HEALTH POLICY PERSPECTIVES
Population Health and Occupational Therapy
Brent Braveman
MeSH TERMS
delivery of health care
health services needs and demands
occupational therapy
public health
Occupational therapy practitioners play an important role in improving the health of populations through the
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 as a concept and describes the appropriateness of occupational therapy practice in population health.
Support of population health practice as evidenced in the official documents of the American Occupational
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
Brent Braveman, PhD, OTR/L, FAOTA, is Director,
Department of Rehabilitation Services, University of
Texas MD Anderson Cancer Center, Houston, and
Secretary, American Occupational Therapy Association
(2013–2016); Bbraveman@gmail.com
.
Much has been written about the Triple
Aim of health care since the Institute
for Healthcare Improvement introduced
the concept in 2007. It is often cited as a
guiding principle of health care and health
insurance reform, including the Patient
Protection and Affordable Care Act of 2010
(ACA; Pub. L. 111–148). Berwick, Nolan,
and Whittington (2008) defined the Triple
Aim as “improving the individual experience of care, improving the health of populations, and reducing the per capita cost of
care” (p. 760). Health care leaders, including those in the discipline of occupational therapy, have explored a range of
issues and connections to the Triple Aim.
In January 2012, the American Journal of Occupational Therapy launched a
new column, “Health Policy Perspectives.”
Since that time, most of the articles published in the column have directly discussed connections between occupational
therapy and the Triple Aim. Examples of
these discussions have included
• Primary care and value-based payment
(Leland, Crum, Phipps, Roberts, &
Gage, 2015; Stoffel, 2013)
• The role of healthy habits and occupational therapy’s role in wellness and
prevention as a strategy to maintain its
relevance (Hildenbrand & Lamb, 2013;
Persch, Lamb,Metzler, & Fristad, 2015)
• New models of interdisciplinary team
practice and a vision of health care as “a
coordinated system built on teams of
professionals with many capabilities
and varied scopes of practice all focused on achieving health” (Metzler,
Hartmann, & Lowenthal, 2012, p. 267;
Moyers & Metzler, 2014)
• Increased use of information technologies supported by the Centers for Medicare and Medicaid Services (CMS) and
telehealth (Cason, 2015; Moyers &
Metzler, 2014)
• The Triple Aim and client centeredness as providing “a compass for future
research demonstrating occupational
therapy’s value through improved outcomes for health care recipients, increased efficiency of care transitions
and prevention of hospital readmissions, and cost-effectiveness of interventions and programs when effectively
and efficiently provided on the basis of
best practice” (Lamb & Metzler, 2014,
p. 9; Mroz, Pitonyak, Fogelberg, &
Leland, 2015)
Brent Braveman, PhD, OTR/L, FAOTA
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• Evidence and promotion of the distinct
value of occupational therapy (Arbesman,
Lieberman, & Metzler, 2014).
One of the three pillars of the Triple
Aim is to improve the overall health of the
population. Comparatively less has been
written about occupational therapy and
population health and the relevance of
population health to the profession than
about the other two pillars and occupational therapy. In this article, I explore the
concept of population health and articulate the relevance of population health to
occupational therapy. I conclude with a set
of recommendations and possible directions for the future.
Defining and Exploring
Population Health
Kindig and Stoddart (2003) provided one
commonly cited definition of population
health: “the health outcomes of a group of
individuals including the distribution of
such outcomes within the group” (p. 381).
This definition has been cited and clarified
by many. CMS (2014) named population
health as a key goal of the State Innovation
Models for health system transformation.
The Institute of Medicine (IOM)
convened a Roundtable on Population
Health in June 2013. Members of the
roundtable noted that “while not a part
of the definition itself, it is understood
that such population health outcomes
are the product of multiple determinants
of health, including medical care, public
health, genetics, behaviors, social factors,
and environmental factors” (IOM, 2015,
para. 4). These clarifying comments from
the IOM roundtable both highlight the
value of population health and provide a
distinction from public health in that consideration of all major population health
determinants such as health care, education, and income typically remains outside
public health authority and responsibility,
even in its assurance functions (Kindig,
2015).
Applying the definition of population
health requires that we understand more
about what the term population includes.
Narrow definitions of what might constitute a population can be as limited as the
patients covered by a specific health plan,
such as Accountable Care Organizations
in Medicare that attempt to improve the
health of the population for which they are
responsible. Broader, or more varied, definitions have been used as well. How population is defined has implications for
health professionals, including occupational therapy practitioners, educators, and
researchers. Kindig (2015) expanded on
the explanation of populations by stating,
“These groups are often geographic populations such as nations or communities,
but can also be other groups such as employees, ethnic groups, disabled persons,
prisoners, or any other defined group”
(para. 3). Occupational therapy has opportunities to affect population health
across all of these groups.
The official documents of the American
Occupational Therapy Association (AOTA)
have defined clients as persons, groups,
and populations and clarified the term
population as meaning “collectives of
groups of individuals living in a similar
locale—e.g., city, state, or country—or
sharing the same or like characteristics
or concerns” (AOTA, 2014a, p. S3). The
third edition of the Occupational Therapy
Practice Framework explicitly stated that
organization- or system-level practice is
valid, although occupational therapy practice models guiding interventions at this
level are less well developed than are practice
models at the level of the individual person
or groups. However, there is much potential
to refine appropriate models to guide
practice applied to populations. Moreover,
occupational therapy practitioners must
analyze the principles of population health
to draw clear connections to the basic
principles of occupational therapy. There is
general agreement that the basic population
health principles are as follows (Kindig,
2010):
• that health outcomes were more than
the absence of disease;
• that these outcomes were produced by
complex interactions of multiple determinants (health care, behaviors, genetics, the social environment, the physical
environment); and
• that in a resource-limited world, the relative cost effectiveness of these determinants was critical for policymakers.
(para. 2)
One construct stated by a member
of the IOM Roundtable may be a good
framing device. Chang observed that population health can be approached in two
ways:
either by (1) starting from the
community and thinking about
the needs of populations and then
integrating with clinical care, or
(2) starting from the individual
needs of patients and learning
about the social or community
factors that are impacting their
health and addressing these needs
through policy or systems change.
(as cited in Alper, 2014, p. 26)
Both of these approaches are familiar to
occupational therapy practitioners, and
the occupational therapy literature
contains many examples of the application of these approaches to population
health, although they have not always
been framed within a population health
perspective. I provide three examples.
First, in the late 1990s Gary Kielhofner
and I identified the needs of the population
of people living with HIV/AIDS. Members
of this population struggled with management of what was being recognized as a
chronic illness and the resulting challenges to
employment and independent living in the
community. These needs, identified at the
population level, were addressed through
the development and delivery of two
clinical care programs in the community
and in supportive living facilities in
Chicago (Kielhofner, Braveman, Fogg, &
Levin, 2008; Kielhofner et al., 2004).
These efforts in turn influenced Social
Security disability policy through invited
testimony provided to the IOM Committee on Social Security HIV Disability
Criteria to include broader language regarding the involvement of multiple disciplines such as occupational therapy in
disability Assessment and determination
(IOM, 2010).
A second example is the recent work of
occupational therapy scholars and colleagues
to explore the role that built, social, and
economic environmental factors play in
facilitating or limiting health, disability, and
rehabilitation outcomes of people with
disabilities both as individuals and as a
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group (Magasi et al., 2015). A third example
is the outcomes and quality measures work
within the CMS Testing Experience and
Functional Tools project. Occupational
therapist Trudy Mallinson and others are
collaborating with CMS to measure population health indicators in the population of
individuals with disabilities served under
certain Medicaid programs. The project
will extend the standardization of functional status items to the state home- and
community-based waiver programs by piloting
how these self-care and mobility items work
in populations who are aging or have disability, intellectual disability–developmental
disability, traumatic brain injury, and serious
mental illness (Medicaid.gov, 2015).
There are multiple examples of occupational therapy practitioners and of
AOTA addressing individual patient and
population needs through advocacy for
policy or systems change. Recent examples
include advocacy for mental health initiatives such as the Mental Health Awareness and Improvement Act (S. 1893) and
success in having licensed occupational
therapists listed as part of the suggested
staff to be considered for inclusion in newly
created certified community behavioral
health clinics (AOTA, 2015a, 2015b). In
essence, the latter approach identified by
Chang (i.e., to start with the needs of individual patients and address population
needs through policy or systems change as
one learns about the social or community
factors that are affecting their health; Alper,
2014) may be at the heart of efforts by those
who see social justice as a relevant cause for
occupational therapy and as a value that is
congruent with the core values of occupational therapy practice as currently stated
by AOTA (2015c).
Growing Opportunities to
Address Population Health
The ACA has been instrumental in bringing
attention to population health. Provisions
of the ACA have helped to expand the focus
of health experts, policymakers, and the
public beyond traditional health care delivery within the limits of the health care
system to the broader array of factors that
play a role in shaping health outcomes and
the broader range of actors (e.g., community organizations) who can affect population health. Alper (2014) stated that
the shift includes a growing recognition that the health care delivery system is responsible for
only a modest proportion of
what makes and keeps Americans
healthy and that health care providers and organizations could
accept and embrace a richer role in
communities, working in partnership with public health agencies,
community-based organizations,
schools, businesses, and many
others to identify and solve the
thorny problems that contribute
to poor health. (p. 2)
Occupational therapy practitioners are
well established in each of these settings
and could play a central role in developing and nurturing such partnerships to
help shape health outcomes. Occupational
therapy practitioners must use their position in these settings to clearly articulate
the role of occupational therapy in working
with populations and in addressing population health and also to expand their
employment, presence, and influence in
other types of settings, such as child day
care, public clinics, homeless shelters, and
aging centers.
Recent calls for increased involvement
of occupational therapy in primary care also
highlight opportunities to begin with individual patients and then have an impact
on larger populations. AOTA (2014b) has
asserted that occupational therapy practitioners are well prepared to contribute to
interprofessional care teams addressing the
primary care needs of people across the
lifespan, particularly those with, or at risk
for, one or more chronic conditions. This
involvement can be an opening for occupational therapy to show its potential by
incorporating a broader view of health that
is not about just one person but rather about
the entire system and how effective it is in
total—which is the essence of the transformation envisioned by the Triple Aim.
New primary care delivery models are
shifting the emphasis of interventions to the
management of chronic conditions with the
goal of reducing costs and improving population health (International Education
Collaborative Expert Panel, 2011; IOM,
2010). These efforts move from populations
to individuals and from individuals to
populations as described by Chang (as cited
in Alper, 2014). Practitioners must understand and perform in ways that showcase
how their perspective and approaches add
distinct value to achieving population health
as well as individual goals.
Relevance of Population Health
for Occupational Therapy
Discussions of the relevance of population
health to occupational therapy are not
new, and occupational therapy practitioners in the United States are not alone
in their interest (Scaffa, 2014). For example, the Canadian Association of Occupational Therapists (CAOT; 2008,
2009) has clearly articulated its position on
the involvement of Canadian occupational
therapists in population health efforts. A
2009 report by the CAOT executive director that included recommendations
intended to improve health human resource planning for occupational therapy
in Canada noted, “Occupational therapists’ broad vision is to enable people who
face emotional, physical or social barriers to
develop healthy patterns of occupation,
and the profession demonstrates an ability
to meet the population health needs of the
Canadian people” (CAOT, 2009, p. 5).
Wilcock and Hocking (2015) from
Australia provided a thorough discussion
of occupation as an agent of population
health in the third edition of their textbook An Occupational Perspective on
Health. They addressed perspectives of
population health founded on World
Health Organization policies and promoted the role of occupational therapy to
“uncover a different way to understand
health in the light of how, what, with
whom, and why people spend time and
effort in ‘doing, being, belonging and
becoming’ through engagement in occupation” (p. xi).
Occupational therapy practitioners’
clinical care of individual clients is commonly understood and embraced by
members of the profession and the public.
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The health of populations is not as clearly
understood by members of the profession,
but it is a concept we must embrace, and
occupational therapy practitioners must
include the broad focus of population
health in their practice. This approach is
not always closely aligned with the entities, processes, and settings that provide
direct clinical care and at this time encompass most occupational therapy provision. Although the applicability of
population health and public health to
occupational therapy has been questioned,
I believe this is exactly where occupational therapy practitioners must cultivate their role, push research, and move
toward the future.
As a profession, occupational therapy
has moved beyond the question “Is that
occupational therapy?” to the equally important questions of “Is that something that
occupational therapy practitioners can do?”
“Can occupational therapy make an important contribution in this area?” and “How can
we demonstrate our distinct value through
contributions to population health?” A
growing number of occupational therapy
scholars and practitioners are exploring these
latter three questions as well as the connection
between population health and individual
occupational performance. The exploration
of new roles for occupational therapy in
population health complements efforts focused on understanding and promoting the
importance of occupation to health outcomes, such as in the Well Elderly studies
(Clark et al., 1996, 1997, 2001, 2012), and
on research related to the provision, outcomes, and efficacy of occupational therapy
services in traditional practice settings.
The appropriateness of populationbased approaches is clearly documented in
AOTA’s official documents. For example,
AOTA’s (2013) Occupational Therapy in
the Promotion of Health and Well-Being
includes a section on a population health
approach and states, “In addition to
providing occupational therapy interventions for individuals, occupational therapy
practitioners can develop and implement
occupation-based population health approaches to enhance occupational performance and participation, quality of life,
and occupational justice” (p. S49). This
statement further delineates the relevance
of health disparities (an issue central to
population health) to occupational therapy, stating, “The term health disparities
refers to population-specific differences in
disease rates, health outcomes, and access
to health care services” (p. S48).
Recommendations and
Directions for the Future
Thus far, I have explored population
health and key related concepts and articulated the relevance of population
health to occupational therapy. Here, I
present a set of recommendations and
possible directions for the future.
First, we should recognize the successes and achievements of occupational
therapy practitioners and of AOTA in
addressing the two approaches to population health described by Chang (as
cited in Alper, 2014). We should clearly
articulate how occupational therapy practitioners address population health to
promote increased recognition and consideration of the profession in policy arenas. Moreover, a clear articulation of our
role in improving the health of the population and achieving the Triple Aim will
contribute to occupational therapy’s becoming a more powerful profession and
achieving our vision for our future.
To guide practitioners and researchers
and to clarify future possibilities, we
should identify specific competencies related to population health and public
health and include them clearly in the
Framework. The current Framework includes populations in its definition of clients but does not include the phrase
population health and does not address the
issue of population health directly. Interventions aimed at populations are addressed, however; for example,
Interventions provided to groups
and populations are directed to
all the members collectively rather
than individualized to specific
people within the group. Practitioners direct their interventions
toward current or potential disabling conditions with the goal of
enhancing the health, well-being,
and participation of all group
members collectively. (AOTA,2014a,
p. S15)
Additional examples should be added,
such as advocating for changes in policy
and education, sitting on government
planning commissions, and helping design
new public spaces; these examples should
be tied to advocacy and other practice roles
described in the Framework.
A related recommendation is to examine how population health is reflected
in our educational accreditation standards.
Current screening, Assessment, and referral
standards include populations as clients
and state that the “process must consider
the continuum of need from individuals to
populations” (Standard B.4.0; Accreditation Council for Occupational Therapy
Education [ACOTE], 2011, p. 21).
However, the term population health does
not appear in the accreditation standards,
and only the standards for doctoral-level
occupational therapist programs include
population-based interventions specifically
(Standard B.5.33; ACOTE, 2011, p. 28).
Contributions to efforts to address population health by occupational therapy
practitioners at all levels hold great opportunity. Our educational accreditation
standards should reflect these opportunities by clear inclusion of the term population health in the standards for all levels
of educational programs.
Perhaps most important is the recommendation that we actively support,
recognize, reward, and value occupational
therapy practitioners who assume roles
in which direct care practice is not their
primary function. In 2015, our profession
grew to more than 213,000 occupational
therapy practitioners and students in the
United States alone. We have both maintained a strong presence in traditional
practice settings and broadened our focus to
include new areas such as population health.
Both of these successes should be celebrated.
Population health spans both occupational therapy’s traditional and its
emerging practices. It encompasses the
work practitioners do when they identify
the health needs of populations such as
people with autism, diabetes, falls, limited
mobility, or cancer and address those needs
through integration with clinical care
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providers in schools, hospitals, private businesses, and community-based organizations
(Roberts & Robinson, 2014; Fisher &
Friesema, 2013). It will also encompass expanded roles practitioners could adopt in the
policy arena, in nonprofit organizational
leadership in organizations such as the
American Cancer Society or the Brain Injury
Association of America, or in federal health
agencies such as the Centers for Disease
Control and Prevention or the National
Institutes of Health. Considering the longterm impact for the profession of supporting, recognizing, rewarding, and valuing the
contribution of occupational therapy practitioners working in organizations such as
these moves us toward answering a question
that will have a big payofffor the profession:
How can we demonstrate occupational
therapy’s distinct value in improving the
individual experience of care, improving
the health of populations, and reducing the
per capita cost of care? s
Acknowledgment
The author acknowledges the guidance
and Helpance of Christina A. Metzler,
Gail Fisher, and Trudy Mallinson in the
preparation of this article.
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