HEALTH POLICY PERSPECTIVES

Population Health and Occupational Therapy

Brent Braveman

MeSH TERMS Occupational therapy practitioners play an important role in improving the health of populations through the

delivery of health care development of occupational therapy interventions at the population level and through advocacy to address
occupational participation and the multiple determinants of health. This article defines and explores population

health services needs and demands
health as a concept and describes the appropriateness of occupational therapy practice in population health.

occupational therapy Support of population health practice as evidenced in the official documents of the American Occupational

public health Therapy Association and the relevance of population health for occupational therapy as a profession are
reviewed. Recommendations and directions for the future are included related to celebration of the
achievements of occupational therapy practitioners in the area of population health, changes to the
Occupational Therapy Practice Framework and educational accreditation standards, and the importance of
supporting, recognizing, rewarding, and valuing occupational therapy practitioners who assume roles in which
direct care is not their primary function.

Braveman, B. (2016). Health Policy Perspectives—Population health and occupational therapy. American Journal of
Occupational Therapy, 70, 7001090010. http://dx.doi.org/10.5014/ajot.2016.701002

M uch has been written about the Triple

Aim of health care since the Institute
for Healthcare Improvement introduced
prevention as a strategy to maintain its
relevance (Hildenbrand & Lamb, 2013;
Persch, Lamb, Metzler, & Fristad, 2015)
the concept in 2007. It is often cited as a • New models of interdisciplinary team
guiding principle of health care and health practice and a vision of health care as “a
insurance reform, including the Patient coordinated system built on teams of
Protection and Affordable Care Act of 2010 professionals with many capabilities
(ACA; Pub. L. 111–148). Berwick, Nolan, and varied scopes of practice all fo-
and Whittington (2008) defined the Triple cused on achieving health” (Metzler,
Aim as “improving the individual experi- Hartmann, & Lowenthal, 2012, p. 267;
ence of care, improving the health of pop- Moyers & Metzler, 2014)
ulations, and reducing the per capita cost of • Increased use of information technolo-
care” (p. 760). Health care leaders, in- gies supported by the Centers for Medi-
cluding those in the discipline of occupa- care and Medicaid Services (CMS) and
tional therapy, have explored a range of telehealth (Cason, 2015; Moyers &
Brent
. Braveman, PhD, OTR/L, FAOTA issues and connections to the Triple Aim. Metzler, 2014)
In January 2012, the American Jour- • The Triple Aim and client centered-
nal of Occupational Therapy launched a ness as providing “a compass for future
new column, “Health Policy Perspectives.” research demonstrating occupational
Since that time, most of the articles pub- therapy’s value through improved out-
lished in the column have directly dis- comes for health care recipients, in-
cussed connections between occupational creased efficiency of care transitions
therapy and the Triple Aim. Examples of and prevention of hospital readmis-
these discussions have included sions, and cost-effectiveness of inter-
• Primary care and value-based payment ventions and programs when effectively
Brent Braveman, PhD, OTR/L, FAOTA, is Director,
Department of Rehabilitation Services, University of
(Leland, Crum, Phipps, Roberts, & and efficiently provided on the basis of
Texas MD Anderson Cancer Center, Houston, and Gage, 2015; Stoffel, 2013) best practice” (Lamb & Metzler, 2014,
Secretary, American Occupational Therapy Association • The role of healthy habits and occu- p. 9; Mroz, Pitonyak, Fogelberg, &
(2013–2016); Bbraveman@gmail.com pational therapy’s role in wellness and Leland, 2015)

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 • Evidence and promotion of the distinct such as Accountable Care Organizations One construct stated by a member
value of occupational therapy (Arbesman, in Medicare that attempt to improve the of the IOM Roundtable may be a good
Lieberman, & Metzler, 2014). health of the population for which they are framing device. Chang observed that pop-
One of the three pillars of the Triple responsible. Broader, or more varied, def- ulation health can be approached in two
Aim is to improve the overall health of the initions have been used as well. How pop- ways:
population. Comparatively less has been ulation is defined has implications for
either by (1) starting from the
written about occupational therapy and health professionals, including occupa-
community and thinking about
population health and the relevance of tional therapy practitioners, educators, and
the needs of populations and then
population health to the profession than researchers. Kindig (2015) expanded on
integrating with clinical care, or
about the other two pillars and occupa- the explanation of populations by stating,
(2) starting from the individual
tional therapy. In this article, I explore the “These groups are often geographic pop-
needs of patients and learning
concept of population health and articu- ulations such as nations or communities,
about the social or community
late the relevance of population health to but can also be other groups such as em-
factors that are impacting their
occupational therapy. I conclude with a set ployees, ethnic groups, disabled persons,
health and addressing these needs
of recommendations and possible direc- prisoners, or any other defined group”
through policy or systems change.
tions for the future. (para. 3). Occupational therapy has op-
(as cited in Alper, 2014, p. 26)
portunities to affect population health
across all of these groups. Both of these approaches are familiar to
Defining and Exploring
The official documents of the American occupational therapy practitioners, and
Population Health
Occupational Therapy Association (AOTA) the occupational therapy literature
Kindig and Stoddart (2003) provided one have defined clients as persons, groups, contains many examples of the applica-
commonly cited definition of population and populations and clarified the term tion of these approaches to population
health: “the health outcomes of a group of population as meaning “collectives of health, although they have not always
individuals including the distribution of groups of individuals living in a similar been framed within a population health
such outcomes within the group” (p. 381). locale—e.g., city, state, or country—or perspective. I provide three examples.
This definition has been cited and clarified sharing the same or like characteristics First, in the late 1990s Gary Kielhofner
by many. CMS (2014) named population or concerns” (AOTA, 2014a, p. S3). The and I identified the needs of the population
health as a key goal of the State Innovation third edition of the Occupational Therapy of people living with HIV/AIDS. Members
Models for health system transformation. Practice Framework explicitly stated that of this population struggled with manage-
The Institute of Medicine (IOM) organization- or system-level practice is ment of what was being recognized as a
convened a Roundtable on Population valid, although occupational therapy prac- chronic illness and the resulting challenges to
Health in June 2013. Members of the tice models guiding interventions at this employment and independent living in the
roundtable noted that “while not a part level are less well developed than are practice community. These needs, identified at the
of the definition itself, it is understood models at the level of the individual person population level, were addressed through
that such population health outcomes or groups. However, there is much potential the development and delivery of two
are the product of multiple determinants to refine appropriate models to guide clinical care programs in the community
of health, including medical care, public practice applied to populations. Moreover, and in supportive living facilities in
health, genetics, behaviors, social factors, occupational therapy practitioners must Chicago (Kielhofner, Braveman, Fogg, &
and environmental factors” (IOM, 2015, analyze the principles of population health Levin, 2008; Kielhofner et al., 2004).
para. 4). These clarifying comments from to draw clear connections to the basic These efforts in turn influenced Social
the IOM roundtable both highlight the principles of occupational therapy. There is Security disability policy through invited
value of population health and provide a general agreement that the basic population testimony provided to the IOM Com-
distinction from public health in that con- health principles are as follows (Kindig, mittee on Social Security HIV Disability
sideration of all major population health 2010): Criteria to include broader language re-
determinants such as health care, educa- • that health outcomes were more than garding the involvement of multiple dis-
tion, and income typically remains outside the absence of disease; ciplines such as occupational therapy in
public health authority and responsibility, • that these outcomes were produced by disability evaluation and determination
even in its assurance functions (Kindig, complex interactions of multiple deter- (IOM, 2010).
2015). minants (health care, behaviors, genet- A second example is the recent work of
Applying the definition of population ics, the social environment, the physical occupational therapy scholars and colleagues
health requires that we understand more environment); and to explore the role that built, social, and
about what the term population includes. • that in a resource-limited world, the rel- economic environmental factors play in
Narrow definitions of what might consti- ative cost effectiveness of these determi- facilitating or limiting health, disability, and
tute a population can be as limited as the nants was critical for policymakers. rehabilitation outcomes of people with
patients covered by a specific health plan, (para. 2) disabilities both as individuals and as a

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 group (Magasi et al., 2015). A third example the broader range of actors (e.g., commu- ulation health (International Education
is the outcomes and quality measures work nity organizations) who can affect pop- Collaborative Expert Panel, 2011; IOM,
within the CMS Testing Experience and ulation health. Alper (2014) stated that 2010). These efforts move from populations
Functional Tools project. Occupational to individuals and from individuals to
the shift includes a growing rec-
therapist Trudy Mallinson and others are populations as described by Chang (as cited
ognition that the health care de-
collaborating with CMS to measure pop- in Alper, 2014). Practitioners must un-
livery system is responsible for
ulation health indicators in the population of derstand and perform in ways that showcase
only a modest proportion of
individuals with disabilities served under what makes and keeps Americans how their perspective and approaches add
certain Medicaid programs. The project healthy and that health care pro- distinct value to achieving population health
will extend the standardization of func- viders and organizations could as well as individual goals.
tional status items to the state home- and accept and embrace a richer role in
community-based waiver programs by piloting communities, working in partner- Relevance of Population Health
how these self-care and mobility items work ship with public health agencies, for Occupational Therapy
in populations who are aging or have dis- community-based organizations,
ability, intellectual disability–developmental schools, businesses, and many Discussions of the relevance of population
disability, traumatic brain injury, and serious others to identify and solve the health to occupational therapy are not
mental illness (Medicaid.gov, 2015). thorny problems that contribute new, and occupational therapy practi-
There are multiple examples of oc- to poor health. (p. 2) tioners in the United States are not alone
cupational therapy practitioners and of in their interest (Scaffa, 2014). For ex-
AOTA addressing individual patient and Occupational therapy practitioners are ample, the Canadian Association of Oc-
well established in each of these settings cupational Therapists (CAOT; 2008,
population needs through advocacy for
and could play a central role in develop- 2009) has clearly articulated its position on
policy or systems change. Recent examples
ing and nurturing such partnerships to the involvement of Canadian occupational
include advocacy for mental health ini-
help shape health outcomes. Occupational
tiatives such as the Mental Health Aware- therapists in population health efforts. A
therapy practitioners must use their posi-
ness and Improvement Act (S. 1893) and 2009 report by the CAOT executive di-
tion in these settings to clearly articulate
success in having licensed occupational rector that included recommendations
the role of occupational therapy in working
therapists listed as part of the suggested intended to improve health human re-
with populations and in addressing pop-
staff to be considered for inclusion in newly source planning for occupational therapy
ulation health and also to expand their
created certified community behavioral in Canada noted, “Occupational thera-
employment, presence, and influence in
health clinics (AOTA, 2015a, 2015b). In pists’ broad vision is to enable people who
other types of settings, such as child day
essence, the latter approach identified by face emotional, physical or social barriers to
care, public clinics, homeless shelters, and
Chang (i.e., to start with the needs of in- develop healthy patterns of occupation,
aging centers.
dividual patients and address population and the profession demonstrates an ability
Recent calls for increased involvement
needs through policy or systems change as of occupational therapy in primary care also to meet the population health needs of the
one learns about the social or community highlight opportunities to begin with in- Canadian people” (CAOT, 2009, p. 5).
factors that are affecting their health; Alper, dividual patients and then have an impact Wilcock and Hocking (2015) from
2014) may be at the heart of efforts by those on larger populations. AOTA (2014b) has Australia provided a thorough discussion
who see social justice as a relevant cause for asserted that occupational therapy practi- of occupation as an agent of population
occupational therapy and as a value that is tioners are well prepared to contribute to health in the third edition of their text-
congruent with the core values of occupa- interprofessional care teams addressing the book An Occupational Perspective on
tional therapy practice as currently stated primary care needs of people across the Health. They addressed perspectives of
by AOTA (2015c). lifespan, particularly those with, or at risk population health founded on World
for, one or more chronic conditions. This Health Organization policies and pro-
involvement can be an opening for occu- moted the role of occupational therapy to
Growing Opportunities to
pational therapy to show its potential by “uncover a different way to understand
Address Population Health health in the light of how, what, with
incorporating a broader view of health that
The ACA has been instrumental in bringing is not about just one person but rather about whom, and why people spend time and
attention to population health. Provisions the entire system and how effective it is in effort in ‘doing, being, belonging and
of the ACA have helped to expand the focus total—which is the essence of the trans- becoming’ through engagement in occu-
of health experts, policymakers, and the formation envisioned by the Triple Aim. pation” (p. xi).
public beyond traditional health care de- New primary care delivery models are Occupational therapy practitioners’
livery within the limits of the health care shifting the emphasis of interventions to the clinical care of individual clients is com-
system to the broader array of factors that management of chronic conditions with the monly understood and embraced by
play a role in shaping health outcomes and goal of reducing costs and improving pop- members of the profession and the public.

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 The health of populations is not as clearly of health disparities (an issue central to members collectively. (AOTA,2014a,
understood by members of the profession, population health) to occupational ther- p. S15)
but it is a concept we must embrace, and apy, stating, “The term health disparities
Additional examples should be added,
occupational therapy practitioners must refers to population-specific differences in
such as advocating for changes in policy
include the broad focus of population disease rates, health outcomes, and access
and education, sitting on government
health in their practice. This approach is to health care services” (p. S48).
planning commissions, and helping design
not always closely aligned with the enti-
new public spaces; these examples should
ties, processes, and settings that provide
Recommendations and be tied to advocacy and other practice roles
direct clinical care and at this time en-
compass most occupational therapy pro-
Directions for the Future described in the Framework.
A related recommendation is to ex-
vision. Although the applicability of Thus far, I have explored population
amine how population health is reflected
population health and public health to health and key related concepts and ar-
in our educational accreditation standards.
occupational therapy has been questioned, ticulated the relevance of population
Current screening, evaluation, and referral
I believe this is exactly where occupa- health to occupational therapy. Here, I
standards include populations as clients
tional therapy practitioners must culti- present a set of recommendations and
and state that the “process must consider
vate their role, push research, and move possible directions for the future.
toward the future. the continuum of need from individuals to
First, we should recognize the suc-
As a profession, occupational therapy populations” (Standard B.4.0; Accredita-
cesses and achievements of occupational
has moved beyond the question “Is that tion Council for Occupational Therapy
therapy practitioners and of AOTA in
occupational therapy?” to the equally im- Education [ACOTE], 2011, p. 21).
addressing the two approaches to pop-
portant questions of “Is that something that However, the term population health does
ulation health described by Chang (as
occupational therapy practitioners can do?” not appear in the accreditation standards,
cited in Alper, 2014). We should clearly
“Can occupational therapy make an impor- and only the standards for doctoral-level
articulate how occupational therapy prac-
tant contribution in this area?” and “How can occupational therapist programs include
titioners address population health to
we demonstrate our distinct value through population-based interventions specifically
promote increased recognition and con-
contributions to population health?” A (Standard B.5.33; ACOTE, 2011, p. 28).
sideration of the profession in policy are-
growing number of occupational therapy Contributions to efforts to address pop-
nas. Moreover, a clear articulation of our
scholars and practitioners are exploring these ulation health by occupational therapy
role in improving the health of the pop-
latter three questions as well as the connection practitioners at all levels hold great op-
ulation and achieving the Triple Aim will
between population health and individual portunity. Our educational accreditation
contribute to occupational therapy’s be-
occupational performance. The exploration standards should reflect these opportuni-
coming a more powerful profession and
of new roles for occupational therapy in ties by clear inclusion of the term pop-
achieving our vision for our future.
population health complements efforts fo- ulation health in the standards for all levels
To guide practitioners and researchers
cused on understanding and promoting the of educational programs.
and to clarify future possibilities, we
importance of occupation to health out- Perhaps most important is the rec-
should identify specific competencies re-
comes, such as in the Well Elderly studies ommendation that we actively support,
lated to population health and public
(Clark et al., 1996, 1997, 2001, 2012), and recognize, reward, and value occupational
health and include them clearly in the
on research related to the provision, out- therapy practitioners who assume roles
Framework. The current Framework in-
comes, and efficacy of occupational therapy in which direct care practice is not their
cludes populations in its definition of cli-
services in traditional practice settings. primary function. In 2015, our profession
ents but does not include the phrase
The appropriateness of population- grew to more than 213,000 occupational
population health and does not address the
based approaches is clearly documented in therapy practitioners and students in the
issue of population health directly. Inter-
AOTA’s official documents. For example, United States alone. We have both main-
ventions aimed at populations are ad-
AOTA’s (2013) Occupational Therapy in tained a strong presence in traditional
dressed, however; for example,
the Promotion of Health and Well-Being practice settings and broadened our focus to
includes a section on a population health Interventions provided to groups include new areas such as population health.
approach and states, “In addition to and populations are directed to Both of these successes should be celebrated.
providing occupational therapy interven- all the members collectively rather Population health spans both oc-
tions for individuals, occupational therapy than individualized to specific cupational therapy’s traditional and its
practitioners can develop and implement people within the group. Practi- emerging practices. It encompasses the
occupation-based population health ap- tioners direct their interventions work practitioners do when they identify
proaches to enhance occupational perfor- toward current or potential dis- the health needs of populations such as
mance and participation, quality of life, abling conditions with the goal of people with autism, diabetes, falls, limited
and occupational justice” (p. S49). This enhancing the health, well-being, mobility, or cancer and address those needs
statement further delineates the relevance and participation of all group through integration with clinical care

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 providers in schools, hospitals, private busi- American Occupational Therapy Association. Clark, F., Azen, S. P., Carlson, M., Mandel, D.,
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Acknowledgment
Arbesman, M., Lieberman, D., & Metzler, C. A. of independently living older people:
The author acknowledges the guidance (2014). Health Policy Perspectives—Using Results of the Well Elderly 2 Rando-
and assistance of Christina A. Metzler, evidence to promote the distinct value of mised Controlled Trial. Journal of Epi-
Gail Fisher, and Trudy Mallinson in the occupational therapy. American Journal of demiology and Community Health, 66,
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