Abstract
Reilly’s (1962) now deeply cherished statement that “man, through the use of his hands, as they are energized by mind and will, can influence the state of his own health” (p. 1) was followed a few years later with a question to current and future occupational therapy practitioners. In 1966, Reilly asked how the profession would respond to the challenges of an expanding knowledge base, accelerating health care costs, and escalating regulatory burden. Visionary Wilma West, a contemporary of Reilly’s, expanded on these themes by focusing on ways occupational therapy practitioners could leverage the breadth and depth of their practice to confront these challenges. These issues are now paramount in the primary care arena. An expanding body of literature, including the articles in a special section in this issue of the American Journal of Occupational Therapy, supports occupational therapy’s role as a vital part of the solution to contemporary health care challenges. Occupational therapy practitioners are educationally prepared and successfully poised through policy to engage in evidence-based practice in the primary care environment.
Katie Jordan, OTD, OTR/L
In her 1966 presidential address, “The Occupational Therapist’s Changing Responsibility to the Community,” Wilma West (1967) encouraged occupational therapy practitioners to critically consider established roles in health and social systems. Later, West (1968) argued for their professional transformation from therapist to health agent, which she defined as a combination of evaluator, consultant, supervisor, and researcher who would amplify occupational therapy’s impact. In reframing the scope of occupational therapy, she emphasized its capacity to contribute to comprehensive health and well-being, promote prevention, and assist in early identification of risk for disease and disability. Many visionaries followed her lead, and the volume of publications building on the concept of occupational therapy in health promotion, prevention, and wellness began to expand exponentially.
West’s (1968) reframing of the occupational therapy practitioner as a health agent is particularly salient to the roles that occupational therapy practitioners can hold in contemporary primary care environments. Primary care, which can be defined as integrated, accessible, and collaborative health care delivered by providers who are responsible for the majority of a patient’s health care needs, is a field with great breadth and depth (Institute of Medicine, 1994; Patient Protection and Affordable Care Act, 2010 [Pub. L. 111-148]). Primary care is generally the first point of contact with the health system, and providers who deliver care across the life course must also coordinate all aspects of care, including other providers at different levels of the system (Starfield et al., 2005; World Health Organization, 2019).
To meet the ongoing and growing demands of primary care, a team-based model that leverages practitioners’ unique strengths must be the standard of care (Wright & Katz, 2018). In this issue’s special section on occupational therapy in primary care, Winship et al. (2019) identify issues in primary care, including workforce shortages, limited time, and a lack of resources, that could best be supported by a team-based model that includes the skills of an occupational therapy practitioner. In fact, health systems with comprehensive, team-based primary care result in improved population health, lower costs, and increased provider satisfaction (Weidner et al., 2018).
Leveraging Our Strengths and Increasing Our Capacity in Primary Care
Occupational therapy leaders, along with American Occupational Therapy Association (AOTA) staff, have worked to leverage the match between occupational therapy practice and health care priorities, paving the way through legislative, reimbursement, and policy victories for occupational therapy practitioners to become meaningfully engaged in primary care settings (Saffer, 2018). Primary care occupational therapy practice must be supported by evidence, but for occupational therapy practitioners to thrive in primary care, five distinct prerequisites must be firmly established.
First, occupational therapy practitioners must be able to evaluate and treat the whole person, which includes addressing health promotion, physical health, mental health, and environmental barriers and supports. The successful 2017 implementation of new CPT ® occupational therapy evaluation codes (American Medical Association, 2019) solidified the significant breadth of occupational therapy as including an occupational profile and the evaluation of physical, psychosocial, and cognitive skills. Moreover, the scope of occupational therapy practice, as defined by the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; AOTA, 2014a), is broad enough to address health and wellness concerns relevant in any primary care setting.
Second, occupational therapy practitioners must be identified as valuable members of the comprehensive primary care team. Inclusion of occupational therapy in Alternative Payment Models has expanded the visibility and evidence base for occupational therapy’s role in community and primary care settings (Halle et al., 2018; Szanton et al., 2014). Legislative wins have made it possible for the Substance Abuse and Mental Health Services Administration to include occupational therapy in the mental and behavioral health workforce (Protecting Access to Medicare Act of 2014 [Pub. L. 113-93]). In addition, recent legislation has recognized occupational therapy’s distinct value in pain management as a means of addressing the opioid crisis (Comprehensive Addiction and Recovery Act of 2016 [Pub. L. 114–198]; SUPPORT for Patients and Communities Act [2018; Pub. L. 115-271]). Pape and Muir’s (2019) Health Policy Perspectives column in this issue, which explores the Patient-Centered Medical Home model of care, expands the viewpoint of where occupational therapy might best be situated to meet primary care needs and the challenges and solutions to occupational therapy integration in these comprehensive care environments.
Third, occupational therapy primary care services must be accessible to consumers. AOTA is committed to promoting the integration of occupational therapy into community and primary care settings. Successful advocacy recently resulted in the permanent removal of the outpatient occupational therapy cap and deletion of functional limitation reporting to expand access to occupational therapy services and reduce administrative burden (AOTA, 2018b; Centers for Medicare & Medicaid Services, 2018). Continued advocacy to support the use of technology such as standard telehealth and emerging telemonitoring technologies is expected to further extend access and opportunities for occupational therapy practitioners to engage with consumers and providers in the community (AOTA, 2014b; Christensen, 2018).
Fourth, to bolster a sustainable future for the profession in primary care, occupational therapy students must be educated on their potential roles and responsibilities in this practice setting. Last year, AOTA (2018b) published a seminal document toward this aim. The document acknowledged the need to educate entry-level students on occupational therapy’s distinct contribution to primary care within the health care delivery system, and it framed the abilities needed to practice in diverse primary care settings with individuals, groups, and populations across the life course as the skills of a master generalist. In the special section of this issue, Halle et al. (2019) explore student learning on geriatric primary care teams and discuss the value of interprofessional education in pursuit of improved primary care processes and outcomes.
The Accreditation Council for Occupational Therapy Education (2018) recently released its revised Standards and Interpretive Guide for occupational therapy education (effective July 31, 2020). Along with adding a definition of primary care programs that reflects currently accepted definitions of primary care, the new guide includes standards meant to support occupational therapy’s role in community and primary care programs and services. The inclusion of standards supporting occupational therapy in primary care will help promote the future of our profession in this practice setting.
Knowledge Mobilization for Primary Care
In addition to these four prerequisites, a fifth—mobilization of the evidence—is required for occupational therapy to thrive in primary care settings. A critical mass of evidence has accumulated that demonstrates the efficacy, cost-effectiveness, and impact of occupational therapy with individuals, groups, and populations in primary care settings (Hart & Parsons, 2015). Most important, the evidence supports occupational therapy as a critical element of care that achieves the “quadruple aim” of health care reform: (1) improved patient experience, (2) better individual and population health, (3) reduction of costs, and (4) enhanced work life and health of providers and staff (Bodenheimer & Sinsky, 2014). Evidence directly supports practitioners’ distinct role in addressing the needs of three key primary care populations—geriatrics, pain management, and pediatrics.
Geriatric Care
The Centers for Disease Control and Prevention (CDC; 2013) projects that by 2030, older adults will represent 20% of the U.S. population. The need for coordinated, cost-effective, and comprehensive primary care is increasingly salient, given the substantial resources needed to efficiently and effectively care for an aging population (U.S. Department of Health and Human Services [HHS], 2010). The majority of adults older than age 65 report having multiple chronic conditions, resulting in disproportionate utilization of health care resources (HHS, 2010; Leland et al., 2017).
Contributing to the burgeoning body of knowledge on occupational therapy’s efficacy in the prevention and management of chronic conditions, Pyatak et al. (2019) provide evidence in their article in the special section of this issue that supports the integration of occupational therapy into primary care to address diabetes management. Comprehensive care models that include occupational therapy have demonstrated positive clinical outcomes and improved participation, self-efficacy, and quality of life (Garvey et al., 2015). Moreover, with the integration of occupational therapy into primary care models, prevention and prehabilitation services, such as Lifestyle Redesign®, could promote healthy aging and cost effectively reduce the risk of age-related health declines (Clark et al., 1997; Hay et al., 2002).
Pain Management
As much as 55.7% of the U.S. adult population reports experiencing pain on most days, a chronic issue that results in a large proportion of primary care visits (Schneiderhan et al., 2017). Occupational therapy has been shown to improve quality of life, self-efficacy, and functional skills for chronic pain patients in a primary care setting (Uyeshiro Simon & Collins, 2017).
Understanding that nonpharmacological behavioral interventions are generally recommended as the first strategy to address lifestyle-sensitive health issues, in the special section of this issue Cunningham and Valasek (2019) present a case series that illustrates the impact that collaborative occupational therapy services can have on comprehensive and coordinated primary care. By improving function, promoting a return to meaningful activities (including paid work), and reducing disability claims and pharmacological dependence, occupational therapy practitioners can significantly reduce the impact of chronic conditions, including pain (Gatchel & Okifuji, 2006; Hart & Parsons, 2015). Moreover, evidence has directly linked chronic pain with the opioid epidemic, prompting the CDC publication “Guideline for Prescribing Opioids for Chronic Pain” (Dowell et al., 2016), targeted toward primary care providers. By focusing on evidence-based strategies such as self-management and functional goal setting, occupational therapy practitioners can support the recommended biopsychosocial model of pain management (Rowe & Breeden, 2018).
Pediatric Care
The American Academy of Pediatrics encourages pediatricians to screen regularly for developmental delays at well-child visits; however, recommended screening practices are inconsistently applied, and developmental delays are often not identified in time for early intervention, especially among underserved populations (Sices, 2007). Failure to conduct timely autism-specific screenings can adversely affect access to family support services and outcomes for children later diagnosed with autism spectrum disorder (ASD).
In this issue, Stein Duker et al. (2019) examine the experience of adults with ASD, caregivers, and primary care providers and uncover the challenges faced by these stakeholders in primary care. Primary care providers are expected to link patients with developmental delays or other risk factors with early intervention and support services, but they often lack the knowledge, training, or resources to create the collaborative practice necessary for a successful outcome for the child and family (Adrihan et al., 2018). In a coordinated, integrated primary care setting, occupational therapy practitioners can support the screening, evaluation, and assessment of early intervention needs and subsequently provide or connect the family with appropriate community-based care (Baranek et al., 2015).
Claiming Our Place on the Primary Care Team
Visionary Wilma West (1968) noted that the occupational therapy profession often resists change and is at risk for being left behind unless practitioners accept their breadth of scope, engage to the depth of their capacity, are trained to be leaders inside and outside of the profession, and open up to possibilities of integration into different care environments. The articles on primary care in the special section of this issue challenge the reader to consider how far the profession has come since West’s original call to action. Systemic constraints have historically molded occupational therapy practice. The profession has bent to the will of regulatory requirements, policy, and reimbursement structures.
Today in primary care, the story is being rewritten. With occupational therapy at the table for conversations regarding best practices, quality, outcome measurement, and financial models, we occupational therapy practitioners have an opportunity to capitalize on our profession’s broad identity and claim our legacy. Primary care practice creates opportunities for the profession to realize its full potential and build capacity to meet the occupational needs of individuals, groups, and populations in the context of their daily lives and in the worlds in which they work, play, learn, and live. The authors of the articles on primary care in the special section of this issue present broad views of occupational therapy practice and identity that set the stage not just for the current health care system but for what comes next.