiatives for years, to enable better access for people with disabilities, including the WIHD/RIX Wiki Multimedia Advocacy initiative. Izel is the project leader for this initiative, with global partners working to bring this technology to North America. This technology gives choice and voice to the client and creates an avenue for communication among service providers, clients, and their families to ultimately improve clients’ quality of life. A brief clip about her project is available at https://youtu.be/ZQcIHr2RF9c.
As Izel says, “It doesn’t get more OT than that!” Izel’s daily work is guided by her belief that the future of our profession is dependent on each one of us bringing our best to our everyday work—remaining rooted in the theory, but excelling in our practice and blending our clinical work with solid evidence and embracing all opportunities, whether they come your way or you make them yourself.
Population Health
Vision 2025 expands on quality occupational therapy to extend its reach to all people, populations, and communities (AOTA, 2017c). Population health is focused on “the health outcomes of a group of individuals, including the distribution of such outcomes within the group” (Kindig & Stoddart, 2003, p. 367). It is commonly linked to the Triple Aim of health care: to improve the quality of health care services, improve efficiency of the system, and decrease costs. Population health is an important area for the profession of occupational therapy as we move toward Vision 2025. As we examine opportunities and potentials in population health, let us consider opportunities with the aging population.
In examining the needs of the aging population, we know the following: Baby boomers are increasing in number, life expectancy and diversity are increasing, chronic disease is the primary driver of rising health care costs, and finally, research shows that disability and decline do not have to be an inevitable consequence of aging.
Studies show the majority of older adults want to age in place; they want to live in their own home and community safely, independently, and comfortably regardless of age, income, or ability level. From an occupational therapy population health perspective, perhaps the greatest area of unmet needs for older adults today is the ability to age in place and chronic care management.
In the book Being Mortal, Atul Gawande (2014) captured clearly what older adults seek in their later years: “All we ask is to be allowed to remain the writers of our own story. . . . We want to retain the freedom to shape our lives in ways consistent with our character and loyalties” (p. 219). All too often we, as occupational therapy professionals, find ourselves in environments in which the wants and needs of our older adult clients are not at the center of decision making. Occupational therapy can transform the way in which we approach this population. We can be their voice, we can help modify homes and apartments to support aging in place, we can create communities that support participation and engagement, and we can help keep older drivers safe. We can give them a voice and a choice as they write the ending to their story.
Population Health in Practice
Elizabeth Hart is an AOTA member and occupational therapist at Carol Woods Retirement Community in Chapel Hill, North Carolina. The community takes an interprofessional approach with older adults across the continuum of care. From a population health perspective, she often has the opportunity to work on projects aimed at improving the well-being of residents. Elizabeth is breaking down the perception that population health is an emerging practice area found only in nontraditional roles or settings. Elizabeth empowers her clients with a set of tools to tackle whatever health challenges might arise rather than just trying to fix the problem that brought them to her.
She promotes the role of occupational therapy not only in direct service provision but also in consultative roles that extend her reach into the broader community to equip clients for success in managing health-related issues. Elizabeth knew this setting had the potential to support her broad view of practice, with an emphasis on client-centered care, collaboration, and innovative practice. So although Carol Woods historically had only one full-time occupational therapist, she wrote the director a letter outlining how the organization and clients would benefit from a more robust occupational therapy presence. Several months later, she was hired part time and immediately worked to expand the role of occupational therapy as she documented the needs of the community, how occupational therapy could contribute to the solution, and examples of success stories.
A series of purposeful actions led to Elizabeth’s success. For example, an opportunity arose when a social worker sent out a mass email asking for feedback on a cognitive impairment support group he ran for residents. Elizabeth shared a handout on everyday occupational strategies for dealing with memory impairment. He invited her to present at the next meeting, and residents were so enthusiastic about her contribution that she became a regular participant. Elizabeth’s contributions make a difference. As one resident shared, “I may not be able to improve my memory, but this group is teaching me ways I can manage with the memory I have.” Today, Elizabeth is full time at Carol Woods as a result of her actions one person, one interprofessional interaction, and one day at a time. She knows that everyday practitioners making the most of everyday interactions will demonstrate occupational therapy’s distinct value to the people, populations, and community they serve.
Occupational Therapy in Evolving Systems
To ensure our relevance in the evolving health care system, occupational therapy practitioners must be able to use data in articulating and demonstrating our distinct value. We must demonstrate best-practice processes that lead to improved outcomes that are important to those we serve, the organizations we work within, and the payers for the services we provide. It is about knowledge translation and applying the evidence in our daily work to improve the health of people and populations served and enhance the quality of service delivery. In September, an independent study by health policy researchers published in Medical Care Research and Review reported that occupational therapy was the only health care category in which additional spending had a statistically significant association with lower readmission rates (Rogers, Bai, Lavin, & Anderson, 2016). What set occupational therapy apart was the immediate focus on patients’ functional and social needs in the determination of whether they were ready to be safely discharged to their preferred environment.
It is here that we find the distinct value of occupational therapy in hospital systems seeking to improve quality of care by preventing costly readmissions. It is the frontline practitioners at hospitals across the United States who are translating this knowledge into their daily work. They further demonstrate the distinct value of occupational therapy in the acute care setting while showing the value of occupational therapy on the interprofessional team as they work to enhance quality and reduce health care spending. Although this evidence is still relatively new, AOTA is working to equip frontline practitioners, rehabilitation managers, and organization and industry leaders and to show how the translation of this knowledge into practice can be a cost-effective part of the health care solution.
Each of our organizations is filled with opportunities to transform occupational therapy practice. Change is occurring all around us; we can speak up and be a part of the change and showcase occupational therapy’s value, or we can sit back and let the change happen to us. I appeal to each of you to step forward and be a part of the dialogues that are occurring in your organization and be a part of the change.
I recognize that it can feel overwhelming. The founders of our profession did not wait until the path was clearly outlined and open before them. Instead, they moved forward to better serve the health care needs of those in the society around them. We must learn from their example. Each day we encounter the things we love about our profession and the things that need to change. At times, what needs to change seems so complex that it is tempting to accept the status quo. It is at these moments that we must remember that one person can indeed make a difference; we have the ability to influence others.
AOTA is here for you; we are your professional home and are working to support you in taking action on these everyday opportunities. Today AOTA is more than 61,000 members strong. Membership provides the resources necessary for AOTA to advance and protect the profession. More members equal more reach. Some of you may be attending Conference for the first time in a long time. Welcome back! We hope you find value in what you are seeing and hearing. I urge you to share the message about what AOTA is doing with colleagues who may not be members. Invite them to join and be a part of the solution. I cannot imagine what it would be like to navigate the chaos of the health care and education environments today without the resources AOTA provides its members. A powerful workforce is an informed workforce, and information drives transformation.
The Journey Ahead
It is time for us to set the path for occupational therapy’s future. It is time to stop just following the trail of insurance and reimbursement, for where that path may lead us we do not know. We must begin innovating in our daily work. Innovation is less about generating brand-new ideas and more about knocking down barriers to make those ideas a reality. Each of us must prioritize delivering high-quality occupational therapy services to show our value. It is then that other professionals within our organizations and larger systems will see exactly what occupational therapy has to offer.
As we embark on our second century, a big vision lies before us. It will undoubtedly be a series of small actions each of us takes every day, every week, and every month that leads to innovation and transformation. Today I am asking you to join me in taking action. I ask for open minds as we examine new ways to prepare occupational therapy professionals for the future, as we translate evidence into practice to more clearly demonstrate the value of occupational therapy in our daily work, and as we further explicate the role of occupational therapy with populations and communities to enhance quality of life.
This journey of change and transformation is one that we will travel together as I work to support you in taking action in your practice, educational program, or research lab. Earlier this week, the Representative Assembly approved a resolution that reaffirms our commitment to occupation-based practice, recognizing that it is the heart of occupational therapy and that our profession must work to reduce barriers that interfere with occupation-based practice and affect the quality of services provided.
Over the past year, I have had several colleagues reach out for advice on a variety of challenges that arose in their work environments. Some are trying to navigate systems change; all are trying to be ethical, occupation-based practitioners. Although I have individually offered mentorship and guidance, it occurred to me that they needed something more. They needed a network—a group of like-minded occupational therapy professionals, action-oriented people who are not interested in the status quo, people who want to practice in the way they know is best for the client. I brought this group of powerful and dynamic professionals together to broaden their connection and strategize about how to increase the use of occupation in practice and enhance quality. The group strategizes about the use of innovation in meeting society’s occupational needs and navigating systems change. I’ve called it #OccupationCircle. I believe this networking and mentoring is vital, whether what we are seeking is ideas, knowledge, encouragement, or inspiration, putting ideas for innovation to action.
Many of you have this same ability, and I hope you will join me and form your own occupation circles within your network as we take action to unlock the potential of everyday opportunities that surround us in our daily work. I invite you to join me in committing to a year of coming together with colleagues who want to be a part of transforming the profession of occupational therapy for its next century. Build each other up, strategize to overcome barriers, be change agents, and create occupation circles in your practice settings or with like-minded practitioners in your area; reach out to your local community and offer your support to others as they work to drive change in their organizations.
I’m also pleased to announce that, beginning in April, we are launching monthly AOTA Membership Appreciation Plus calls. Knowledge is power, and at AOTA we want to equip you, our members, with meaningful knowledge that will inform your practice and equip you to take action to innovate and show the distinct value of occupational therapy. Topics will focus on where occupational therapy can further demonstrate its distinct value and on successes, challenges, and strategies to support members in their daily work. Our membership appreciation event that occurs annually in November has grown in popularity, and we are responding by giving you even more value. April’s Membership Appreciation Plus call will focus on the new occupational therapy evaluation codes and highlight how to use the AOTA occupational profile template in your practice. Details on how to participate will be coming soon, and I hope you take advantage of these opportunities.
Closing
As we conclude our time together, I would like to share a few additional words with you from our fearless pioneer leader Eleanor Clarke Slagle in a 1937 editorial titled “From the Heart”: “The integrity of your profession is in your hands. I bid you all Godspeed in your work” (p. 345). Today, as we leave this hall, let us remember that the integrity of occupational therapy is indeed in all of our hands, and our commitment to demonstrate the value of occupation in our daily work protects the integrity of the profession. In addition, each of us has the power to create real and lasting change. Let us see the opportunities around us and choose to step forward and take action to transform the profession of occupational therapy to a higher dimension.
Thank you for being here today; it is an honor to serve as your President.