Exploring Reimbursement Pathways for Lifestyle Medicine and Health Promotion Services in Occupational Therapy

Occupational Therapy’s Historical Role in Health Promotion Efforts

The notable recent decrease in life expectancy in the United States, which is directly related to unhealthy behaviors associated with substance use, obesity, poor mental health, diabetes, and hypertension, highlights the urgency to find solutions (Vodovotz et al., 2020). Occupational therapy is uniquely positioned to address these health dilemmas through lifestyle medicine, health management, and occupation-based approaches to care as an interdisciplinary field within larger health systems (Braveman, 2016). To be specific, occupational therapy’s role in health promotion can be viewed from three angles: (1) supporting healthy-focused lifestyles, (2) using occupation as a conduit for improving health, and (3) providing these strategies or interventions at both the individual and population health levels (AOTA, 2020a). Health promotion programs have been conducted and organized by occupational therapy practitioners as valued members of an interprofessional team using effective approaches, such as Lifestyle Redesign^®, weight management, activities of daily living (ADL) retraining, sleep management, and the management of multiple comorbid conditions to both improve patient outcomes and reduce health care costs (Edelstein et al., 2022; Garvey et al., 2015 ; Ho & Siu, 2018; Nielsen & Christensen, 2018; Pyatak et al., 2022). Lifestyle Redesign is a framework that has set the stage for occupational therapy practitioners to do health promotion work that centers on the interplay between everyday occupations and health, which is predicated on people’s habits, roles, and routines (Pyatak et al., 2022).

Occupational Therapy Practice Framework Connections and Justification

The Occupational Therapy Practice Framework: Domain and Process (4th ed. [OTPF–4]; AOTA, 2020b) serves as an official overview of occupational therapy practice that can be used not only by occupational therapy practitioners and students but also by interdisciplinary health care providers, educators, researchers, payers, policymakers, and consumers of occupational therapy services. This document illuminates the existing justification for and language around our distinct role in health promotion and prevention work. Therapeutic intervention approaches such as “create, promote,” which are linked to health promotion services, and “prevent,” which is used for clients irrespective of disability status, support our role as they are included within our domain of practice in the OTPF–4. Occupational therapy outcomes outlined in the OTPF–4 include prevention, health and wellness, quality of life, and well-being, all of which support and justify our efforts to be reimbursable prevention players.

More recently, the updated OTPF–4 added health management as a distinct area of occupation that includes “social and emotional health promotion and maintenance; symptom and condition management; communication with the health care system; medication management, physical activity, nutrition management, personal care device management” (AOTA, 2020b, p. 32). The addition of health management amplifies the connection to the pillars of lifestyle medicine because it encompasses social connection, physical activity, stress management, and healthy nutrition. As professionals, occupational therapy practitioners already have knowledge of the OTPF–4 language around and justification for our role as contributing prevention partners on interdisciplinary teams. The challenge is getting reimbursed for work we are already qualified to be doing and, in fact, are doing. As occupational therapy practitioners, we need to enhance our relevance and unique contributions to the right audiences, which may differ from traditional rehabilitation entities and should be expanded to include government agencies, community partners, faith groups, and charitable and nonprofit organizations (Braveman, 2016 ; Hildenbrand & Lamb, 2013). These efforts can be amplified further by incorporating language pertaining to population health, which overlaps with the work of lifestyle medicine and health promotion, into our educational standards so that understanding of our role in health promotion starts in the formative development of new practitioners (Braveman, 2016). Moreover, occupational therapy practitioners may benefit from exploration of alternative payment models (APMs), which offer incentives, most frequently to primary care practices that inherit some type of risk related to patient outcomes to promote high-quality care. Another option to consider is bundled encounter payments, whereby physicians and other health care professionals can collectively address an episode of care (Halle et al., 2018). Occupational therapy practitioner services are a component of APMs, creating the opportunity to continue to innovate in this space (Szanton et al., 2015). Several professional papers support occupational therapy practitioners’ role in health promotion and population health; however, to date there has been limited research on how they can translate their scope of practice into actual, reimbursable practice.

Inherent Value of Occupational Therapy

Occupational therapy practitioners have a well-established reputation as rehabilitation professionals who support clients with chronic diseases. In addition to rehabilitative efforts, occupational therapy practitioners are equally qualified to collaborate with other providers to prevent, through lifestyle measures, another health care episode or disease progression (Fields & Smallfield, 2022). Primary, secondary, and tertiary levels of prevention all fit within our scope of practice to implement occupation-based therapy with consideration given to the client’s habits, roles, routines, and contexts (Fields & Smallfield, 2022). Failing to reimburse occupational therapy practitioners for this work artificially constrains their full scope of practice and needlessly restricts consumer access to valuable preventive care.

Yet another area in the larger health care system that benefits from occupational therapy services is hospital readmission rates. We are trained to work with and address people’s occupational needs, which are often affected by communicable and noncommunicable diseases (NCDs), among other factors. There are a variety of NCDs, and therefore the value of lifestyle medicine interventions that occupational therapy practitioners use lies in the fact that these interventions allow not only for the treatment of chronic disease outcomes and multiple chronic conditions but also for the prevention of subsequent episodes and exacerbated symptoms (AOTA, 2020a ; Leland et al., 2017; Rogers et al., 2017). Policymakers, hospital administrators, and payers are increasingly under pressure to produce the highest quality care for the lowest cost that still meets or exceeds patients’ and providers’ expectations. Thus, these types of interventions warrant more attention to reimbursement and coverage under payer policies that use Current Procedural Terminology^® (CPT^® ) codes (American Medical Association [AMA], 2023).

A recent study supported occupational therapy’s role in reducing costs while improving patient outcomes related to hospital readmission rates (Edelstein et al., 2022). The results indicated that hospitalized patients who received acute occupational therapy services were less likely to be readmitted than those who received occupational therapy services during hospitalization, suggesting that occupational therapy services can in fact lower readmission rates in acute care settings. The interventions noted were supported by CPT codes related to ADLs and self-care training (Edelstein et al., 2022). We should note that the patients who received occupational therapy in the hospital had other comorbidities or NCDs and often were discharged to alternate living environments. The study highlighted the need to identify ways to use additional interventions and occupation-based activities with the current CPT codes, which allow for broad use and may work to our advantage with strong justification through documentation and advocacy. This hallmark study illuminates the value of occupational therapy services in helping reduce health care costs surrounding readmission rates. Moreover, it demonstrates the urgent need for occupational therapy practitioners to be reimbursed for their qualified and distinct role in implementing lifestyle medicine and health- promoting interventions that ultimately reduce costs and improve patient outcomes.

Getting the Word Out: Lifestyle Medicine Ideas for Occupational Therapy Practice

Health care providers typically have foundational and scientific knowledge of how lifestyle modifications can help treat and prevent a variety of chronic diseases; however, they often do not have the tools to relay these benefits to clients and patients (Motley, 2020). Some of the barriers practitioners face in trying to deliver lifestyle interventions (e.g., sleep hygiene, physical activity, and healthy eating) include time limitations, limited self-efficacy in coaching patients, limited support from larger health systems, and a missing infrastructure for a transdisciplinary team to collaborate on these efforts. Implementing a systemic and inclusive health promotion practice is the key to success; this can include a variety of delivery models, including private practice, academic institutions, and community-based programming. There are several ways to build a promising lifestyle medicine practice that could very well apply to allied health professionals, including occupational therapy practitioners. For example, Motley (2020) suggested several promising options, including building relationships at the local community level through public speaking engagements at locations such as libraries, churches, and health fairs. Forming a social media presence creates another avenue to spread awareness and build credibility by offering snippets of valuable information to help elicit health behavior change.

As occupational therapy professionals, we need to build relationships with primary care physicians to create a pipeline for lifestyle medicine referrals, and that requires visibility, advocacy, and attendance at local networking events (Motley, 2020). Thus, when it comes time for primary care providers to refer patients to outside services, the first discipline that comes to mind for the implementation of lifestyle interventions is occupational therapy (Jordan, 2019). In addition, using lifestyle medicine educational resources and assessments is a valuable way to engage clients and interdisciplinary team members with the language around lifestyle interventions that go hand in hand with occupations.

Currently, for occupational therapy practitioners delivering lifestyle-focused interventions, there are limited models of health care reimbursement, including fee-for-service, grant funding, and “incident-to.” Fee-for-service is used when a practitioner bills a payer source (government, commercial, or consumer) directly for services rendered. For new or emerging practices, which may not be reimbursable in fee-for-service models, grant funding may support the services, or they may be provided as part of a research, quality improvement, or clinical program development project. Practitioners may bill for services under a physician by leveraging incident-to billing for Medicare beneficiaries, if certain criteria are met. Although there are additional strategies and reimbursement models to consider, it is advantageous to use current practices offered in primary care offices, which include private practices, group visits, and individual visits under respective CPT billing codes, such as occupational therapy evaluation (97165, 97166, 97167), cognitive function (97129, 97130), therapeutic activities (97530), sensory integrative techniques (97533), and self-care/home management training (97535). 1 To build additional and sustainable reimbursement models, we first need to create a stronger awareness of our profession’s value, and we can do that by creating a presence locally to collaborate and network with primary care referral sources.

Reimbursement: Solutions, Codes, and Challenges

Some of the ways in which we can pursue reimbursement for lifestyle and health promotion services include, but are not limited to, the Prevention and Public Health Fund (PPHF), a nationwide funding source dedicated to public health programs to reduce mortality that is due to common chronic diseases; the Health Care Innovation Awards, which provide funding to organizations that develop and use innovative approaches to improving health care and reducing associated costs; and Community Transformation Grants, which offer funding through the PPHF to deliver community-based interventions (Hildenbrand & Lamb, 2013). By developing health promotion and lifestyle medicine programs in nontraditional settings and through novel payer sources, we will need to clearly articulate how and why we are uniquely poised to deliver this type of work in such a way that communicates how we improve quality of life, deliver effective care, and reduce costs (Hildenbrand & Lamb, 2013).

A recent study surveyed health care providers, including physicians, health coaches, and health educators, to determine how they are getting reimbursed for lifestyle medicine services (Jensen et al., 2018). Practice settings of respondents ranged from independent practice settings, to solo settings, to hospital settings in both suburban and urban geographic areas. The most common reimbursement pathways respondents reported were cash and insurance, employer-funded programs, and grant funding, with cash payment being the highest source. In this study, those who billed insurance used CPT codes related to preventive care, behavior modification, counseling services, and family medicine, whereas others billed via membership-driven fees. CPT code use is contingent on payer policy to determine who is a qualified health care professional (QHP) for that service. The health and behavior assessment/intervention codes (96156–96171) can be used by a QHP, depending on payer policy, which creates a potential opportunity for more occupational therapy professionals to deliver lifestyle- oriented interventions while being reimbursed. Advocacy with payers in using this CPT code set can include education about occupational therapy’s scope of practice, sharing clinical guidelines, and highlighting relevant sections of the OTPF–4. Artificial limitations due to a perceived lack of evidence to support an intervention, a poor understanding of a practitioner’s or profession’s scope, and outdated policy manuals can all contribute to a lack of coverage for medically necessary services. Given that the majority of patients are covered through a federal payer or employee-sponsored private insurance, advocacy and education are needed at the national, state, and local levels to overcome these challenges (Jordan & Sandhu, 2019).

To effectively and efficiently deliver lifestyle and health promotion services, adequate resources, support, and training need to be in place. For example, survey respondents in a recent study reported wanting more patient educational materials in a wider variety of languages, fact sheets, online learning modules, group sessions, reimbursement training, and guidelines for delivering these services (Jensen et al., 2018). These suggestions are not new for occupational therapy practitioners because we are trained to deliver patient education and create educational handouts often in the form of home programs. However, what we could also benefit from are reimbursement trainings; knowing what codes (published annually by AOTA) we can add to our reimbursement tool kit; and advocating, to primary care providers and other referring providers, that occupational therapy is part of the solution (AMA, 2021).

What’s Next? Implications for the Future

The occupational therapy profession’s scope of practice, which has a focus on health-promoting occupations and cost-effective outcomes, positions it as a key player for achieving reimbursement for lifestyle services. As the aging population increases and the number of people with NCDs continues to rise, the need for QHPs who can address lifestyle factors will also grow. Although occupational therapy practitioners already provide lifestyle interventions in many settings, we are not widely recognized as integral to interdisciplinary lifestyle medicine teams and thus need to advocate our inherent value given that shared efforts toward reimbursement can elevate all involved professions (Braveman, 2016; Halle et al., 2018 ; Leland et al., 2017). To leverage occupational therapy’s potential to be reimbursed for the provision of lifestyle services, we need to focus on long-term strategic goals that coordinate efforts across several facets of the profession to establish sustainable reimbursement models.

The translation of what health promotion could look like in practice at the individual level includes consulting; educating; adapting; and providing training in areas such as accessibility, ergonomics, home modifications, body mechanics, stress management, and independent living skills, to name just a few. At the group level, health promotion includes running group activities for older adults to prevent mental health decline, parent skills training, hosting health promotion classes for people with chronic diseases, and providing leisure-based strategies for adults with mental health disorders. At the organizational level, interventions can involve consultations in the workplace on topics such as ergonomics and stress management strategies, modification of gyms for accessibility, and development of procedures for medical equipment or assistive technology. At the community level, occupational therapy practitioners can advocate for and promote universal play structures at parks and playgrounds and conduct community screening programs (AOTA, 2001).

Advocacy, education, and professional identity and scope are key strategic areas we should focus on to achieve reimbursement outcomes for the provision of lifestyle and health management services in occupational therapy. Advocacy demands a clear understanding of occupational therapy’s capacity, domain, and skills in providing the time-intensive and longitudinal services necessary for success in helping clients make health behavior changes (Gobble et al., 2022). Successful advocacy efforts rely on practitioners’ clarity about and confidence in communicating potential roles, value, and intersection with other professions in relationship to lifestyle services. Education for future and current occupational therapy practitioners critically relates to advocacy efforts so that practitioners can clearly articulate and advocate for services (Juckett et al., 2021).

Reimbursement training related to lifestyle services and evidence-based interventions need to be included in occupational therapy educational programs as well as continuing education offerings. Such advocacy efforts can help occupational therapy play a role in larger reimbursement shifts. Moving away from fee-for-service models, for example, and toward value-based models that focus on population health may align with the Centers for Medicare & Medicaid Services’ Innovation Center priorities and drive changes in health care delivery (Gobble et al., 2022).

Last, lifestyle medicine embraces the evidence for the multidisciplinary use of a “coach approach” to providing the ongoing services needed to support patients’ health behavior changes (Matthews et al., 2022). “Coaching is the key verb in lifestyle medicine” (Frates et al., 2021, p. 46), and the coach approach is understood to help catalyze health behavior changes in patients. A coach approach moves away from health professionals functioning as experts and toward working to support patients’ self-efficacy in changing their own health behaviors (Frates et al., 2021). Health coaches are gaining ground in receiving reimbursement for services. Occupational therapy’s agility in expanding into new practice areas, which has been demonstrated in the past, can serve us well at this point if we make strategic decisions in planning, especially regarding reimbursement. These strategic decisions to serve the future of the practice may involve changes in how occupational therapy educational programs teach students about using lifestyle and health management interventions in practice, increasing continuing education offerings on occupational therapy’s role in coaching for health behavior change, and proactively advocating for occupational therapy to provide lifestyle interventions by networking with lifestyle medicine physicians. In each of these scenarios, reimbursement should be a central tenet of the education on how occupational therapy can play a vibrant role in the future of lifestyle medicine and health management service delivery.