Christina Metzler Chief Public Affairs Officer

KOTA Annual Conference September 2015

Identify, promote distinct value

Prepare evidence to improve practice

Promote thinking, implementation of primary care

Engage in transdisciplinary advocacy

Advocate for role in mental health

Create codes that reflect true practice

Give you insight into the future

Reducing avoidable hospital readmissions

Assisting patients with adherence to treatment regimens

Helping people maintain independence

Identifying the need for early interventions

Management of chronic conditions

Transitioning patients through care continuum

Occupational therapy's distinct value is to improve health and quality of life through facilitating participation and engagement in occupations, the meaningful, necessary, and familiar activities of everyday life. Occupational therapy is client-centered, achieves positive outcomes, and is cost-effective

“90% of the management of a chronic disease must come from the person who has the disease.”

California Healthcare Foundation, 2008

“Self-management is defined as the tasks that individuals must undertake to live well with one or more chronic conditions. These tasks include having the confidence to deal with medical management, role management, and emotional management of their conditions.” Institute of Medicine, 2003

Readiness/motivation Skills analysis/synthesis Habits Routines Roles Rituals Context & environments

Patient Activation is a fancy word for what OT practitioners have always done.

Alzheimer’s Disease and Related Disorders (Schaber,

2010)

‣ Compensatory and environmental strategies help maintain function.

‣ Compensatory and environmental strategies improve participation in desired activities

‣ Caregiver education increases caregiver self-efficacy

‣ Management of the environment promotes participation in activities, enhancing wellness

‣ Management of nighttime sleep hygiene assists with caregiver burden.

VALUE

◦What matters

◦What can be done

◦What it costs

◦Who cares

VALUE

◦How we calculate

◦How we ask

◦How we ?????

Advancing the Value and Quality of Occupational Therapy in Health Service Delivery

Leland, Crum, Phipps, Roberts, Gage

Prevention and Wellness

◦ Fall Intervention

Systemic Outcomes

◦Discharge Intervention by OT

Health Outcomes:

Policy: ACA/ Healthcare Reform/ Health Systems Reform

Changes in Health Delivery: CMMI; ACO; Medical Homes; Other Innovation Models

PRIMARY HEALTH CARE Interprofessional Collaborative Practice

Chronic

Care

Health &

Wellness Integrated

Health Care

Population

Health

Community

Based Practice

Transition

Planning

Quality Measures/ Outcomes/ Value

Defining Primary Care: Envisioning the

Roles of Occupational Therapy

Metzler, Hartmann, Lowenthal

Integrated, Comprehensive Care

◦Whole person orientation

Range of Life

◦Well-Elderly Study

‣ Body Structure or Body Function

‣ Sensation and Sensory Processing

‣ Mental Functions and Social Skills/Psychosocial

‣ Cognitive Strategies, Actions

‣ Activities of Daily Living (ADLs)

‣ Instrumental activities of daily living (IADLs) ALL WOULD BE PER SESSION; SOME SPECIALTY CODES (WHEELCHAIR ASSESSMENT)

KEPT

• IMPACT Act

Quality Measures

Data Gathering

• 21st Century Cures Act

• AOTA Proposed Core OT Codes

• Collect data in post acute across settings

• Equalize payment?

• Equalize access? Choice?

• Change payment systems?

22

Care Planning/ Decision Support

Payment

Quality Reportin

g

QI Care

Transitions

Data Element and Response Code

IRF-PAI

LTCH CARE

Data Set

OASIS-C

MDS 3.0

Data Elements

HCBS CARE

Uniformity

Data categories:

◦ Functional status

◦ Cognitive function and mental status

◦ Special services, treatments, and interventions

◦Medical conditions and co-morbidities

◦ Impairments

◦Other categories required by the Secretary 24

Use of Standardized Assessment Data: HHAs: no later than January 1, 2019 SNFs, IRFs, and LTCHs: no later than October 1, 2018

Functional Cognition

Appropriate Testing

Role for OT in care to achieve

◦ Better outcomes

◦ Fewer adverse events

◦ Less caregiving

◦Optimum independence

Distinction

Impact Value

Help and Hope for Patients Through Biomedical Innovation

(Passed the House by a vote of 344-77 on July 10, 2015)

Bipartisan!

New incentives to develop new drugs Removing regulatory uncertainty for new medical

options Helping the entire biomedical ecosystem

coordinate more efficiently to find faster cures. Investing in 21st century science and next

generation investigators. Removing barriers to increased research

collaboration Incorporating the patient Measuring success and identifying diseases earlier

through personalized medicine. Modernizing clinical trials.

“We in America do not have government by the majority. We have government by the majority who participate.”

-Thomas Jefferson

6 JANUARY 19, 2015 • WWW.AOTA.ORG

C A P I T A L B R I E F I N G

he Improving Medicare Post-Acute Care Transformation (IMPACT) Act (Pub. Law 113-185) was passed by both houses of Congress in Septem-ber and signed into law by President Obama on October 6, 2014. AOTA has been proactive with Congress and the Centers for Medicare & Medicaid Services (CMS) regarding the effect of the IMPACT Act on

occupational therapists and occu-pational therapy assistants working in post-acute care (PAC) settings. IMPACT emphasizes several key areas that can provide the opportunity to highlight the distinct value of occupa-tional therapy.

The objective of Congress in passing IMPACT is to capture better, consistent data; carefully and specif-ically document outcomes related to function and cognition; and rethink how services in skilled nursing facil-ities (SNFs), home health agencies, inpatient rehabilitation facilities, and long-term-care hospitals are provided, evaluated, and paid for. Ultimately, the goal is to ensure that appropri-ate, quality care is provided through equitable costs across these settings. But occupational therapy practition-ers will have to be ready to meet the challenges, expand their practice, and meet the targeted patient needs emphasized in IMPACT.

What are the details? Starting on October 1, 2016, and continuing over several years, CMS is directed to have in place systems to capture data sets that will be the same across the four PAC settings. These patient character-istic data must look at certain clinical areas, including critical points of

intervention for occupational therapy, such as:� Function, including mobility, self-

care, and history of falls� Cognitive function and mental

conditions, such as depression and dementia

� Medical conditions and comorbidi-ties, such as diabetes and pressure ulcers

� Impairments, such as incontinence

Occupational therapy practitioners cover all these areas. But cognition and mental health have often been secondary considerations in settings like SNFs and home health. In some cases, this is because reimbursement was thought to be less likely to be approved for treatment that addressed dementia, depression, or executive function. Many therapy providers assume that these areas are not reimbursable and incorrectly advise that these areas be given less or no emphasis in occupational therapy interventions.

The IMPACT Act shows that Con-gress and CMS see things differently. The underlying message of IMPACT is that PAC settings must look more at the whole patient, just as occupational therapy practitioners consider all of their clients’ basic and instrumental activities of daily living needed to function and remain healthy (i.e., not re-hospitalized) when they move from PAC to community outpatient care.

AOTA believes that the profession of occupational therapy is poised to enter this wide-open door presented by IMPACT to prove its distinct value for the whole client, so why wait for

October 2016? The time is now to start thinking about protocols and clinical judgment to be sure that the profes-sion of occupational therapy maxi-mizes its impact on clients’ function, cognition, and mental health.

Will Medicare pay for addressing these areas of intervention? If it does not, we must challenge those denials. We must read and understand the federal Medicare guidance and local coverage determinations for ourselves and be flexible, pushing the boundar-ies of our own clinical thinking as well as the boundaries of our PAC settings. Facilities are also reading the words in the law—function, self-care, cognition, falls, depression, and dementia—and realizing that they must ensure they collect and measure these patient data, as well as provide interventions that demonstrate improvement. Occu-pational therapy practitioners must be ready with the methods of assessment, evidence knowledge, and professional skill to help clients achieve outcomes as well as help facilities be ready for new data collection that reflects a new, focused approach to care.

For more details about the IMPACT Act, see AOTA’s summary and comment letter at http://tinyurl.com/mokjbfn.

Be part of the future. Examine your evaluations and plans of care, think about your assessment choices, and keep your occupational therapy vision wide open. �

Sharmila Sandhu, JD, is AOTA’s director of

Regulatory Affairs.

Chris Metzler is AOTA’s chief public affairs

officer.

TMake an IMPACT on

Post-Acute CareSharmila Sandhu and Chris Metzler

C A P I T A L B R I E F I N G

he Patient Protection and Affordable Care Act (ACA) may seem like ancient history, but its wide-ranging effects are still being felt today on Capitol Hill, with questions about how to fund health care programs intertwined with Medicare spending and many other issues. The debate over the ACA included much discussion about how to “bend the cost curve,” or slow down spending within Medicare. This hoped-for slowdown was partly to correct problems (e.g., inappropriate utiliza-tion, excessive billing) and partly to subsidize new health care programs.

EMPHASIZING VALUEAlthough the debate over the ACA was at times acrimonious, the con-cepts of using alternative payment methodologies (APMs; e.g., account-able care organizations [ACOs], primary care medical homes), coordi-nating care, checking payment levels for errors, and promoting a focus on outcomes has brought Congress and the White House, as well as Repub-licans and Democrats, together: All agree that we must pay for value, not volume, when it comes to health care. The ongoing debate concerns exactly how. The ACA directed the Centers for Medicare & Medicaid Services (CMS) to scale up what had previously been small demonstration projects, and APMs have proliferated in Medi-care, Medicaid, and private insurance. At the same time, the focus on quality reporting in Medicare has increased steadily. For instance, failure to report on quality measures through the Phy-sician Quality Reporting System now results in negative payment adjust-ments for private practitioners in Medicare. The Improving Post-Acute

Care Act, passed last fall, is expected to lead to data collection and quality measures becoming a more critical aspect of payment at skilled nurs-ing facilities, home health, inpatient rehabilitation facilities, and long-term acute hospitals. In January, the U.S. Department Health and Human Ser-vices (HHS) began promoting a long-term initiative to aggressively move payments to quality-based APMs, such as ACOs and the Comprehensive Pri-mary Care Initiative. The HHS goal is for 50% of Medicare reimbursement to be made through APMs by 2018, with all other payment under Medicare to be tied strictly to quality by 2018.

CONGRESSIONAL ACTIONAt press time, Congress was working on a bill to alter how providers are paid under Medicare, also known as the Sustainable Growth Rate, which drives the levels of payment under the Medicare Physician Fee Sched-ule. This overhaul would prevent a 30% cut to therapy and physician payments under Part B, and would provide bonus incentives for certain practitioners participation in APMS beginning in 2017. The overhaul would also, sometime before 2024, launch a Merit-Based Incentive Payment System, the complexity of which makes selecting G-codes seem easy by comparison. These changes are part of a steady move toward reducing the growth of spending in Medicare and toward paying for health care value over volume.

GETTING INVOLVEDCongress and CMS are showing no hesitation about pushing value-based purchasing and APMs in often

untested forms, making advocacy by the occupational therapy profession critical to preserving our clients’ best interests. Thus, you will be at the front lines of defending your profession every time you determine a plan of care and report on an intervention. Occupational therapy practitioners’ ability to speak to quality and value measures, through clear evaluation reports and substantive progress notes, is crucial. Equally important is the profession’s ability to convey its value to the overall health, wellness, and management of the Medicare population.

We must assume that, eventually, all occupational therapy practitioners reimbursed under Medicare will have their payment linked to quality report-ing and participation in an APM. This may create challenges, but providing higher quality, prevention-oriented services is far preferable to the other alternative: caps on and cuts to benefi-ciary services. New and improved sys-tems should mean better outcomes for beneficiaries of occupational therapy services. Occupational therapy practi-tioners possess a unique understand-ing of the interaction between person, task, and environment, and how ones’ habits, role, and routines can affect health outcomes, valuable knowledge in these new, value-oriented systems of care. We must be ready to say so loudly and clearly.

For more on these issues and infor-mation on how to get involved, visit www.aota.org/advocacy. �

Christina Metzler is AOTA’s chief public affairs

officer.

Heather Parsons is AOTA’s director of Legislative

Advocacy.

TValue, Not Volume

Making Occupational Therapy’s Distinct Value ShineChristina Metzler Heather Parsons

7OT PRACTICE • APRIL 13, 2015

HEALTH POLICY PERSPECTIVES

Advancing the Value and Quality of OccupationalTherapy in Health Service Delivery

Natalie E. Leland, Karen Crum, Shawn Phipps, Pamela Roberts,

Barbara Gage

MeSH TERMS

� delivery of health care

� occupational therapy

� patient outcome assessment

� quality of health care

� value-based purchasing

Natalie E. Leland, PhD, OTR/L, BCG, FAOTA, is

Assistant Professor, Mrs. T.H. Chan Division of

Occupational Science and Occupational Therapy and

Davis School of Gerontology, University of Southern

California, Los Angeles; nleland@osot.usc.edu

Karen Crum, MA, OTR/L, is Clinical Doctorate

Resident, Rehabilitation Health Services Research Lab,

Mrs. T.H. Chan Division of Occupational Science and

Occupational Therapy, University of Southern California,

Los Angeles.

Shawn Phipps, PhD, MS, OTR/L, FAOTA, is Chief

Quality Officer and Associate Hospital Administrator,

Rancho Los Amigos National Rehabilitation Center, Los

Angeles, and Director, American Occupational Therapy

Association Board of Directors, Bethesda, MD.

Pamela Roberts, PhD, OTR/L, SCFES, FAOTA,

CPHQ, is Program Director, Physical Medicine and

Rehabilitation and Neuropsychology, Cedars–Sinai

Medical Center, Los Angeles, and Vice Chair and

Chair-Elect, Accreditation Council for Occupational

Therapy Education, Bethesda, MD.

Barbara Gage, PhD, MPA, is Senior Vice President,

Scientific Research and Evaluation, PAC Center for

Research, and Fellow, Brookings Institution, Washington,

DC.

Leland, N. E., Crum, K., Phipps, S., Roberts, P., & Gage, B. (2015). Health Policy Perspectives—Advancing the value and

quality of occupational therapy in health service delivery. American Journal of Occupational Therapy, 69,

6901090010. http://dx.doi.org/10.5014/ajot.2015.691001

The Patient Protection and Affordable Care Act of 2010 (ACA; Pub. L. 111–

148) is driving the health care system to shift from a volume-based re-

imbursement system to one based on value and high quality with an emphasis

on evidence-based and patient-centered care. The objective of this new para-

digm is to improve patient outcomes by incentivizing providers to deliver

scientifically grounded best practices by linking payment to performance. The

end goals are to improve population health outcomes, enhance consumer sat-

isfaction, and reduce health care costs—often referred to as the Triple Aim(Berwick, Nolan, & Whittington, 2008). In this health care reform context, it is

imperative to define and delineate the distinct value and unique role of occu-

pational therapy. Failure of the profession to clearly demarcate what constitutes

high-quality occupational therapy and demonstrate its contribution to the

broader patient outcomes that value-based care will measure may marginalize

occupational therapy in the rapidly changing health care environment.

The objective of this article is to provide a foundation on which to build

further dialogue and evidence to highlight the profession’s distinctive contri-

bution, significance, and viability as health care policies shift to focus on quality

and value. To achieve this goal, we present a framework for examining health

care quality and patient outcomes, describe the health care context that is driving

the need for quality measurement in occupational therapy, explain the concept of

value-based care in the context of occupational therapy, and discuss how occu-

pational therapy can define high-quality care processes to enhance outcomes and

ensure a viable future for the profession.

Framework for Examining Health Care Quality

To improve patient outcomes in clinical practice, it is necessary to understand the

theory behind health care quality. Donabedian (1966, 2003) proposed a theo-

retical framework in which health care quality can be evaluated and outcomes

targeted for improvement. In his model, Donabedian postulated that outcomes

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are the result of the care processes that are provided and the

structure in which care is delivered. Donabedian defined

care processes as actions offered by the health care provider

to the patient, whereas structure includes the character-

istics of the context and environment in which the care is

delivered (e.g., physical space, practice culture, policies

and procedures, staffing). Guided by this model, the most

direct way to improve outcomes is to target the care

processes that are delivered (Donabedian, 1966, 2003).

Care processes have been identified as the most readily

adaptable elements within Donabedian’s model, which

makes them an ideal target for quality improvement.

Medicare’s Physician Quality Reporting System

(PQRS) and the American Medical Association’s (AMA’s)

Physician Consortium for Performance Improvement (PCPI),

among other bodies, are engaged in the development of

both process and outcome measures (Commission on Ac-

creditation of Rehabilitation Facilities, 2014; Joint Com-

mission, 2014; PCPI, 2011). To target outcomes for

improvement, it is necessary to identify what care should

be provided, document the delivery of that care, and

evaluate the outcomes resulting from the delivery of those

care processes, also referred to as care process quality in-dicators. These quality indicators are evidence-based and

patient-centered clinical action items that reflect critical and

prioritized interventions that can be delivered and docu-

mented consistently across organizations and by clinicians in

pursuit of achieving desired patient outcomes (Mainz, 2003).

Defining High-Quality Care: Developing Care ProcessQuality Indicators

Many health care professions have developed care process

quality indicators to improve outcomes, demonstrate their

unique value, and enhance service delivery (Min et al.,

2011; Rubenstein et al., 2004; Wenger et al., 2010).

Although the emphasis has been on the development of

care process measures, outcome measures (e.g., 30-day

readmissions) and composite measures, which combine

information on more than one performance measure, are

also being developed. PCPI, the National Quality Forum

(NQF), and the Agency for Healthcare Research and

Quality (AHRQ) have standardized protocols for de-

veloping both process and outcome quality measures

(Batelle, 2011; NQF, 2011; PCPI, 2011). The protocol

comprises six phases, the first of which is measure de-velopment. During this initial phase, an expert panel is

convened to prioritize a set of measures drawn from the

existing evidence base and stakeholder priorities using the

RAND Appropriateness Model (Battelle, 2011; NQF,

2011). The panel is made up of a broad group of

stakeholders relevant to the measure development topic

area and includes, but is not limited to, providers,

topical experts, researchers, payers, administrators, and

informatics specialists.

The protocol requires that the identified measures

then go through five additional phases: measure specification,evaluation, implementation, maintenance, and enhancement.Measures are currently being developed by a variety of health

care stakeholder groups, including national organizations,

the federal government, consumer advocates, professional

societies, and researchers.

Improving Outcomes: Integrating Quality MeasuresInto Practice

The objective of developing care process quality measures

is to define minimum standards of care. Guided by the

standardized six-phase protocol described in the preceding

section, physicians have been actively engaged in defining

care process quality measures and integrating those

measures into clinical practice in an effort to improve

patient outcomes (Wenger, Shekelle, & ACOVE Investi-

gators, 2001). For example, a group of physician researchers

were acutely aware of the devastating impact accidental falls

had on the health and quality of life of community-

dwelling older adults. In an effort to prevent this undesir-

able outcome and enhance care delivery, they developed

a series of care process quality measures for fall prevention

in primary care (Rubenstein et al., 2004). The objective

was to decrease the likelihood of falling, and the associated

subsequent poor outcomes, for older adult patients.

Using the standardized six-phase protocol, physician

groups have defined fall prevention care processes, oper-

ationalized them as quality measures, and then integrated

these measures into clinical documentation to support

clinical decision making (Min et al., 2011; Rubenstein et al.,

2004). The essential quality measures include improving

screening rates, enhancing fall risk factor identification, and

facilitating necessary referrals to other disciplines targeting

the identified risk factors. A controlled trial found that

primary care facilities that integrated the quality measures

into clinical practice had a higher rate of delivering and

documenting the care process quality measures and im-

proving patient outcomes than facilities that did not use the

measures in their practice (Wenger et al., 2009, 2010).

Although physicians have been at the forefront of

quality measure development through the AMA’s lead-

ership and the establishment of the PCPI, this example

of quality improvement can also be applied and im-

plemented by occupational therapy practitioners. Indeed,

occupational therapy practitioners in private practice who

bill Medicare are able to report these three items as part of

the PQRS (Hitchon, 2014). Furthermore, occupational

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therapy practitioners have participated in the fall prevention

measure development process as integral stakeholders,

have attended the AMA’s PCPI biannual meetings, and

have advocated for the linkage of process measures to

occupational therapy.

To align with the priorities of health care reform,

occupational therapy practitioners can use the six-phase

measure development methodology to define and evaluate

the value of occupational therapy services in other areas

of health care delivery. To this end, we must define our

evidence-based and patient-centered care processes to

enhance the delivery of occupational therapy services and

improve patient outcomes, thereby demonstrating the

value that the profession contributes to patient care.

Context of Health Care Reform: Attention toAcute and Postacute Care

The United States spends more than any other developed

country on health care. Unfortunately, despite outspending

other developed countries, patient outcomes in the United

States are worse than those of other countries, indicating

a need to improve the quality and efficiency of our health

care system (Davis, Schoen, & Stremikis, 2010; Honore

et al., 2011). Further, rising health care costs are exacer-

bated by an aging population that is relying on Medicare

in growing numbers, placing further financial strain on the

fee-for-service system in which volume is the key driver

instead of outcomes. For example, Medicare spending

for postacute care has more than doubled over the past

10 years, with expenditures increasing from $26.6

billion to $63.6 billion, yet patient outcomes are sub-

optimal, resulting in Medicare’s growing scrutiny of re-

habilitation quality in postacute care (Medicare Payment

Advisory Commission, 2010, 2012). Cumulatively, esca-

lating health care expenditures, gaps in quality of care, and

the exponential growth of the older adult population served

as drivers of reform in the U.S. health care system, facili-

tating the passage of the ACA.

The transition to value-based reimbursement is an

ACA initiative designed to achieve the Triple Aim. The

traditional fee-for-service model, in which payment is

based on the volume of services provided, has been as-

sociated with a financial incentive to provide more care

without improving outcomes (Schroeder & Frist, 2013).

The ACA’s emphasis on quality is facilitating a paradigm

shift that aims to incentivize the achievement of desired

outcomes by rewarding the provision of high-quality care.

Although most of the ACA’s proposals are linked to

Medicare, some efforts it fosters address multiple types of

payers. Furthermore, because Medicare is the major payer

of health care in the United States, using Medicare to test

innovations will have an impact on the larger U.S. health

care system (Boccuti & Moon, 2003; Finkelstein, 2007).

Initial value-based payment initiatives that have been

rolled out focus on reducing negative outcomes that re-

search has demonstrated are preventable, are associated

with high health care costs, and should not occur (e.g.,

hospital readmissions, hospital-acquired conditions). The

initiatives also have focused on promoting consumer

satisfaction and improving health overall. In any value-

based payment model, facility or provider payments are tied

to performance on outcomes, and the unit of analysis is the

provider (e.g., acute care hospital, individual occupational

therapy practitioner). In such a model, poor performance is

tied to financial penalties. For example, in fiscal year 2013,

2,200 acute care hospitals with excessive 30-day readmission

rates incurred a total of $280 million in penalty payments to

Medicare (Centers for Medicare & Medicaid Services, 2013;

James, 2013). Thus, this reimbursement structure provides

a strong financial incentive for providers to deliver high-

quality care, accompanied by the corresponding preferred

patient outcomes, to avoid such penalties.

Value-Based Care in the Context ofOccupational Therapy

To be responsive to the current health care reform ini-

tiatives, the field of occupational therapy needs measures

that can reliably and validly assess the quality and value of

its services across practice settings. Also, because occu-

pational therapy is now included in lump-sum facility

payments, as value-based purchasing becomes more so-

phisticated it will be important to identify, protect, and

recognize the specific contribution of occupational therapy

to facility or system outcomes (Lamb & Metzler, 2014).

Roberts and Robinson (2014) discussed the important

role occupational therapy practitioners can play in ad-

dressing readmissions and hospital-acquired conditions to

improve provider performance on these outcome measures;

the authors specifically addressed the role occupational

therapy has in improving outcomes in the area of accidental

falls. We must push forward the identity and utility of oc-

cupational therapy in all settings, however, to make sure

a link is understood and validated. One critical aspect of

ensuring the value of occupational therapy’s contribution to

optimizing outcomes is to encourage practitioners to use

evidence to inform clinical interventions. Some estimates

indicate that use of evidence in occupational therapy fall

prevention interventions is limited and that quality im-

provement initiatives are needed (Philibert, Snyder, Judd, &

Windsor, 2003; Thomas, Saroyan, & Lajoie, 2012).

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As an example of quality measure development, fall

prevention is useful. Improvement initiatives addressing

falls must be multidimensional. First, we must clearly

define occupational therapy care processes in the area of

fall prevention, and then these processes must be widely

disseminated to influence practice. For instance, protocols

for patients seen in certain settings (e.g., hospital emer-

gency rooms) must be developed to enable application of

the processes identified in the evidence. Follow-up on

longer-term outcomes, such as monitoring patients who

experience a fall and receive preventive interventions, will

also be necessary to determine effectiveness. Further, docu-

mentation and reporting systems must be transformed to

ensure that clinicians consistently provide and document their

delivery of appropriate, evidence-validated fall prevention

care processes. These systems may then be used to create

a robust data set that can be examined to demonstrate oc-

cupational therapy’s distinct value in preventing falls to in-

form the broader context of health care reform.

Defining High-QualityOccupational Therapy

A growing knowledge base of clinical research trials is

providing evidence of occupational therapy’s efficacy,

but the translation of that evidence into practice must be

amplified. To align with the priorities of the ACA, we

need to ensure that the care occupational therapy prac-

titioners provide and document is grounded in evidence

and is patient centered. Moreover, we need to demon-

strate our efficacy across settings, geographic regions,

and subpopulations to establish care processes for the

specific patient populations we serve (e.g., patients with

stroke, brain injury, spinal cord injury, orthopedics). As

a profession, we need to ask, What are the essential care

processes that every occupational therapy practitioner

should provide for each patient population we serve?

For example, what are the core interventions that

constitute high-quality care to be provided across the

continuum for all patients who have experienced a hip

fracture, regardless of the setting in which they are receiving

care? This is a population at high risk for subsequent falls,

both while in rehabilitation and during the initial transition

back to the community, which can increase the risk of

hospital readmissions and long-term institutionalization

(Mahoney et al., 2000). A recent study found that occu-

pational therapy home safety assessments before commu-

nity discharge decreased 30-day hospital readmissions

(Johnston, Barras, & Grimmer-Somers, 2010). Home

safety assessments are an efficacious care process that

occupational therapy practitioners identify as being within

our scope of practice, particularly in the area of fall pre-

vention (Gillespie et al., 2012; Leland, Elliott, O’Malley,

& Murphy, 2012). An occupational therapy care process

such as “an environmental safety assessment is provided

and documented prior to community discharge” could be

proposed as a process indicator for quality measure de-

velopment using the standardized measure protocol (Min

et al., 2011; Rubenstein et al., 2004; Wenger et al., 2010).

If this process is validated as a quality measure, clinicians

could then provide and document the care process, which

would serve as a means of validating the quality of occu-

pational therapy. Longitudinal data would optimally show

that patients who received the assessment from an occu-

pational therapy practitioner did better (e.g., experienced

fewer injuries from falls), thus improving the facility’s

overall care rating and further validating occupational

therapy’s distinct value in home safety and fall prevention.

Implications for Occupational TherapyPractitioners, Educators, and Researchers

The transition to value-based care will require the partici-

pation of occupational therapy practitioners, educators, and

researchers to develop strategies that will align the practice of

occupational therapy with the Triple Aim of health care

reform. Occupational therapy researchers working together

with clinicians can enhance the translation of evidence into

practice. Furthermore, as a team, researchers and clinicians

can integrate current evidence with the pragmatics of clinical

practice to define high-quality occupational therapy practice

using the standardized quality measure development

methods of the PCPI, AHRQ, and NQF (Min et al., 2011;

Rubenstein et al., 2004; Wenger et al., 2010).

In the context of the ACA’s “meaningful use” man-

date (i.e., the “use of certified electronic health record

[EHR] technology to improve quality, safety, efficiency,

and reduce health disparities” to improve clinical out-

comes; healthIT.gov, 2014) and the emergence of EHRs,

clinicians need documentation platforms that reflect the

clinical reasoning and decision-making processes of oc-

cupational therapy practitioners. Additionally, these sys-

tems must promote documentation of the actual care

provided and the outcomes achieved. For institutions to

develop documentation systems that capture the quality

care occupational therapy practitioners define as value,we must come to consensus as a profession and com-

municate those care processes and critical elements to

the developers of the EHR platforms. Accurate docu-

mentation reflecting high-quality occupational therapy

serves as the foundation for validating the value of our

services.

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In the context of value-based care, clinicians need to

ensure that their documentation reflects the care they

provide, that the care is grounded in evidence, and that

they use their own data to assess the quality of their care

processes. Quality improvement in the clinical setting is

a continuous process. Clinicians and administrators need

to work collaboratively, examining practice patterns and

establishing minimum standards of practice. The ongoing

use of clinical data can identify areas in which the facility

exceeds expectations and reveal areas of care delivery that

would benefit from improvement. By taking action and

engaging in self-appraisal, we can enhance our practice,

thereby improving patient outcomes.

The demand is growing for health services research in

occupational therapy. The profession needs researchers to

use new and emerging EHR data sources to examine the

impact of occupational therapy services and build the

evidence that measures the value of our contributions

within the context of the broader health care community.

The use of Medicare administrative data, registries, and

EHRs provides opportunities for the assessment of service

delivery in the clinical setting for populations of patients,

thereby allowing us to move beyond clinical trials to

demonstrate the value of occupational therapy services on

a broader scale. For example, data from fall prevention care

process measures may demonstrate that patients who received

the fall prevention care processes during rehabilitation across

all postacute care settings while recovering from hip fracture

had lower rates of falls and hospital readmissions after dis-

charge back to the community compared with those who did

not receive high-quality care. For the profession to have the

evidence base needed to advocate for high-quality occupa-

tional therapy in the era of value-based reimbursement, we

need not only to produce more research, but also to develop

a critical mass of trained researchers who can evaluate the

quality, access, timing, and utilization of occupational therapy

services.

Each occupational therapy practitioner needs to be

accountable for the type and value of services he or she

provides to ensure optimal outcomes. Measuring and

improving the value of occupational therapy remains

a central priority of the profession (Porter, 2010). Value-

based payment has significant implications for the edu-

cation of occupational therapy practitioners. Health care

is changing so rapidly that educational programs are

challenged to prepare their students for the ever-changing

health care environment. In addition to being prepared to

engage in the evolving practice environment, students

need the skills to appraise evidence, articulate the care

they provide, document evidence-based care processes,

and examine data from clinical practice. Furthermore,

academic programs can team up with health information

technology programs to expose students to the emerging

area of electronic health and health information systems.

It will be critical to have occupational therapy–trained

people on the front lines of health information technol-

ogy, developing EHR systems that capture the quality

and value of occupational therapy.

Conclusion

As the focus in health care shifts toward supporting higher

quality, the occupational therapy profession needs to develop

quality measures that will allow practitioners to provide,

document, and evaluate our valuable contribution to optimal

patient outcomes. This paradigm shift presents an oppor-

tunity for clinicians, researchers, and educators to collabo-

ratively contribute to defining quality care measures, promote

the adoption of these standards of service, and evaluate the

delivery of care that occupational therapy provides. By using

data to reflect our contribution to improved patient outcomes

and recognizing areas for future progress, the profession will

be strengthened. s

Acknowledgments

Natalie Leland was funded during the development of

this manuscript by the National Center for Medical

Rehabilitation Research, National Institute of Child

Health and Development, and the National Institute of

Neurological Disorders and Stroke (K12 HD055929, PI

Ottenbacher).

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HEALTH POLICY PERSPECTIVES

Defining Primary Care: Envisioning the Roles ofOccupational Therapy

Christina A. Metzler, Kimberly D. Hartmann, Lisa A. Lowenthal

KEY WORDS

� occupational therapy

� patient care management

� Patient Protection and Affordable Care

Act

� primary health care

� professional role

Metzler, C. A., Hartmann, K. D., & Lowenthal, L. A. (2012). Health Policy Perspectives—Defining primary care: Envisioning

the roles of occupational therapy. American Journal of Occupational Therapy, 66, 266–270. http://dx.doi.org/

10.5014/ajot.2010.663001

Christina A. Metzler is Chief Public Affairs Officer,

Public Affairs Division, American Occupational Therapy

Association, and Treasurer, American Occupational

Therapy Political Action Committee, Bethesda, MD;

cmetzler@aota.org

Kimberly D. Hartmann, PhD, OTR/L, FAOTA, is

Professor and Chair of Occupational Therapy, Quinnipiac

University, Hamden, CT, and Chair, Special Interest

Section Council, American Occupational Therapy

Association; hartmann@quinnipiac.edu

Lisa A. Lowenthal is an Occupational Therapy

Graduate Student, Quinnipiac University, Hamden, CT.

Primary care is a key theme in the Pa-

tient Protection and Affordable Care

Act (ACA; 2010). But what does the term

mean? Is there a difference between pri-mary care and primary health care? Does

primary care encompass occupational ther-

apy? What are the possible roles for occu-

pational therapy in primary care and in

achieving primary health care goals?

This column defines the terms, pro-

vides questions for occupational therapy

professionals to consider in connecting the

domain of practice to primary care and

primary health care, and suggests some

possible connections between the defi-

nitions and practice.

Definition of Primary Care

The ACA addresses primary care in several

ways, but the definition is usually con-

strued as limited, even as the descriptions

of what primary care should be and should

accomplish are expansive. Is this a problem

of expectations—that primary care shouldaddress a “large majority of personal health

needs” (ACA, 2010) or that it should ad-

dress a plurality of care? In defining primarycare practitioners, the ACA identifies

physicians, nurse practitioners, and physi-

cian assistants.

This definition may be a carryover

from the language that defines services

provided by community health centers

(CHCs). Occupational therapy is identi-

fied as a “supplemental service” along with

all other rehabilitative services (42 C.F.R.

x 51c.102(j)(4)); CHCs refer their clients

to other providers of rehabilitative services

because the federal funding provided to

CHCs through the Health Resources and

Services Administration is to be used only

for basic services.

In the ACA, primary care is defined

with similar constraints:

the provision of integrated, accessi-

ble health care services by clinicians

who are accountable for addressing

a large majority of personal health

care needs, developing a sustained

partnership with patients, and

practicing in the context of family

and community. (x 3502)Therefore, the exact definition of

primary care in the ACA is limited by who

can provide it (physicians and physician

extenders), but it is intended to address

most of the needs of patients over a period

of time, including family and community.

Are these contradictory requirements?

There are high expectations for pri-

mary care as expressed in a description of

supports for the primary care workforce:

The Obama Administration believes

that strengthening and growing our

primary care workforce is critical to

reforming the nation’s health care

system. Increasing access to primary

care physicians and nurses can help

prevent disease and illness and ensure

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all Americans—regardless of where

they live—have access to high quality

care. It can also reduce costs by in-

creasing access to preventive care.

(healthreform.gov, n.d., para. 2)

But how can primary care achieve

these lofty goals if it is not viewed more

broadly? Are there conflicting concepts in

these definitions and in the expectations? If

certain care is primary, then what is the rest

of care? Answers to these questions are

critical to ensure quality of health care. But

who will answer these questions, and when?

Can we as a profession mobilize and

promote a broader discussion of the concept

and the actualization of primary care with

occupational therapy as a critical element?

Some have indicated this as a possibility. A

rethinking of what specialist and supple-

mental services are and how they can achieve

the “triple aim” of health care may be one

avenue to promote occupational therapy.

The triple aim of health care as con-

ceived by the Institute for Healthcare Im-

provement, founded by Donald Berwick,

who served as the administrator of the

Centers for Medicare andMedicaid Services

from July 2010 toDecember 2011, provides

a link to be considered:

Improving the U.S. health care

system requires simultaneous pursuit

of three aims: improving the expe-

rience of care, improving the health

of populations, and reducing per

capita costs of health care. Pre-

conditions for this include the en-

rollment of an identified population,

a commitment to universality for its

members, and the existence of an

organization (an “integrator”) that

accepts responsibility for all three

aims for that population. The in-

tegrator’s role includes at least five

components: partnership with in-

dividuals and families, redesign of

primary care, population health man-

agement, financial management, and

macro system integration. (Berwick,

Nolan,&Whittington, 2008, p. 759)

This description of a new and more

effective health care system recognizes

primary care, but Berwick et al. (2008)

also recognized that primary care may

need to be redefined and reconceived:

We believe that any effective in-

tegrator will strengthen primary care

for the population. To accomplish

this, physicians might not be the

sole, or even the principal, providers.

Recently, physicians and other

clinicians have proposed principles

for expanding the role of primary

care under the title of the “medical

home.” This expanded role includes

establishing long-term relations be-

tweenpatients and their primary care

team; developing shared plans of

care; coordinating care, including

subspecialists and hospitals; and

providing innovative access to ser-

vices through improved scheduling,

connection to community resources,

and new means of communication

among individuals, families, and the

primary care team facilitated by a pa-

tient-controlled personalized health

record. (p. 759)

Barbara Starfield is sometimes referred

to as the “pathfinder of primary care” be-

cause of her attempts since the early 1990s to

redefine primary care (Stange, 2011,

p. 292). The four pillars of primary care she

defined continue to be cited: “first contact

care, continuity over time, comprehensive-

nesss, and coordination with other parts of

the health system underlie the practice of the

future” (Starfield, 1998, as cited inMargolius

& Bodenheimer, 2010, p. 779).

This kind of broad thinking goes be-

yond the Minute Clinic concept of readily,

easily available basic care to one that

envisions a coordinated system built on

teams of professionals with many capa-

bilities and varied scopes of practice all

focused on achieving health. This is where

occupational therapy can contribute and

enhance the approach to primary care,

helping to achieve the triple aim of ensuring

care, promoting true health, and using

resources wisely to achieve that health.

Primary Health Care andInternational Models

Although the terms primary care and pri-

mary health care are nearly identical and

influence one another, they differ in the

purpose of their service. As previously de-

scribed, primary care refers to the services

provided by physicians, nurse practi-

tioners, and physician assistants to address

diagnosis, treatment, and management of

illness. Primary health care focuses on idealcomprehensive health care that provides

preventative and curative services that in-

clude the rehabilitation professions (World

Health Organization [WHO], 1978).

Through these services, the goal is to im-

prove health—leading to a decreased occur-

rence of chronic diseases and injuries (which

may lead to hospitalizations)—and support

community development and chronic dis-

ease management (Fong, 2008; Leclair et al.,

2005).

In addition, primary health care val-

ues interprofessional collaborative practice

to improve health and access to services,

more efficiently use resources, and increase

satisfaction for clients and providers

(Fong, 2008; Fong & Siu, 2007; Leclair

et al., 2005; WHO, 2008). The nature of

the core competencies for interprofessional

collaborative practice address the critical

need for health care personnel to work to-

gether as a team to meet the current and

future demands that health care be afford-

able and high quality to meet the needs of

all people (Interprofessional Education

Collaborative Expert Panel, 2011). Thus,

interprofessional collaboration may pro-

vide one method to connect occupational

therapy to primary care to promote healthy

living in a variety of settings, such as the

workplace, the school environment, or the

home (Fong, 2008).

International efforts support the need

for primary health care. Both New Zea-

land and Manitoba, Canada, have de-

veloped charters that advocate for the need

for health promotion for all people (Leclair

et al., 2005; New Zealand Association of

Occupational Therapists, 2009). These

charters are founded on the principles from

WHO (2008), which supports putting the

public’s needs first to provide the most

comprehensive care possible. These tenets

are integral to occupational therapy. A

person is not solely his or her physical or

mental impairment; external factors and

context variables can also hinder or con-

tribute to success and quality of life.

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Occupational therapists are skilled in

evaluating all factors in a client’s life,

leading to a comprehensive understanding

of the link between occupation and health.

The profession’s scope of practice goes

beyond treating illness and can be in-

corporated into promoting healthy living

and preventing disease and disability. De-

spite having the skills and knowledge nec-

essary to get involved in the field of primary

health care, there is a lack of support from

practitioners. Many occupational thera-

pists may actually feel as though they do

not have competency-based training or

knowledge readily available to provide

preventative services (Flannery & Barry,

2003; Seymour, 1999). In addition to these

internal barriers, there is a low rate of re-

ferral from professionals who are unaware

that preventative care falls under occupational

therapy’s scope of practice (Arsenault &

Swan, 2011; Flannery&Barry, 2003; Leclair

et al., 2005; Seymour, 1999).

It is essential for occupational thera-

pists to acknowledge their competency to

work in primary health care and advocate

for the incorporation of these services in

the United States to benefit the general

public. Some literature provides evidence

linking the use of occupational therapy

services in primary health care for a variety

of populations. For example, older adults in

a cost-effective program leading to im-

proved quality of life scores and a greater

prevention of functional decline tend to

have lower future health care costs (Clark

et al., 1997; Jackson, Carlson, Mandel,

Zemke, & Clark, 1998; Matuska, Giles-

Heinz, Flinn, Neighbor, & Bass-Haugen,

2003; Scott, Butin, Tewfik, Burkardt,

Mandel, & Nelson, 2001). Occupational

therapy services can also be used through

ergonomic worksite visits to address envi-

ronmental issues and by restructuring

workplace maladaptive habits to decrease

the prevalence of injuries in the workplace

and their associated costs (Franche et al.,

2004).

Hughes (2009) found that many

general practitioners felt the need for oc-

cupational therapists to be involved in the

care of their patients with chronic fatigue

syndrome or myalgic encephalomyelitis.

Because of the nature of this condition,

those affectedmay experience occupational

disruption that eventually leads to occu-

pational dysfunction. Many physicians felt

that diagnosing the condition and providing

medical management were the only areas

they had time to address. Patients concurred,

feeling that doctors did not provide sufficient

management advice or treatment strategies.

Occupational therapists can address the

psychosocial aspect, providing supportive

advice and meaningful interventions to “fa-

cilitate self-management of fatigue symp-

toms” (Hughes, 2009, p. 8).

Opportunities for OccupationalTherapy in the ACA

Are there opportunities for occupational

therapy in the system the ACA envisions?

There are, but the envelope may need to be

pushed. It is up to the profession and in-

dividual practitioners to create the research,

to advocate for the changes, and to support

what can be done by occupational therapy

within a broadened, more expansive view

of primary care and primary health care

teams.

Several forms of health system design

are supported by the ACA, such as the

medical home concept, accountable care

organizations, and other approaches. The

ACA provided more funding to establish

and support CHCs (healthcare.gov, 2011),

but as noted earlier occupational therapy is

only supplemental, not funded by the basic

grants.Most of these systems are built on the

more limited concept of primary care but

also include the previously noted concepts

of “large majority of personal health needs”

and “plurality” of care.

Section 3502 of the ACA may provide

a glimmer of hope. Grants are allowed for

states to coordinate primary, acute, behav-

ioral, and long-term supports and services for

people eligible for both Medicare and

Medicaid (Center forMedicare andMedicaid

Innovation, 2012).

For the most part, however, the ACA

seems to split care into primary and other.

The ACA continues this bifurcation by

focusing on physicians, nurse practitioners,

and physician assistants. Loan programs and

incentive payments under Medicare and

Medicaid are restricted to these practi-

tioners. Yet, the concept of a long-term

relationship that is responsible for health

care, health, and costs seems to run contrary

to parts of how primary care is defined.

Can occupational therapy overcome

these limitations and challenges? When

comparing the concept of primary care in

the ACA with some of the incentive

programs for systems to provide co-

ordinated care, one can see some overlap

and potential. The role expected of oc-

cupational therapy in this context is not

clear, but what the profession believes

about the best and most important con-

tributions it can make should be what

guides the profession’s advocacy.Wellness,

self-management, rehabilitation, screen-

ing, prevention, and patient education by

occupational therapy practitioners who are

part of the primary care team must be

included.

Implications forOccupational Therapy

There are many implications for occupa-

tional therapy in terms of developing

opportunities in primary care that advo-

cate for the profession and enable signif-

icant contributions to client health. There

are potential challenges to the profession

as well.

The challenges are clear—occupational

therapy is not listed as a primary care

provider. As with other rehabilitation ser-

vices, occupational therapy is considered

supplemental, and its roles in the ability to

procure grants or incentives programs is

unclear. Despite these challenges, the lan-

guage of the ACA does provide opportu-

nities for the profession to align with the

definitions of primary care, international

models of this alignment with primary care

do exist, and the broader definition of

primary health care does include the do-

mains of practice that are consistent with

occupational therapy. What does the pro-

fession need to do?

First, we must collaborate with each

other to become educated in the termi-

nology of primary care and to merge our

collective power to align our knowledge

and skills with that terminology and the

definitions. Second, we must strengthen

alliances with the identified primary care

practitioners (physicians, nurse practi-

tioners, and physician assistants) through

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interprofessional care teams and practices

to ensure the inclusion of referrals in the

processes of coordinated and integrated

care (Peranich, Reynolds, O’Brien, Bosch,

& Cranfill, 2010).

The connection of occupational ther-

apy as more than a supplemental service but

instead a key team member in ACA is clear

when we match the components of ACA to

the profession’s domain of practice. “Ad-

dress a large majority of personal health

needs” can be connected to areas of occu-

pation, including activities of daily living,

instrumental activities of daily living, rest

and sleep, education, work, play and leisure,

and social participation (American Occu-

pational Therapy Association [AOTA],

2008). The domain of practice in and of

itself meets the definition of addressing

a large majority of personal health needs.

Within these domains the roles of occupa-

tional therapy in functional mobility, life-

style adaptation, medication management,

and participation for health promotion have

been building evidence to support their ef-

ficacy in health care.

“Coordinated and integrated care”

aligns with practitioners being case manag-

ers and patient enablers in mental health,

long-term care, and acute and rehabilitation

settings. “Developing sustained relation-

ships” can become a trait of occupational

therapy in this component of the definition,

because the profession promotes functional

skills and services across all practice settings

from initial screenings to patient education

to hospital to outpatient to home and to

work or participation in leisure pursuits.

“Practice in the context of family and

community” connects to the profession’s

ability to conduct activity analyses within

the contexts of different environments that

include home and social connections as well

as the community. Programs related to

wellness and lifestyle adjustments, fall pre-

vention, and environment redesign are but

a few areas that align with this terminology.

“Whole person orientation” is em-

bedded in the occupational therapy scope

of practice and skill set. The profession’s

accreditation standards, scope of practice

and other practice and official documents,

and the Occupational Therapy PracticeFramework (AOTA, 2008) all describe our

skill set and practice in the holistic man-

agement of client factors, values, and body

structures and functions to yield a complete

client occupational profile in psychologi-

cal, social, physical, and cognitive function

as it relates to occupations.

“Chronic care coordination” connects

with occupational therapy’s involvement in

engaging the client in goal setting, which

increases participation in activities to pro-

mote well-being. The prevention of reinjury

and increasedmedical involvement is seen in

environmental and ergonomic interventions.

The use of the professional approaches to

create, maintain, modify, and prevent ad-

dresses the needs of those who have chronic

conditions for independent functioning.Not

only the language of the profession but also

its close involvement with clients meets the

definition of primary care and the purposes

of primary health care; occupational therapy

does have roles to “support health and par-

ticipation in life through engagement in oc-

cupation” (AOTA, 2008, p. 652).

Occupational therapy must also ex-

amine its literature and evidence and pro-

mote its role, showing how the triple aim can

be addressed when the profession provides

self-management to address chronic disease,

health promotion to keep older adults in-

dependent, fall prevention in the home,

participation in discharge planning from

acute care, and the integration of mental

health issues into overall care management.

These are but a few of the areas of possible

opportunity for occupational therapy.

Looking to existing models, such

Kaiser Permanente of Northern California

(Murphy, Greathouse, & Matsui, 2005)

and its triage system to refer to physical

therapy before a physician’s visit, may

provide ideas for an occupational therapy

triage focus. The University of Southern

California Health Care System’s Eisner

Family Medical System uses a broad team

concept and integrates occupational ther-

apy throughout family practice from initial

patient contacts through treatment and

management. This unleashes the power of

occupational therapy within the context of

primary care (Prestwich, 2012).

Preparing for the Future

The possibilities for occupational therapy

in primary care are endless, but the op-

portunities must be seized. Research, in-

terprofessional training and collaboration,

education and lifelong learning, and

a mindset that moves beyond the clinic

walls will carry occupational therapy into

primary care and perhaps transform pri-

mary health care into a system that

encompasses the whole person, the family,

and the community. s

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