Ot in Community Based Practice Setting

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SECOND EDITION
Occupational Therapy
in Community-Based Practice Settings
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
Professor and Chair
Department of Occupational Therapy
University of South Alabama
Mobile, Alabama
S. Maggie Reitz, PhD, OTR/L, FAOTA
Professor and Chair
Department of Occupational Therapy and
Occupational Science
Towson University
Towson, Maryland
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Library of Congress Cataloging-in-Publication Data
Scaffa, Marjorie E.
Occupational therapy in community-based practice settings / Marjorie E. Scaffa, S. Maggie Reitz. — 2nd ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-8036-2580-8 (pbk. : alk. paper)
I. Reitz, S. Maggie. II. Title.
[DNLM: 1. Occupational Therapy—methods. 2. Community Health Services. WB 555]
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For all those special people

who see what others ignore,
embrace what others fear,
and create new paths that others can follow.
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Dedication
This text is dedicated to the memory of Dr. Gary Kielhofner (1949–2010), scholar,
teacher, mentor, and friend. His extraordinary contributions to occupational therapy
education, research, and practice are unparalleled.
iv
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Introduction to the Foreword
This is the foreword that appeared in the first edition of this text. It is particularly meaning-
ful to me as it was written by Dr. Gary Kielhofner, who was my occupational therapy pro-
fessor and mentor. Dr. Kielhofner died in September 2010 after a short battle with cancer,
but his legacy lives on in the many students he taught and professionals he mentored. For
these reasons, we have chosen to retain this foreword and dedicate the second edition of
this text to Dr. Gary Kielhofner.
—M ARJORIE E. S CAFFA , P H D, OTR, FAOTA
Foreword
Twenty-five years ago I collaborated on my first publication with one of my mentors,

Florence Cromwell. The paper described preparation of occupational therapy students to
work in community settings (Cromwell & Kielhofner, 1976). I had the good fortune of
working with a mentor who appreciated that much of the future of occupational therapy
would be in community practice. A quarter century ago, this was still a new idea.
In the intervening period a number of changes in health care, health demographics,
and funding of health services have made community-based practice not only common
but the most promising direction for the future of practice in occupational therapy.
It gives me great satisfaction to see that one of my former students has gone on to edit
the first comprehensive volume in community practice. It is even more gratifying to note
the scope and quality of chapters that make up this ambitious volume. Community prac-
tice means much more than physical placement in a community setting. Importantly,
it represents a different paradigm of care than that seen in traditional hospital and rehabil-
itation settings. The therapist working in the community most likely works in an organi-
zation whose traditional medically defined settings. Moreover, the voices and viewpoints
of those served will often carry much more weight than in a traditional setting. Therapists
who wish to be effective in community practice must be prepared to take on new roles,
to take unusual risks, and to envision service in creative ways. Thus, although community
practice is not as anomalous as it was 25 years ago, it still represents new territory for most
of occupational therapy.
Marjorie Scaffa and her colleagues have assembled a remarkable set of resources for the
occupational therapist in community practice. The scope and depth of the chapters make
this at once an authoritative work on community practice and an invaluable collection of
resources.
—G ARY K IELHOFNER , D R PH, OTR
Cromwell, F.S., & Kielhofner, G. (1976). An educational strategy for occupational therapy community service.
American Journal of Occupational Therapy, 30, 629-633.
v
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Preface
This book is the culmination of one aspect of the professional journey of Marjorie Scaffa that
started when she was an undergraduate major in psychology with a minor in health education
and continued on in an entry-level master’s program to become an occupational therapist.
During her years as an occupational therapy student at Virginia Commonwealth University,
she was introduced to the Model of Human Occupation by Dr. Kielhofner and became in-
creasingly excited about the potential for practice in nonmedical settings. When given the
opportunity to choose a topic for a paper, Marjorie wrote about occupational therapy’s role
in community health, and the seeds of what would later become this book were sown.
As a practicing occupational therapist, she gained experience in a variety of settings
but was most energized and excited by home health practice. Providing services in the
home enabled her to become part of the person’s daily life context in which the client
participated in self-care, work, and leisure. Marjorie was impressed by how much more
meaningful occupations were to individuals and their families in real-life environments.
Through our practice and further education, we both came to believe firmly that if
occupation could restore function and enhance the quality of life for individuals with
disabilities and their families, then it could also be used to prevent injuries and promote
health in communities. Thus began our quests for doctorates in health education. We
quickly realized that much of what we had learned in occupational therapy would be
useful in community-based prevention and health promotion, but that we needed to be-
come acculturated to the mind-set and conceptual frameworks of health educators, which
were quite different from those of occupational therapy practitioners. We were exposed to
planning, implementing, and evaluating preventive interventions directed at groups and
populations rather than rehabilitative interventions directed at individuals.
Through time we were able to assimilate both of our professional identities as occupa-
tional therapists and health educators, which enabled us to envision this Second Edition.
It is clearly and straightforwardly an occupational therapy text with an appreciation of the
importance of community as a context for health.
We hope that you find the Second Edition of the book to be a useful and more developed
discussion of the issues related to present-day community practice in occupational therapy
and descriptions of a variety of settings in which this practice currently occurs. The book has
grown from 18 chapters in the original edition to 29 chapters in this Second Edition, with
sections devoted to each of the six areas of the American Occupational Therapy Association’s
Centennial Vision. Chapters have been added on community mental health services for
children and youth as well as on forensic transition services. The number of chapters on
productive aging has increased from one to five, with chapters being added on driving and
community mobility, low-vision services, fall prevention, and aging in place. Chapters related
to work have increased from one to three, with new chapters on ergonomics and welfare
to work programs being the enhancements to this edition. The ability to add chapters on
Lifestyle Redesign, technology in community-based practice, as well as chapters on health
promotion in faith-based organizations, primary care settings, and academic communities
together with the other additional chapters exemplifies how the profession’s contributions
to community health and well-being have significantly expanded since the first edition of
this book.
vi
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Preface vii
The book remains designed as a textbook for entry-level occupational therapy students,
but it also proves useful to practitioners wishing to facilitate a transition from medical
model practice to community-based practice. We are grateful for the opportunity to par-
ticipate in and contribute to the profession’s expanding role in prevention, health promo-
tion, and community health.
—M ARJORIE E. S CAFFA
S. M AGGIE R EITZ
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Contributors
Abigail Baxter, PhD Erin Guillory Caraway, MS OTR

Professor Occupational Therapist
Department of Leadership and Teacher Education Physical Medicine Department
University of South Alabama Lake Charles Memorial Health System
Mobile, Alabama Lake Charles, Louisiana
Mary Frances Baxter, OT, PhD, FAOTA Roxanne Castaneda, MS, OTR/L
Associate Professor Public Health Advisor
School of Occupational Therapy Center for Mental Health Service
Texas Woman’s University Community Support Programs
Houston, Texas Substance Abuse Mental Health Services
Administration
Mary Becker-Omvig, MS, OTR/L
Rockville, Maryland
Program Manager
Howard County Office on Aging S. Blaise Chromiak, MD
Columbia, Maryland Family Practice Physician
Mobile, Alabama
Shirley A. Blanchard, PhD, ABDA, OTR/L,
FAOTA Camille Dieterle, OTD, OTR/L
Associate Professor Director
Department of Occupational Therapy USC Occupational Therapy Faculty Practice
Creighton University Assistant Professor of Clinical Occupational Therapy
Omaha, Nebraska Division of Occupational Science and Occupational
Therapy
Peter Bowman, OTD, MHS, OTR/L,
University of Southern California
OT(C), Dip COT
Los Angeles, California
Assistant Professor
Division of Occupational Therapy Joy D. Doll, OTD, OTR/L
Medical University of South Carolina Assistant Professor
Charleston, South Carolina Director
Post-Professional OTD Program
Carol A. Brownson, MSPH
Program Director
Creighton University
Advancing Chronic Care through Excellence Omaha, Nebraska
in Systems & Support (ACCESS)
George Warren Brown School of Social Work David Ensminger, PhD
Washington University in St. Louis Assistant Professor
St. Louis, Missouri Teaching and Learning Program
School of Education
Kimberly Mansfield Caldeira, MS
Loyola University Chicago
Associate Director
Chicago, Illinois
Center on Young Adult Health and Development
University of Maryland School of Public Health
College Park, Maryland
viii
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Contributors ix
Rebecca I. Estes, PhD, OTR/L, CAPS Susan M. Nochajski, PhD, OTR/L

Associate Professor Clinical Associate Professor and Occupational Therapy
Occupational Therapy Department Program Director
Nova Southeastern University Department of Rehabilitation Science
Fort Lauderdale, Florida University at Buffalo
State University of New York
Wendy M. Holmes, PhD, OTR/L
Buffalo, New York
Associate Professor
School of Occupational Therapy Shannon Norris, OTR/L
Brenau University Private Practice Owner
Gainesville, Georgia Kids Kount
Daphne, Alabama
Sonia Lawson, PhD, OTR/L
Associate Professor Laurette Olson, PhD, OTR/L, FAOTA
Department of Occupational Therapy & Professor
Occupational Science Graduate Program in Occupational Therapy
Towson University Mercy College
Towson, Maryland Dobbs Ferry, New York
Paula Lowrey, MOT, OTR/L, CAPS Michael A. Pizzi, PhD, OTR/L, FAOTA
Occupational Therapist Assistant Professor
Independent Contractor Department of Occupational Therapy
Home Health Long Island University
Fort Lauderdale, Florida Brooklyn, New York
M. Beth Merryman, PhD, OTR/L, FAOTA Ruth Ramsey, EdD, OTR/L
Professor Associate Professor and Chair
Department of Occupational Therapy & Department of Occupational Therapy
Occupational Science Dominican University of California
Towson University San Rafael, California
Towson, Maryland
Lauren Ashley Riels, MS, OTR/L
Emily Wilson Mowrey, MS, OTR/L Occupational Therapist
Occupational Therapist Advanced Medical Personnel Services
Westerville, Ohio Hattiesburg, Mississippi
Penelope A. Moyers, EdD, OTR, FAOTA Courtney Sasse, MA EdL, MS, OTR/L
Dean Assistant Professor
Henrietta Schmoll School of Health Department of Occupational Therapy
St. Catherine University University of South Alabama
Saint Paul, Minnesota Mobile, Alabama
Peggy Strecker Neufield, PhD, OTR/L, FAOTA Janie B. Scott, MA, OT/L, FAOTA
Community Consultant and Advocate Occupational Therapy and Aging in Place Consultant
St. Louis NORC Research and Community Liaison Columbia, Maryland
St. Louis, Missouri
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x Contributors
Theresa Marie Smith, PhD, OTR/L, CLVT Lynn M. Swedberg, MS, OT

Assistant Professor Consultant, Occupational Therapist
Department of Occupational Therapy & Occupational Outreach Therapy Consultants, Inc.
Science Spokane, Washington
Towson University
Shun TAKEHARA, OTR
Towson, Maryland
Assistant Professor
Wendy B. Stav, PhD, OTR/L, SCDCM, FAOTA Department of Occupational Therapy
Chair and Professor Yamagata Prefectural University of Health Sciences
Occupational Therapy Department Yamagata City, Japan
Nova Southeastern University
Nancy Van Slyke, EdD, OTR/L, FAOTA
Fort Lauderdale, Florida
Associate Professor (Retired)
Virginia C. Stoffel, PhD, OT, BCMH, FAOTA Department of Occupational Therapy
Associate Professor University of South Alabama
Graduate Program Coordinator Mobile, Alabama
Department of Occupational Science & Technology
Donna A. Wooster, PhD, OTR/L
University of Wisconsin-Milwaukee
Associate Professor
Milwaukee, Wisconsin
President University of South Alabama
American Occupational Therapy Association Mobile, Alabama
Bethesda, Maryland
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Reviewers
Mariana D’Amico, EdD, OTR/L, BCP Catherine McNeil, MS, OTR/L

Assistant Professor Assistant Professor
Medical College of Georgia Worcester State College
Augusta, Georgia Worcester, Massachusetts
Carolyn R. Dorfman, PhD, OTR/L Jennifer J. Saylor, MEd, OT/L
Assistant Professor Program Director, Fieldwork Coordinator
The College of St. Scholastica New Hampshire Community Technical College
Duluth, Minnesota Claremont, New Hampshire
Karen P. Funk, OTD, OTR Stacy Smallfield, DrOT, OTR/L
Clinical Associate Professor, Program Chair Assistant Professor
University of Texas at El Paso The University of South Dakota
El Paso, Texas Vermillion, South Dakota
Susan Leech, EdD, OT
Assistant Professor
University of Texas at El Paso
El Paso, Texas
xi
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Acknowledgments
The Second Edition of this text would not have been possible without the encourage-
ment and assistance of many people who share our enthusiasm for community practice.
We would first like to acknowledge our universities, the University of South Alabama
and Towson University, for funding graduate assistants and other forms of support.
Several exceptional occupational therapy students and graduates were valuable contribu-
tors to the organization and production of this book, including Courtney Sasse from
the University of South Alabama and Marie Chandler, Stacey Harcum, Hollie Hatt,
and Stacey Greenberg from Towson University.
We are also indebted to the fine staff at F.A. Davis Company, especially Christa
Fratantoro, Senior Acquisitions Editor, for her encouragement and unwavering faith in
our work, and Peg Waltner, freelance developmental editor, for her exceptional guidance
and assistance throughout the project.
And last, but certainly not least, we would like to acknowledge the support of family
and friends. We are fortunate to have understanding, caring, and thoughtful people in our
lives, as we could not have completed this textbook without their assistance. However, our
spouses, Blaise Chromiak and Fred Reitz, deserve the South Alabama Jaguar and Towson
Tiger share of our gratitude and love for their patience as this project unfolded, evolved,
and finally came to fruition.
xii
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Contents
SECTION I Basic Principles and Relevant Issues 1

Chapter 1 Community-Based Practice: Occupation in Context 1
M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA
Introduction 2
Historical Perspectives of Community-Based Practice 2
Definitions of Terms 4
Health 4
Community 5
Community-Based Practice 5
Community Health Promotion 5
Community-Level Intervention 5
Community-Centered Initiatives/Interventions 5
Trends and Roles in Community-Based Practice 6
Role Descriptions 6
Characteristics of Effective Community-Based Occupational Therapy Practitioners 7
Paradigm Shifts in Occupational Therapy 8
Community Practice Paradigm 11
Characteristics of the Community Practice Paradigm 12
Conclusion 15
Chapter 2 Public Health, Community Health, and Occupational Therapy 19
M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA, AND C OURTNEY S. S ASSE , MA E D L, MS, OTR/L
Introduction 19
Public Health 20
Prevention 21
Health Promotion 21
Community Health 21
National Health Goals and Objectives for the United States 22
A Global Perspective 25
Improving Health and Well-Being Through Occupation 26
Practitioner Roles in Health Promotion and Community Health 27
Conclusion 27
Chapter 3 Theoretical Frameworks for Community-Based Practice 31
S. M AGGIE R EITZ , P H D, OTR/L, FAOTA, M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA,
AND M. B ETH M ERRYMAN , P H D, OTR/L, FAOTA
Introduction 31
Review of Terminology 32
Concepts and Constructs 32
Principle 32
Model 32
Theory 32
Paradigm 33
Conceptual Model of Practice 33
xiii
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xiv Contents
Theories Related To Community-Based Practice 33

Community Organization Approaches 33
Selected Health Education and Public Health Models and Theories 35
Social Cognitive Theory 35
Health Belief Model 37
Transtheoretical Model of Health Behavior Change 37
PRECEDE-PROCEED Planning Model 40
Diffusion of Innovations Model 41
Selected Occupational Therapy Models 42
Model of Human Occupation 42
Ecology of Human Performance 44
Person-Environment-Occupation Model 46
Examples of Research Using the PEO Model 46
Conclusion 47
Chapter 4 Legislation and Policy Issues 51

M. B ETH M ERRYMAN , P H D, OTR/L, FAOTA, AND N ANCY V AN S LYKE , E D D, OTR/L, FAOTA
Introduction 51
Legislation and Disabilities 53
Protection and Care Referenced Legislation 54
Educational and Developmental Referenced Legislation 54
Medical Rehabilitation Referenced Legislation 55
Civil Rights Referenced Legislation 56
Environment Referenced Legislation 56
Consumer Referenced Legislation 57
Federal and State-Level Policy and Community Practice 57
Advocacy Activities That Support Community Practice 58
Conclusion 58
SECTION II Community-Based Program Development 61

Chapter 5 Program Planning and Needs Assessment 61
M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA, AND C AROL A. B ROWNSON , MSPH
Introduction 62
Environmental Scanning and Trend Analysis 62
Program Planning Principles 63
Plan the Process 63
Plan With People 63
Plan With Data 64
Plan for Performance 64
Plan for Priorities 64
Plan for Evaluation 64
Plan for Measurable Outcomes 64
The Planning Process 64
Preplanning 65
Needs Assessment 66
Program Plan Development 71
Planning With Evidence 77
Conclusion 77
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Contents xv
Chapter 6 Program Design and Implementation 80

J OY D. D OLL , OTD, OTR/L
Introduction 80
Mission Statement 81
Implementation Plan 82
Program Goals and Objectives 82
Participant Recruitment 84
Location and Space Issues 85
Supplies and Equipment 86
Staffing and Personnel 86
Compliance With Practice Regulations 87
Financing Options 87
Start-Up Costs 87
Funding Sources 87
Establishing Fees for Service 88
Budgeting 88
Team Development 89
Establishing Partnerships 90
Program Management 91
Program Sustainability 92
Developing a Sustainability Plan 93
Conclusion 93
Chapter 7 Program Evaluation 96
D AVID E NSMINGER , P H D, M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA,
AND S. M AGGIE R EITZ , P H D, OTR/L, FAOTA
Introduction 96
Purpose of Program Evaluation 97
Focus of Program Evaluations 97
Needs Assessment 98
Program Theory Evaluation 98
Program Implementation Evaluation 99
Program Impact Evaluation 100
Program Efficiency Evaluation 100
Approaches to Program Evaluation 101
Objectives Approach 101
Managerial Approach 102
Participatory Approach 103
Utilization-Focused Approach 104
Appreciative Inquiry Approach 105
The Process of Planning and Conducting Evaluations 105
Identifying Stakeholders 105
Developing Evaluation Questions 106
Determining Data Needs 106
Choosing Evaluation Methods 107
Utilizing Evaluation Results 108
Communicating Evaluation Results 109
Ethical Issues in Community-Based Program Evaluation 109
Conclusion 112
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xvi Contents
Chapter 8 Entrepreneurship and Innovation in Occupational Therapy 114

M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA, M ICHAEL A. P IZZI , P H D, OTR/L, FAOTA,
AND W ENDY M. H OLMES , P H D, OTR/L
Introduction 114
Research on Entrepreneurs 115
The Entrepreneurial Mind-Set 115
The Entrepreneurial Process 115
Intrapreneurship 116
Social Entrepreneurship 117
Entrepreneurship and Innovation 118
Occupational Therapy Entrepreneurship 119
Identification of Trends 119
Characteristics of Effective Entrepreneurs 119
Importance of Research, Skill Building, and Planning 120
Benefits and Barriers to Starting a New Business 120
Starting a New Business: The Basics 120
For-Profit or Nonprofit 121
Incorporation Process 122
Starting a For-Profit Business 122
Developing a Business Plan 123
Starting a Non-Profit Organization 124
Strategic Planning 124
Fund-Raising 125
Grant Writing 127
Grant Proposals 128
Conclusion 129
SECTION III Children and Youth 133
Chapter 9 Early Intervention Programs 133
D ONNA A. W OOSTER , P H D, OTR/L, AND A BIGAIL B AXTER , P H D
Introduction 134
EI Programs 134
Components of Early Intervention 135
Individualized Family Service Plan 136
Team Members 136
Transition Planning 137
Occupational Therapy Services in EI 137
Occupational Therapy Evaluation 137
Sensory Processing and Neuromotor Status 140
Occupational Therapy Interventions 140
Conclusion 145
Case Study 9-1 Juan 145
Case Study 9-1 Discussion Questions 146
Chapter 10 Community-Based Services for Children and Youth With Psychosocial Issues 148
L AURETTE O LSON , P H D, OTR/L, FAOTA, AND C OURTNEY S. S ASSE , MA E D L, MS, OTR/L
Introduction 148
Mental Health Disorders in Children and Youth 149
Evaluation of Children and Youth in Community-Based Settings 151
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Contents xvii
Considerations in Designing Interventions for Children and Youth 152

Intervention Approaches for Community-Based Programming 153
Interventions to Develop Self-Regulation 154
Interventions to Increase Social and Task Competence 154
Family-Based Interventions 155
After School Programs 156
Family-Based Programming in ASPs 157
Summer Camps 158
Conclusion 159
Case Study 10-1 Sean and Serena 160
SECTION IV Productive Aging 167
Chapter 11 Driving and Community Mobility for Older Adults 167
W ENDY B. S TAV , P H D, OTR/L, SCDCM, FAOTA
Introduction 168
Contributions of Driving and Community Mobility 168
Consequences of Not Engaging in Community Mobility 169
Alternatives to Driving 169
Driving and Community Mobility Practice 171
Driving Rehabilitation Program Development 171
Role of Occupational Therapy Practitioners in Interventions 174
Interventions With the Person 174
Interventions With Organizations 175
Interventions With Populations 176
Conclusion 177
Case Studies 177
Case Study 11-1 Mr. Martin 177
Case Study 11-2 Mrs. Brown 178
Chapter 12 Adult Day Services Programs and Assisted Living Facilities 180
C OURTNEY S. S ASSE , MA E D L, MS, OTR
Introduction 180
Regulatory and Accrediting Agencies 181
Continuum of Care and Program Models 181
Adult Day Services Programs and Home Care Agencies 182
Independent Living Communities 183
Assisted Living Facilities 183
Nursing Homes 184
Occupational Therapy Roles 185
Maintaining and Maximizing Independence 185
Managing Chronic Conditions 186
Enhancing Quality of Life 186
Safety, Security, and Support for Caregivers and Community 187
Conclusion 187
Case Study 12-1 Nina and Jim 188
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xviii Contents
Chapter 13 Low Vision Services in the Community 191

T HERESA M ARIE S MITH , P H D, OTR/L, CLVT
Introduction 191
Low Vision and Occupational Performance 192
Low Vision Rehabilitation Team 193
Occupational Therapy for Clients With Low Vision 193
Low Vision Practice Settings 193
Referrals for Occupational Therapy 194
Intervention for Clients With Low Vision 195
Person 195
Environment 196
Occupation 196
Psychosocial Issues Associated With Low Vision 196
Low Vision Community Support 197
Funding and Billing Issues for Low Vision Occupational Therapy Services 197
Conclusion 198
Case Study 13-1 Mrs. Kindred 198
Chapter 14 Fall Prevention 201
K IMBERLY M ANSFIELD C ALDEIRA , MS, AND M ARY B ECKER -O MVIG , MS, OTR/L
Introduction 201
Fall Prevention in a Rural Senior Center 201
Overview of the Project 201
Needs Assessment 202
Program Planning 202
Program Implementation 204
Program Evaluation 204
Aging in Place Initiative 205
Conclusion 207
Case Study 14-1 Ms. Fay 207
Chapter 15 Aging in Place and Naturally Occurring Retirement Communities 210
P EGGY S TRECKER N EUFELD , P H D, OTR/L, FAOTA
Introduction 210
Societal Trends Impacting Aging in Place and Implications 211
NORC: A Solution for Successful Aging in Place 212
Research Evidence Linking Healthy Aging, Community Characteristics,
and Occupations 214
Occupational Therapy Roles in Aging in Place Communities and NORCs 214
Conclusion 217
Case Study 15-1: Morris, Finding Purpose in Helping Others 218
SECTION V Work and industry 223
Chapter 16 Ergonomics and Prevention of Work-Related Injuries 223
P ETER B OWMAN , OTD, MHS, OTR/L, OT(C), D IP COT
Introduction 224
Ergonomics Definitions and History 224
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Contents xix
Role of Occupational Therapy in Community Ergonomics 225

General Ergonomic Considerations 225
Posture, Positioning, and Lifting 225
Cognitive Workload 226
Psychosocial Factors 228
Sites for Community Ergonomics 228
Home 229
Recreation Sites 229
Workplace 230
Universal Design 230
Occupational Risks and Common Work Injuries 232
Injury Prevention 233
Comprehensive Work-Related Ergonomic Evaluation: Worker Assessment 235
Objective Assessment 235
Work Location Assessment 236
Occupational Therapy Intervention Evidence 236
Return to Work and Work Modification 237
Computer Equipment and Accessories 238
Laptop/Notebook Computer Issues 238
Program Development and Business Consultation 239
Conclusion 239
Case Study 16-1 Sandy 239
Chapter 17 Work and Career Transitions 243
S USAN M. N OCHAJSKI , P H D, OTR/L, AND S. M AGGIE R EITZ , P H D, OTR/L, FAOTA
Introduction 243
Transitioning From School to Employment 244
Role of Occupational Therapy in School to Work Transition 244
Community-Based School to Work Transition Programs 245
School to Work Transitions Program 245
Transitioning to Work Following a Disability 248
Transitioning to Active Duty or Civilian Employment 249
Transition to Retirement 251
Occupation-Based Retirement Planning 251
Bridge Employment 251
Legacy Planning in Employment and Volunteer Settings 252
Conclusion 252
Case Study 17-1 Carol 253
Chapter 18 Welfare to Work and Ticket to Work Programs 257
E MILY W ILSON M OWREY , MS, OTR/L, AND L AUREN A SHLEY R IELS , MS, OTR/L
Introduction 257
Welfare to Work 258
History of Welfare Reform 258
Recipient and Participant Demographics 258
Assessment of Welfare to Work Programs 259
Issues Related to Welfare to Work Transition 259
Causes of Low Job Retention 259
Enhancing Success in Welfare to Work Programs 260
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Occupational Therapy in Welfare to Work Programs 260

Occupational Therapy Roles 261
Barriers to Occupational Therapy Practice in Welfare to Work Programs 262
The Future of Occupational Therapy in Welfare to Work Programs 263
Ticket to Work Programs 263
Background 264
Employment Networks 264
Implementation Process 264
Payment Systems 265
Benefits and Limitations of the Ticket to Work Program 265
Implications for Occupational Therapy 267
Conclusion 267
Case Study 18-1 Aundria 268
Case Study 18-2 Austin 269
SECTION VI Mental Health 271
Chapter 19 Community Mental Health Programs 271
R UTH R AMSEY , E D D, OTR/L
Introduction 272
Theoretical and Conceptual Models 273
Stress-Vulnerability Model 274
Psychiatric/Psychosocial Rehabilitation Models 274
Recovery Model 275
Occupation-Based Approach 275
Community-Based Services for People With Serious Mental Illness 276
Partial Hospitalization/Intensive Outpatient Programs 276
Home Health Services 277
Peer Support and Peer-Run Programs 278
Supported Education Programs 278
Veterans Support Services 279
Transitional Housing 279
Evidence-Based Practices 280
Assertive Community Treatment 280
Supported Employment 281
Permanent Supportive Housing 282
Illness Management and Recovery 283
Family Support and Education 283
Occupational Therapy in Community Mental Health Settings 284
Role of Occupational Therapists 284
Occupational Therapy Evaluation and Interventions 284
Funding For Community-Based Mental Health 286
Conclusion 287
Case Study 19-1 Antonio 287
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Chapter 20 Community-Based Approaches for Substance Use Disorders 292

M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA, L AUREN A SHLEY R IELS , MS, OTR/L, P ENELOPE A.
M OYERS , E D D, OTR, FAOTA, AND V IRGINIA C. S TOFFEL , P H D, OT, BCMH, FAOTA
Introduction 292
Substance Use Terminology 293
Substance Use Disorders and Occupation 293
Community-Based Substance Abuse Services 295
Crisis Intervention 295
Intensive Outpatient Programs 296
Evidence-Based Practices 298
Brief Interventions 298
Motivational Approaches 299
Motivational Interviewing 300
Motivational Enhancement Therapy 301
Cognitive-Behavioral Approaches 301
Occupational Therapy in Substance Abuse Programs 303
Conclusion 304
Case Study 20-1 Richard 305
Chapter 21 Forensic Mental Health Practice Within the Community 309
R OXANNE C ASTANEDA , MS, OTR/L, AND S. M AGGIE R EITZ , P H D, OTR/L, FAOTA
Introduction 309
Entry Process to Criminal Justice System and/or the Forensic Mental Health System:
Client, Defendant, or Inmate? 310
Court System 310
Criminal Justice System 311
Forensic Mental Health System 311
Route to Community Reintegration 311
Defendant/Inmate 311
Adjudicated Not Criminally Responsible 312
Role of Occupational Therapy Community Re-entry With Forensic Clients 312
Challenges to Community Intervention 313
Public Safety 313
Cultural Dynamics of Criminal Justice and Forensic Mental Health Contexts 314
Institutional Jail/Maximum Security Hospital 314
Person 315
Community Agency Context 315
Mental Health Recovery Movement 315
Occupational Therapy Community Practice With Persons With Mental Health and
Criminal Justice/Forensic Involvement 316
Occupational Therapy Community Consultation-Liaison Service 316
Conclusion 318
Case Study 21-1 Aretha 318
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SECTION VII Rehabilitation and Participation 321

Chapter 22 Accessibility and Community Integration 321
J ANIE B. S COTT , MA, OT/L, FAOTA
Introduction 322
Accessibility Issues 322
Home Accessibility 323
Community Accessibility 323
Community Mobility 324
Personal Transportation 324
Public Transportation 325
Transportation Safety 325
Community Integration 325
Community Integration Post-Injury or Illness 326
Leisure and Recreation 327
Work 327
Wounded Warrior Project 328
Advocacy 328
Conclusion 328
Case Study 22-1 Veretta 329
Case Study 22-2 Paul 330
Chapter 23 Independent Living Centers 332
C OURTNEY S. S ASSE , MA E D L, MS, OTR/L
Introduction 332
History and Philosophy of the Independent Living Movement 333
History 333
Philosophy 334
Leaders and Advocates of the Independent Living Movement 334
Independent Living Programs: Meaningful Participation in the Community 336
The Four Core Services of Independent Living Programs and Centers 337
The Role of Occupational Therapy in Independent Living Centers 338
Preventive Occupational Therapy Services 339
Health Promotion Services 339
Services for Special Populations 340
The Future of Independent Living Centers 341
Conclusion 342
Case Study 23-1 Marianne 343
Case Study 23-1 Discussion Question 344
Chapter 24 Technology and Environmental Interventions in Community-Based Practice 346
R EBECCA I. E STES , P H D, OTR/L, P AULA L OWREY , MOT, OTR/L,
AND M ARY F RANCES B AXTER , P H D, OT, FAOTA
Introduction 346
Technology and Environmental Intervention Outcomes 347
Universal Design 348
Wheeled Mobility 349
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Communication Technology 351

Computer Access 352
Universal Design in Computer Use 353
Adaptations for Computer Access 353
Home Modifications and Electronic Aids to Daily Living 354
Electronic Aids to Daily Living 355
Funding for Home Modification 355
Advanced Training in Home Modification 356
Conclusion 356
Case Study 24-1 RP 357
SECTION VIII Health Promotion and Wellness 359
Chapter 25 Occupational Therapy in Faith-Based Organizations 359

L YNN M. S WEDBERG , MS, OT, AND S HIRLEY A. B LANCHARD , P H D, ABDA, OTR/L, FAOTA
Introduction 360
Historical Background 360
Faith Community as a Resource 360
Faith Communities and Health 360
Spirituality and Health 361
Occupational Therapy and Spirituality 361
Need for Occupational Therapy Involvement in Faith-Based Organizations 362
Health Ministry 362
Functions and Roles of the Faith-Community Practitioner as Health Minister 363
Disability Ministry 367
Missions and Outreach 367
Other Community-Based Occupational Therapy Roles in Faith-Based
Organizations 368
Recommended Training and Experience 369
Ethical Considerations 370
Self-Care 370
Future Directions 370
Conclusion 371
Case Study 25-1 Elaine 372
Chapter 26 Lifestyle Redesign Programs 377
C AMILLE D IETERLE , OTD, OTR/L
Introduction 377
Lifestyle Redesign Defined 378
Development of Lifestyle Redesign 379
Key Components of the Lifestyle Redesign Intervention Created for the USC
Well Elderly Study 381
Lifestyle Redesign Programs and Applications Since the USC Well Elderly Study 382
Lifestyle Redesign Weight Management Program 383
Lifestyle Redesign for Diabetes 385
Lifestyle Redesign for Chronic Headaches 385
Lifestyle Redesign for the College Student 385
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Lifestyle Redesign for Mental Health 385

Lifestyle Redesign Interventions Outside of USC Settings 386
Reimbursement for Lifestyle Redesign 386
Conclusion 386
Cases Study 26-1 Linda 387
Chapter 27 Occupational Therapy in Primary Health Care Settings 390
S. BLAISE CHROMIAK, MD, MARJORIE E. SCAFFA, PHD, OTR/L, FAOTA, AND SHANNON NORRIS, OTR/L
Introduction 390
Primary Health Care Services 391
Health Promotion in Primary Care Settings 393
Weight Loss 395
Tobacco Use and Smoking Cessation 396
Low Back Pain 397
Family and Intimate Partner Violence 397
Mental Health 398
Integrating Health Promotion Practices Into Routine Primary Care 400
Brief Office Interventions 400
Health Literacy Interventions 401
Chronic Disease Self-Management 401
Developing Health Promotion Programs for Primary Care 402
Working With Primary Care Physicians 404
Marketing Occupational Therapy Services to Physicians in Primary Care 404
Funding Occupational Therapy Services in Primary Care 405
Conclusion 405
Case Study 27-1 Doris 406
Chapter 28 Health Promotion Initiatives Within Academic Communities 409
J ENNA Y EAGER , P H D, OTR/L, S. M AGGIE R EITZ , P H D, OTR/L, FAOTA, M. B ETH M ERRYMAN ,
P H D, OTR/L , F AOTA , AND S ONIA L AWSON , P H D, OTR/L
Introduction 409
Policy Support for Occupational Therapy Involvement in Health Promotion in
Academic Communities 410
Healthy Campus Task Force 411
Promoting a More Inclusive Environment for Individuals With Psychiatric
Disabilities 412
Stroke Support Group 413
General Education/Core Curriculum Courses 415
Leisure and Health Course: Overview 415
Leisure and Health Course: Philosophical and Theoretical Foundation 415
Flow Theory 416
Model of Human Occupation 416
Health Belief Model 416
Leisure and Health Course: Assignments 416
Leisure and Health Course: Assessment 417
Leisure and Health Course: Replicability 417
Conclusion 418
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SECTION IX Looking Ahead 421

Chapter 29 Future Directions in Community-Based Practice 421
M ARJORIE E. S CAFFA , P H D, OTR/L, FAOTA, E RIN G UILLORY C ARAWAY , MS, OTR,
AND S HUN TAKEHARA, OTR
Introduction 422
An Ecological Worldview 422
Creating Opportunities in the Community 423
Innovative Ideas Put Into Action 424
Transition Services for Youth With Disabilities 424
Obesity Prevention and Intervention 426
Driving Across the Life Span 427
Aging-in-Place Home Modifications 427
Telerehabilitation 428
The Influence of Occupational Justice: An International Example 429
Implications for Professional Preparation and Education 429
Community Service Learning 432
Implications for Research in Community-Based Practice 433
Diffusion of Innovations 434
Conclusion 434
Case Study 29-1 Yuriko 435
Index 441
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SECTION I
Basic Principles
and Relevant Issues
Chapter 1
Community-Based Practice:
Occupation in Context
Marjorie E. Scaffa, PhD, OTR/L, FAOTA
We know what we are, but we know not what we may be.

—Shakespeare
Learning Objectives
This chapter is designed to enable the reader to:
• Describe the history of community-based practice in occupational therapy.
• Describe the variety of roles for occupational therapy practitioners in community-based practice.
• Describe the characteristics of effective community-based practitioners.
• Describe the history of paradigm shifts in occupational therapy.
• Identify key characteristics of a community practice paradigm for occupational therapy.
Key Terms
Client-centered approach Ecological approach
Community Health
Community-based practice Paradigm
Community-centered initiative/intervention Paradigm shift
Community health promotion Strengths-based
Community-level intervention occupational therapy
Dynamical systems approach
1
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2 SECTION I | Basic Principles and Relevant Issues
Introduction violence and abuse, and social discrimination

and stigma. Meeting the occupational needs of
In 2017, the profession of occupational therapy and society will require not only the provision of occu-
the American Occupational Therapy Association pational therapy services to individuals and families
(AOTA) will turn 100 years of age. In order to set in community-based settings, but also the provision
a course for the future and to celebrate the profes- of occupational therapy services to organizations,
sion’s history, the AOTA developed a Centennial communities, and populations.
Vision that reads: “We envision that occupational An overview of community-based practice for
therapy is a powerful, widely recognized, science- occupational therapy is provided in this chapter. Also
driven, and evidence-based profession with a glob- included are a review of the historical perspectives
ally connected and diverse workforce meeting of community-based practice, an identification of
society’s occupational needs” (Baum, 2006, p. 610). the various roles associated with community-based
A community practice paradigm is entirely con- practice, and a description of the characteristics nec-
sistent with this vision. For example, expanding essary for effective community-based occupational
community-based occupational therapy services and therapy practice. The major paradigm shifts in occu-
population-based interventions could make occupa- pational therapy, highlighting the impact of systems
tional therapy more visible, thereby enhancing theory, are presented. Concluding the chapter is a
understanding and recognition of the profession. discussion of the community practice paradigm as a
The improved awareness of occupational therapy client-centered approach to practice.
also may increase consumer demand for services.
If occupational therapy practitioners are working in
more varied settings and providing needed services, Historical Perspectives of
then more opportunities to influence policies and
take on leadership roles may result. Practicing in the
Community-Based Practice
community increases involvement with other pro- Community-based practice is not a new concept in
fessionals and assists in building alliances that also occupational therapy (Table 1-1). Two founders of
may expand the profession’s power base. In addi- the profession, George Barton and Eleanor Clarke
tion, community practice enables the development Slagle, developed community-based programs in the
of a variety of new roles for occupational therapy early 1900s. Barton, who was disabled by tubercu-
practitioners. Finally, because community practice losis and a foot amputation, established Consolation
occurs in environments where people work, play, go House in New York in 1914. The program used oc-
to school, and participate in activities of daily living, cupations to enable convalescents to return to pro-
the profession is more likely to be aware of and meet ductive living (Punwar, 1994; Sabonis-Chafee,
society’s occupational needs. 1989). Eleanor Clarke Slagle was hired in 1915 to
The AOTA Centennial Vision outlines six broad develop a program to provide persons with mental
practice areas, including children and youth; produc- or physical disabilities an opportunity to work and
tive aging; mental health; rehabilitation, work, and become self-sufficient. The project was funded by
industry; disabilities and participation; and health philanthropic contributions and was located at Hull
and wellness (Baum, 2006, p. 611). Community- House, a settlement house in Chicago. In its first
based services exist and can be developed within year of operation, the program served 77 persons
each of these practice areas, for example, ergonomic who developed manual skills and received wages for
consultation, driver evaluation and training, hip- their work. The goods produced in the workshop
potherapy, welfare-to-work programs, aging-in-place included baskets, needlework, rugs, simple cabinets,
services, aquatic therapy, and violence prevention and toys (Reed & Sanderson, 1999).
programs (Johansson, 2000; Scaffa, 2001). Occupa- Banyai (1938) wrote about the care individuals
tional therapy as a profession has the opportunity to with tuberculosis were receiving while residing in san-
respond to and help resolve the social and health itariums. While acknowledging the importance of
problems of the 21st century, including poverty, occupational therapy intervention in the institution,
homelessness, addiction, depression, joblessness, she emphasized the need to follow the patient into
chronic disease and disability, unintentional injury, the community. The ultimate goal was to restore the
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Chapter 1 | Community-Based Practice: Occupation in Context 3
Table 1-1 Historical Timeline of Community Practice in Occupational Therapy

Date Event
1914 George Barton establishes Consolation House in New York.
1915 Eleanor Clarke Slagle establishes the work program at Hull House in Chicago.
1937 Humphreys advocates community treatment for persons with developmental disability.
1938 Banyai advocates following tuberculosis patients into the community after discharge from
sanitariums.
1940 The AOTA reports on roundtable discussions held at national conference on the role
of occupational therapy in community health.
1968 Bockhoven suggests that occupational therapy take responsibility for community
occupational development.
1969—1973 In the United States, West, Reilly, and Mosey describe the need for occupational therapy
services in the community.
1972 Llorens describes a community-based program in San Francisco for pregnant teenagers.
1972 Finn argues that the profession move beyond the role of therapist to “health agent.”
1973 Hasselkus and Kiernat describe an independent living program for the elderly.
1974 The AOTA Task Force on Target Populations expands the role of the profession to include
health promotion and disability prevention.
1977 Laukaran describes the major obstacles to community-based practice.
1982 Kirchman, Reichenback, and Giambalvo describe a prevention program for the well
elderly.
1997 Well-elderly study published in the Journal of the American Medical Association.
2006 ACOTE accreditation standards revised with increased emphasis on health promotion
and population-based services.
2006 AOTA adopts the 2017 Centennial Vision.
individual to a satisfactory level of social and eco- competencies. This broader perspective requires the
nomic functioning. Banyai (1938) believed that this professional to provide therapeutic programming in
required the occupational therapist to work with the the individual’s milieu, including home, workplace,
person in the community after discharge from the and community.
institution. In spite of these early admonitions to focus on
The professional literature of the 1960s suggests broader health needs and services outside of institu-
that the field was on the verge of expanding its ser- tional settings, the move to community-based prac-
vices outside of traditional medical settings (Laukaran, tice was short-lived and very limited in scope. In the
1977). West (1969) asserted that “the traditional 1970s and 1980s, examples of outreach into the com-
role of the occupational therapist, that of the rein- munity included an independent living project for
tegration of social function, is not a hospital service the elderly (Hasselkus & Kiernat, 1973), a project in
but rather a function that can be best filled in the San Francisco for pregnant teenage girls (Llorens,
community” (p. 231). Reilly (1971) advocated that 1972), and prevention services for the well elderly
the future growth of the profession was predicated (Kirchman, Reichenback, & Giambalvo, 1982).
on the transition of occupational therapy services According to Laukaran (1977), three major obstacles
from the hospital to the community. The focus of to community-based practice existed at that time.
occupational therapy, in her view, should be to These barriers were practical constraints, historical
develop experiences and programs in the individ- factors within the discipline, and gaps in knowledge
ual’s community environment that enhance adaptive and theory related to community-based practice. The
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practical constraints were related to the limited num- (p. 25). The AOTA (1974) Task Force on Target
ber of opportunities for community-based practice Populations redefined occupational therapy as “the
at that time and the public perception of occupational science of using occupation as a health determinant”
therapy as a medical discipline. Historically, occupa- (p. 158). This definition advanced the notion that
tional therapy practitioners’ professional identities occupational therapy was not limited to the seri-
had been associated with work in medical institu- ously or chronically ill but also could remediate mild
tions. In addition, professional education programs to moderate impairments and contribute to health
emphasized preparation for practice in medical rather promotion and disability prevention.
than community-based settings. Laukaran (1977) Finn (1972), in the 1971 Eleanor Clarke Slagle
noted that some theoretical frameworks of that era Lecture, states: “In order for a profession to main-
(e.g., occupational behavior, biopsychosocial, and de- tain its relevancy it must be responsive to the trends
velopmental models) were compatible with commu- of the times … Occupational therapists are being
nity-based practice. However, these early models were asked to move beyond the role of therapist to that
inadequate in providing guidelines and rationales of health agent. This expansion in role identity will
for services in community settings. require a reinterpretation of current knowledge, the
Some of these same obstacles exist today, albeit in addition of new knowledge and skills, and the revi-
different forms. Opportunities for utilizing occupa- sion of the educational process” (p. 59).
tional therapy expertise in community settings are lim- These words are still true today. The expanded
itless but typically not designated as occupational role of health agent requires practitioners to move
therapy positions. For the profession to move into into the community and provide a continuum of
these settings, practitioners must seek out positions services; these include health promotion and disabil-
that although not labeled “occupational therapy” ity prevention in addition to the intervention services
could benefit from the unique contributions of the typically provided by the profession. Health agent is
discipline. The perception of occupational therapy as more than “therapist.” Other roles, such as consult-
strictly a medical discipline continues to exist both ant, advocate, community organizer, program devel-
outside and within the profession. The identity of oper, and case manager, are also included.
“medical professional” is an alluring one, as in the past
it denoted an aura of legitimacy. Many occupational
therapy practitioners today are reluctant to “let go” of Definitions of Terms
this restrictive image in favor of a more broadly
To conceptualize and operationalize community-
defined role. In addition, professional preparation
based practice in occupational therapy, definitions of
programs are slow to shift focus. However, many
some terms have been adopted for the purposes of this
educators concur that the future of the profession will
textbook. These terms include health, community,
largely be determined by its ability to expand the scope
community-based rehabilitation, community-based
of practice into community-based settings (Holmes
practice, community health promotion, community-
& Scaffa, 2009a). Many more theoretical frameworks
level intervention, and community-centered initiatives/
exist today than existed in the 1960s. These newly
interventions.
emerging models, based on the work of previous
theorists, are readily applicable to community-based
practice. Some of these theories and models are Health
described in detail later in Chapter 3. Health is defined as the ability to: “realize aspira-
Interestingly, one of the boldest predictions and tions, to satisfy needs, and to change or cope with
strongest support for the validity of occupational the environment. Health is, therefore, seen as a
therapy services in the community came from resource for everyday life … a positive concept em-
a physician in 1968. Bockhoven (1968) suggested a phasizing social and personal resources, as well as
new role for occupational therapists, described as physical capacities. . . . The fundamental conditions
“taking responsibility for community occupational and resources for health are peace, shelter, educa-
development, alongside the businessman, city plan- tion, food, income, a stable ecosystem, sustainable
ner and the economist … to support growth of resources, social justice and equity” (World Health
respect for human individuality in occupation” Organization, 1986, p. 1).
2580_Ch01_001-018 16/07/13 2:42 PM Page 5
Community more appropriately referred to as “community out-

reach” (Robnett, 1997).
“Community” means different things to different
people. No single definition appears to capture the
richness and diversity of the term, but combining Community Health Promotion
the following definitions provides a broad and com-
Community health promotion can be defined as
prehensive perspective. Community refers to “non-
“any combination of educational and social sup-
institutional aggregations of people linked together
ports for people taking greater control of, and
for common goals or other purposes” (Green &
improving their own or the health of a geographi-
Raeburn, 1990, p. 41). It is the “space where people
cally defined area” (Green & Ottoson, 1999,
think for themselves, dream their dreams, and come
p. 729). Educational programs may be directed at
together to create and celebrate their common hu-
individuals, families, groups, or communities
manity” (O’Connell, 1988, p. 31). Community is
through schools, work sites, organizations, and/or
“a social unit in which there is a transaction of com-
mass media. Social approaches focus on organiza-
mon life among the people making up the unit”
tional, legal, political, and economic changes that
(Green & Anderson, 1982, p. 26). This social unit
support health and well-being. “Organized com-
has its own norms and through the regulation of re-
munity effort is the key to community health.
sources organizes both the environment and indi-
There are some things the individual can do entirely
vidual and group behavior.
alone, but many health benefits can be obtained
The community or neighborhood setting is
only through united community effort” (Green &
a vital part of growing up, raising families, and
Anderson, 1982, p. 4).
meeting the many challenges and stresses of mod-
ern life (Warren & Warren, 1979). According to
Nisbit (1972), people do not come together in Community-Level Intervention
community relationships merely to be together;
Community-level interventions “attempt to modify
they come together to do something that cannot
the socio-cultural, political, economic and environ-
easily be done in isolation.
mental context of the community to achieve health
goals” (Scaffa & Brownson, 2005, p. 485). These
Community-Based Practice are population-based approaches to health and do
Community-based practice is more comprehensive not focus on individual health behavior change.
than community-based rehabilitation. Community- Community-level interventions are directed at
based practice includes a broad range of health-related impacting systems that affect health in communi-
services: prevention and health promotion, acute and ties. Often initiated by health care and government
chronic medical care, habilitation and rehabilitation, agencies, they typically involve community organi-
and direct and indirect service provision, all of which zation strategies. Decisions are often based on the
are provided in community settings. “Community” source of funding, and planning is done by a “lead”
in this framework “means more than a geographic agency. The professional serves as an expert in a
location for practice, but includes an orientation to leadership capacity.
collective health, social priorities, and different
modes of service provision” (Kniepmann, 1997,
p. 540). Community models are responsive to indi- Community-Centered
vidual and family health needs in homes, workplaces, Initiatives/Interventions
and community agencies. In this way, interventions Community-centered initiatives/interventions are
are contextually embedded. The goal in community- often generated by leaders and members of the com-
based practice is for the client and the practitioner to munity and typically utilize existing community
become integral parts of the community. Some resources. Community coalitions form to identify
hospitals and rehabilitation centers provide field trips common concerns and needs and to design ap-
in the community for patients or clients and health proaches to solve community problems. Community-
fairs for community members, but these activities are centered interventions follow the principles of
not considered community-based services. They are client-centered practice, where the client is the entire
2580_Ch01_001-018 16/07/13 2:42 PM Page 6
community. In this way, community-centered ini- the community. This vision acknowledged the newly
tiatives promote community participation, exchange emerging focus on prevention and health promotion
of information, and community autonomy. The role in medicine and the impact this new focus would have
of the professional is as a consultant, facilitator, and on practice settings, roles, and responsibilities. West
mentor in the community. Occupational therapists (1967) predicted that, as a result of the change in
can participate in community-centered initiatives by focus, practice would move into new settings,
“identifying occupational risk factors, engaging in “namely, the communities in which our potential
problem-solving and proposing and implementing patients live, work and play” (p. 312). She described
solutions” that meet the community’s unique occu- four emerging roles that at the time were adding new
pational needs (Scaffa & Brownson, 2005, p. 485). dimensions to the traditional role of the clinically
based occupational therapist. These new roles included
evaluator, consultant, supervisor, and researcher.
Trends and Roles in Other roles that community-based practitioners
may fulfill include program planners and evaluators,
Community-Based Practice staff trainers, community health advisors, policy
makers, and primary care providers. Practitioners in
The AOTA 2010 Workforce Study (AOTA, 2010)
the community may function as community health
indicated that 2.0% of occupational therapy practi-
advocates, consultants, case managers, entrepreneurs,
tioners work in community settings including adult
supervisors, and program managers. Descriptions of
day care, independent living centers, assisted living
these roles follow in the next section. It is important
facilities, senior centers, and supervised housing
for community-based practitioners in these roles to
among others. In addition, 2.3% work in settings
develop networks for support and collaboration with
characterized as “other” including driving programs,
other occupational therapy practitioners, health and
supported employment, sheltered workshops, and
social service professionals, and community leaders.
industrial rehabilitation/work programs, all of which
are community-based. A total of 4.8% of occupa-
tional therapy practitioners work in early interven- Role Descriptions
tion programs. These data reveal that approximately
9.1% of occupational therapy practitioners work in Community Health Advocate
community settings. This does not include the 2.9% As a community health advocate, practitioners iden-
of occupational therapy practitioners who work in tify the social, physical, emotional, medical, educa-
community-based mental health programs and the tional, and occupational needs of community
5.8% who work in home health. members for optimal functioning and advocate for
Median annual compensation for occupational services to meet those needs. In addition, practition-
therapists working full-time in community settings ers act as advocates and lobbyists by providing input
ranged from $59,000 to $71,350, depending on the and shaping legislation and government policies,
number of years of experience. The overall median thereby affecting local and national physical and
annual compensation for occupational therapists mental health issues and changing environmental
working in community settings was $68,000, while conditions to promote health.
for occupational therapists working full-time across
all settings it was $64,722. This demonstrates that the Consultant
common perception that occupational therapists in Occupational therapy practitioners in the role of
community settings earn less than their counterparts consultant provide information and expert advice
in more traditional settings is a myth (AOTA, 2010). regarding program development and evaluation,
Occupational therapy practitioners have a signifi- supervisory models, organizational issues, and/or
cant role to play in supporting individuals in their clinical concerns. Consultation is “an interactive
homes and workplaces, facilitating their independ- process of helping others solve existing or potential
ence, and promoting their integration into the com- problems by identifying and analyzing issues, devel-
munity (Stalker, Jones, & Ritchie, 1996). More than oping strategies to address problems and preventing
30 years ago, West (1967) described her vision of the future problems from occurring” (Epstein & Jaffe,
changing responsibility of occupational therapists to 2003, p. 260). Consultation services are most often
2580_Ch01_001-018 16/07/13 2:42 PM Page 7
utilized when new programs are being developed or A broad overview of entrepreneurship is provided
undergoing significant change and may be short- in Chapter 8.
term or long-term, depending on the needs of the
program. Within the community, occupational ther- Supervisor
apy practitioners can act as consultants to a variety Supervisors typically manage and are responsible for
of groups, such as Scouts or Boys & Girls Clubs, all the activities of their team members. A supervisor
adult education programs, adult day care, transi- sets up work schedules, delegates tasks, recruits and
tional living programs, independent living centers, trains employees, and conducts performance ap-
community development and housing agencies, praisals. In occupational therapy practice, supervision
health departments, military bases and organizations, is designed to “ensure the safe and effective delivery
and work site safety and health programs. of occupational therapy services and foster profes-
sional competence and development” (AOTA, 2009,
Case Manager
p. 797). The role of an occupational therapy supervi-
As a case manager, a practitioner coordinates the sor varies from facility to facility but generally in-
provision of services; advises the consumer, family, cludes training and evaluating staff and fieldwork
or caregiver; evaluates financial resources; and advo- students, developing and reviewing intervention plans
cates for needed services. Case management requires and progress updates, solving problems as needed,
a professional who has ample clinical experience, and contributing to budget and program develop-
understands reimbursement mechanisms, and has ment. Supervisors typically do not have final budget-
good organizational skills. Frequently, the qualifi- ary or personnel authority but assume responsibility
cations and duties of case managers are dictated by for the day-to-day operations of the program.
state regulations. Occupational therapy practitioners
are most often designated as case managers in men- Program Managers
tal health and children and youth practice areas. Program managers are responsible for the overall
While the primary role of case managers is to design, development, function, and evaluation of a
ensure access to community services and resources, program; budgeting; and staff hiring and supervision.
they may also assist in the development of inde- Many occupational therapists have served as program
pendent living skills (e.g., money management, managers in community settings (Fazio, 2008). Pro-
social interaction, and cognitive skills such as deci- gram managers conduct needs assessments, SWOT
sion making and problem solving). Occupational (strengths, weaknesses, opportunities, threats) analy-
therapists are qualified by their education and train- ses, strategic planning, and program development
ing to serve as case managers and/or to supervise functions. Occupational therapists not in positions
others in case management positions. officially designated as program manager may be
Private Practice Owner/Entrepreneur asked to expand existing programs or develop new
programs to meet client needs. Program managers in
An occupational therapy entrepreneur is “an indi-
community-based settings tend to “use a more inter-
vidual who organizes a business venture, manages
active approach that promotes open communication,
its operation, and assumes the risks associated with
feedback and collaboration than managers in more
the business” (Vaughn & Sladyk, 2011, p. 167).
traditional, institutionally-driven medical settings”
The entrepreneur may own a private practice, pro-
(Scaffa, Doll, Estes, & Holmes, 2011, p. 320).
vide services on a contractual basis, and/or function
as a consultant. In order for entrepreneurs to be suc-
cessful, they must be able to assess and respond to
the unique needs of their communities. Changing Characteristics of Effective
demographics, including the significant growth of Community-Based
the aging population, will provide a variety of
opportunities for occupational therapy entrepre- Occupational Therapy
neurs. In order to be successful, entrepreneurs must Practitioners
have a wide range of skills including financial man-
agement, marketing, leadership, and organizational According to Learnard, “occupational therapy in
and team-building skills (Vaughn & Sladyk, 2011). community health is both an art and a science”
2580_Ch01_001-018 16/07/13 2:42 PM Page 8
(Robnett, 1997, p. 30). In addition to the typical • Networking skills

occupational therapy focus on enhancing function • Organizational skills
through task analysis and modification of important • Professional autonomy
life tasks and the environment, occupational thera- • Program planning and evaluation skills
pists in community-based practice need a variety of • Public relations skills
other skills and attributes. According to Robnett
(1997), Learnard believes effective community-based
therapists exemplify the following characteristics: Paradigm Shifts in
• Sense of positive hopefulness Occupational Therapy
• Understanding of individuals in their specific
personal circumstances A paradigm is a conceptual framework that allows
• Creativity to envision a variety of possibilities explanation and investigation of phenomena. Kuhn
• Ability to set aside one’s cultural, personal, (1970) defined a paradigm as “universally recog-
and professional biases and respect individual nized scientific achievements that for a time provide
choices rather than passing judgment model problems and solutions to a community of
practitioners” (p. viii). Paradigms have two essential
Holmes and Scaffa (2009b) studied twenty-
characteristics. They are (a) sufficiently unprece-
three occupational therapists working in emerging
dented scientific achievements that draw a large
practice areas and attempted to identify the com-
number of constituents from competing areas of in-
petencies needed to work in new or underdevel-
quiry, and (b) adequately open-ended enough to
oped practice settings. The competencies were
allow for the exploration of solutions to a variety of
identified through the use of the Delphi technique
problems. A paradigm is a worldview that charac-
of forecasting, whereby respondents have multiple
terizes a particular group or discipline that has com-
opportunities to identify, rate, and rank the char-
mon interests. It is a “consensus-determined matrix
acteristics they deem essential for emerging prac-
of the most fundamental beliefs or assumptions of
tice. The competencies and characteristics were
a field” (Kielhofner, 1983, p. 6). A profession or
classified into five categories used in the AOTA
discipline-specific paradigm determines
Standards for Continuing Competence (AOTA,
1999), which included: • how professionals view their phenomenon of
interest;
1. knowledge required for multiple roles,
• what puzzles, problems, or questions practi-
2. critical reasoning necessary for decision
tioners will seek out in their work;
making in those roles,
• what solutions will emerge; and
3. interpersonal abilities to establish effective
• what goals will be set for the direction of the
relationships with others,
profession.
4. performance skills and proficiencies for
practice, and A paradigm is the “cultural core of the discipline”
5. ethical reasoning for responsible decision and “provides professional identity” (Kielhofner,
making. 1997, p. 17).
Kuhn (1970) asserted that change within a disci-
A sixth category—traits, qualities, and character-
pline or profession does not occur gradually. Rather, it
istics—was added based on the Delphi panel
occurs very dramatically. When a discipline abandons
responses. The competencies and characteristics
one view of the world for another, it has undergone
identified by the Delphi panel are listed in Box 1-1
a revolution, a drastic conceptual restructuring, called
(Holmes & Scaffa, 2009b).
a paradigm shift. Often, there is much resistance to
In addition, the following attributes and skills are
paradigm shifts and to those initiating them. Para-
recommended for those contemplating practice in
digm shifts dramatically change the existing rules, cre-
community settings:
ate new trends, and trigger innovations. Paradigm
• Comfort with indirect service provision shifts occur in four stages: preparadigm, paradigm,
• Grant-writing skills crisis, and return to paradigm.
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Box 1-1 Competencies and Characteristics Needed for Emerging Practice Areas
Listed in order of importance ratings Think outside of the box

Knowledge Competencies* Use good judgment—know when to seek assistance
Think abstractly
Occupation-based practice for evaluation and
Complete a SWOT analysis
intervention
Philosophy of occupational therapy Ethical Reasoning Competencies*
Occupational therapy models and frames of Self-assessment of strengths and needs for ongoing
reference applied to intervention professional development
Principles of client-centered practice Principles of social justice
Occupational therapy practice framework: domain Principles of occupational justice
and process Interpersonal Abilities Competencies*
Core values of occupational therapy
Listen actively
Program development
Communicate occupational therapy concepts to
Potential occupational therapy role and contribution
a variety of audiences
in the practice area
Establish relationships with stakeholders and
Community systems
community leaders
Public health principles and practice models
Network effectively with other professionals
Performance Skills Competencies Demonstrate cultural competence
Envision occupational therapy roles and service Establish and maintain relationships with
possibilities professionals
Implement client-centered practices Seek mentors within and outside of the
Assess, evaluate, and provide intervention for occupational therapy profession
occupational issues Understand and use language and terms of other
Work collaboratively with others professions
Identify and access available resources Negotiate effectively
Search, analyze, and synthesize evidence-based Ask for feedback, advice, and assistance from
research for emerging practice colleagues and friends
Seek opportunities to demonstrate and use skills to Traits, Qualities, and Characteristics
meet clients’ needs
Self-starter, self-directed
Select, administer, and interpret evaluation results
Adaptable to new situations
for variety of practice areas
Able to step outside of the medical model
Conduct comprehensive task and activity analyses
Self-confident
Provide consultation to groups and individuals
Persevering, determined, and persistent
Critical Reasoning Competencies* Flexible
Reason holistically Tolerant of ambiguity
Translate theory to practice An independent worker
Solve problems Creative
Use clinical reasoning for client services Able to challenge the status quo
Category headings* from “Standards for Continuing Competence” by the American Occupational Therapy
Association, 1999, American Journal of Occupational Therapy, 53, 559—560.
Data from: Holmes & Scaffa (2009). An exploratory study of competencies for emerging practice in
occupational therapy. Journal of Allied Health, 38 (2), 81—90.
Kielhofner conducted an historical examination of a daily routine of occupations in a family-like atmos-

paradigm shifts in occupational therapy (Fig. 1.1). phere (Neidstadt & Crepeau, 1998). Participation in
According to Kielhofner (1983), the pre-paradigm occupations was believed to normalize disorganized
stage in occupational therapy traces its roots to the habits and behaviors (Kielhofner, 1997). During the
moral treatment movement with its humanistic focus. 18th and 19th centuries, the moral treatment philos-
Moral treatment proponents advocated that the treat- ophy was competing with a pathology-oriented
ment of persons with mental illness should emphasize approach in the treatment of the mentally ill.
2580_Ch01_001-018 16/07/13 2:42 PM Page 10
Emerging Crisis occupational therapy educational programs. Occu-

paradigm (1970s) pational therapy practice began to align itself more
(from 1980 closely with the medical model and adopted
through Mechanistic the medical paradigm of reductionism with few
the 1990s) paradigm modifications (Kielhofner, 1983).
(1960s) The reductionist, or mechanistic, paradigm of the
Paradigm of Crisis 1960s asserted that by focusing on the inner mech-
occupation (1950s) anisms of disease and disability (i.e., neurophysiol-
(from 1900 ogy, anatomy, kinesiology, and psychoanalysis),
through occupational therapy could actually alter function
the 1940s)
and thereby gain professional respect as a scientific
discipline. The early paradigm of occupation had a
Moral holistic appreciation of the occupational nature of
treatment human life. The new paradigm provided a more
(18th and in-depth view and shifted professional thinking
19th from the gestalt to a reductionist focus on parts. The
centuries)
medical model, or reductionist paradigm, was not
Fig. 1•1 Paradigm Shifts in Occupational Therapy. simply added to the paradigm of occupation; the
(From Kielhofner, G. [1997, p. 48]. Conceptual foundations former replaced the latter and, as a result, the focus
of occupational therapy [2nd ed.]. Philadelphia, PA: F.A. of occupational therapy practice changed dramati-
Davis. With permission.) cally in the 1960s and 1970s. Practitioners dropped
“occupations” from therapy in favor of exercise, talk
groups, specialized treatment techniques, and
During the first four decades of the 20th century, modalities (Kielhofner, 1983).
a remarkable degree of consensus emerged among The reductionist, or mechanistic, paradigm was
practitioners and in the literature regarding “occu- not, and is not, altogether negative. New assistive
pation” as the central phenomenon of interest. devices and technology, new techniques (e.g., sen-
Although the paradigm of occupation originated in sory integration and neurodevelopmental treat-
the mental health arena, it was easily applicable to ment), and greater respect from the medical
physical disabilities. Occupation referred to the bal- community emerged from this approach. The major
ance of work, play, self-care, and rest. Occupational loss was the profession’s commitment to the occu-
therapists of the time viewed the individual holisti- pational nature of human beings and the impor-
cally, composed of both mind and body, participat- tance of occupation as a therapeutic medium.
ing in daily tasks in interactions with his or her Without this common theme of early practice, the
environments. Occupations were graded according specialty areas within the field began to drift apart,
to the individual’s capabilities. Persons progressed leading to a second paradigm crisis.
from simple activities that stimulated the senses This second paradigm crisis, which occurred in
to more demanding occupations requiring concen- the 1970s, was precipitated by the recognition
tration and skill (Kielhofner, 1997). that reductionism was an inadequate framework
The first paradigm crisis is evident in the pro- for understanding the complexities of human
fessional literature of the late 1940s and early occupational behavior. Awareness grew that the
1950s, when increasing pressure from medicine to problems of the chronically disabled could not be
be more scientific led to the questioning of the par- solved by technology alone. In addition, occupa-
adigm of occupation. The literature began to favor tional therapists expressed dissatisfaction over a
kinesiological, neurophysiological, and psychoan- loss of professional identity, a fragmented ideol-
alytic approaches to occupational therapy practice. ogy, and a lack of professional unity (Kielhofner,
The depression of the 1930s caused much job in- 1983, 1997).
security, compelling occupational therapy to de- According to Kielhofner (2004), a new para-
velop a closer relationship with medicine. The digm is emerging that recommits itself to the core
American Medical Association began accrediting construct of occupation and attempts to regain the
2580_Ch01_001-018 16/07/13 2:42 PM Page 11
profession’s identity and holistic orientation. The the role of the professional and the therapeutic
emerging paradigm is characterized by a synthesis relationship between provider and “patient” is dif-
of useful concepts from the mechanistic paradigm ferent in the two paradigms (Table 1-2). In addi-
with contemporary knowledge of occupation from tion, some basic terminology from the medical
many disciplines. In addition, the emerging para- model, such as “patient,” is clearly inappropriate
digm utilizes a systems perspective. An underlying in community settings. Occupational therapy prac-
assumption of “systems theory is that no system titioners must make a conscious effort to modify
(e.g., cell, person, or organization) can be fully their use of terminology from patient to client, from
explained by examining the component parts treatment to intervention, and from reimbursement
of which it is made” (Kielhofner, 2004, p. 66). to funding. Use of medical language can limit one’s
A systems viewpoint emphasizes that occupational perspective, unnecessarily narrow professional focus,
performance results from the dynamic interaction and decrease the ability to perceive options.
between the person, the environmental context, In the transition from a medical model paradigm
and the occupations in which the person engages. to community practice, professionals need to relin-
In addition, it allows for a more complex perspec- quish responsibility, power, and control to the
tive on factors that impact occupational perform- recipient of services, client, or community member.
ance and therefore a broader range of potential The client is the expert regarding his or her situa-
solutions to occupational performance problems. tion, needs, and desires. Therefore, the client is the
The purpose of occupational therapy in this person who makes the decisions regarding the services
perspective is to provide “opportunities and envi- utilized. For community practice to be successful,
ronmental resources that support the emergence planning must be coordinated with and through a
of new patterns of performance and participation variety of agencies, organizations, and individuals in
in everyday life” (Kielhofner, 2004, p. 66). the community. The impact of culture also must be
recognized, appreciated, and incorporated into service
delivery. Ultimately, the professional reports to the
Community Practice Paradigm client who is both the recipient and evaluator of the
Community health care is more than just a decen- services provided.
tralization of services through outreach into the In the community, professionals function as
community. It includes a focus on community facilitators whose role is to build and reinforce
health in addition to individual health. Functioning capacity and develop leadership in others. This
effectively in the community will require a range of requires humility, the ability to share successes with
new roles for the practitioner and a unique set of
knowledge, skills, and attitudes (Wiemer & West,
1970). A main difference between the model of Table 1-2 Contrasting Paradigms
community health espoused by Wiemer and West
(1970) and the model that is currently being pro- Medical Model Community Model
posed is that Wiemer and West believed that com- Professional Community member
munity health was merely an extension of the is responsible is responsible
medical model into community-based settings. The Professional Community member
current belief is that community health requires a has power has power
paradigm different from that of the medical model,
Professional makes Community member
a reductionist perspective, that is, a shift to a new decisions makes decisions
way of thinking. This new paradigm is, however,
consistent with the early foundations of occupa- Professional is Community member
the “expert” is the “expert”
tional therapy and represents a return to the early
principles of the profession. Professional answers Professional answers
Though it is easy to critique the limitations of to the agency to the consumer
medical models of health care delivery, it is far more Planning is fragmented Planning is coordinated
difficult to describe the essential components of a Culture is denied Culture is appreciated
new, more community-oriented paradigm. Clearly,
2580_Ch01_001-018 16/07/13 2:42 PM Page 12
others, and patience. Successful practice in the Box 1-2 Assessment of Population
community requires more time than in the typical and Context
clinical setting, as consensus must be developed and
resources identified and obtained to support indi- I. Assessment of the population:
viduals in maintaining a satisfying lifestyle in the A. General demographics (age, gender,
community of their choice. diagnoses, etc.)
B. Current and anticipated living and working
Assessment of individuals in community settings
environments and role expectations
may include the traditional components of occupa- C. Current performance in areas of activities of
tional therapy evaluation, such as areas of occupa- daily living, instrumental activities of daily living,
tion, performance patterns, performance skills, and work, education, sleep/rest, play/leisure, and
client factors (AOTA, 2008). However, this type of social participation
evaluation is usually insufficient in the community D. General performance component assets and
setting. Client factors are often the primary focus in deficits
the medical model. In community practice, the per- E. Significance of these factors with respect to
formance areas of activities of daily living, instru- community members’ goals and needs
mental activities of daily living, rest/sleep, work, II. Assessment of the context:
education, play/leisure, social participation, and A. General characteristics of the agency/program
(mission, goals, etc.)
contexts/environment take on much more signifi-
B. Characteristics of the physical environment
cance. If the focus of intervention is not the individ- C. Characteristics of the social environment/milieu
ual but rather on a collection of individuals—for (norms, emotional and cultural climate, etc.)
example, a family, a community, or some subpopu- D. Availability of resources (space, materials,
lation of a community such as members of a senior staff, etc.)
center—then assessment must be much broader in E. Significance of these factors with respect to
scope. Assessment in community settings requires community members’ goals and needs
attention to the population to be served and the
context in which the services will be delivered
(Box 1-2). Intervention planning utilizes the infor- • Supported with evidence
mation generated from the comprehensive assess- • Based on dynamic systems theory
ment, and potential programs of services are • Ecologically sound, and
identified with input from the intended service • Strengths-based
recipients and community organizations. Commu-
nity institutions, such as schools, churches, mosques, Client-Centered
temples, social organizations, health care providers, The community practice paradigm requires a
and political entities, are all part of the context of ser- client-centered approach that “promotes partici-
vice and therefore are integral components of assess- pation, exchange of information, client decision-
ment and intervention. The process of program making, and respect for choice” and “focuses on
development in community settings is described in de- the issues which are most important to the person
tail in Chapter 6 and program evaluation in Chapter 7. and his or her family” (Law, 1998, preface). The
collaborative process is designed to enable the
client to identify occupational performance prob-
Characteristics of the Community lems, engage in problem solving, and propose
Practice Paradigm solutions that meet his or her unique individual
A well-developed community practice paradigm can needs and circumstances. The occupational thera-
enhance the likelihood of achieving the Centennial pist is a facilitator, educator, and mentor in the
Vision. The following are some preliminary sugges- process (Law, 1998). A client-centered model has
tions on the nature of the community practice three key elements. It:
paradigm. The emerging community practice para-
• Considers the values, goals, roles, activities,
digm has the following characteristics. It is:
and tasks of the person, group, or community
• Client-centered • Involves the client as an active participant
• Occupation-based in the entire process of needs assessment,
2580_Ch01_001-018 16/07/13 2:42 PM Page 13
intervention planning, implementation, and Box 1-3 Characteristics of

evaluation Occupation-Based Practice
• Establishes a partnership between the client
and practitioner that enables the client to • Occupation is infused throughout the evaluation
assume responsibility for the process and the and intervention process.
outcome of services (Baum, Bass-Haugen, • Occupational history taking, occupational perfor-
mance assessment, and the development of an
& Christiansen, 2005).
occupational profile are essential elements of
Use of the term “client” in the community prac- client evaluation.
tice paradigm may refer to an individual, a family, • Occupational performance patterns including
an organization, or an entire community (AOTA, roles, habits, routines, and rituals are assessed
2008). Regardless of the type of client identified, and incorporated into the therapeutic process.
• Therapeutic goals are based on the client’s
the principles of client-centered practice are still
occupational needs and values.
relevant. • Participation in occupation is used as an intervention
Occupation-Based modality and is a desired outcome of therapy.
A community practice paradigm in occupational • Activity selection, analysis, and modification take
into consideration the client’s desired and
therapy should be occupation-based and supported
meaningful occupations.
with evidence. The focus on occupation is what • Environmental and contextual impacts on
makes the profession unique, and evidence of occupational performance and participation
effectiveness is what makes occupational therapy are considered and addressed.
services valuable. Occupation-based practice is
defined as an “intervention in which the occupa- Data from “Occupational Therapy Practice Framework: Domain
tional therapy practitioner and client collabora- & Process” (2nd ed.) by the American Occupational Therapy
Association, 2008, American Journal of Occupational
tively select and design activities that have specific Therapy, 62 (6), 625—683.
relevance or meaning to the client and support the
client’s interests, need, health, and participation in
daily life” (AOTA, 2008, p. 672). Characteristics Based on Dynamic Systems Theory
of occupation-based practice are listed in Box 1-3. Communities function as systems; therefore, a
Supported With Evidence dynamic systems perspective is extremely useful in
Demonstrating the effectiveness and efficiency conceptualizing community practice. According to
of occupational therapy services through research Capra (1982, p. 43), systems theory “looks at the
enhances the profession’s credibility. Scientific world in terms of the inter-relatedness and interde-
evidence provides data for decision making regard- pendence of all phenomenon, and in this framework
ing the importance and changeability of risk factors an integrated whole whose properties cannot be
and the appropriateness of specific interventions. reduced to those of its parts is called a system.”
Evidence-based decision making is the “process of Dynamic systems are characterized by complete
coming to a conclusion or making a judgment that interconnectedness. This means that all variables are
combines clinical expertise, patient concerns, and interrelated and that a change in one variable impacts
evidence gathered from scientific literature to arrive all other variables that are part of the system. In
at best practice recommendations” (Abreu & addition, dynamic systems are nested; every system
Chang, 2011, p. 331). According to Holm (2000), is part of another larger system with the same
evidence-based practitioners: dynamic principles operating at each level. Subsys-
tems settle into preferred, although not predictable,
• Examine what they do by asking questions patterns called attractor states. Attractor states are
• Take the time to find the best evidence to temporary with various strengths. The development
guide their practice of dynamic systems is in part dependent on initial
• Appraise the evidence carefully states. Minor differences in the beginning can be-
• Use the evidence to “do the right things right” come huge effects with dramatic consequences in the
• Evaluate the impact of their evidence-based long term. Dynamic systems are constantly develop-
practices ing and changing through interactions with their
2580_Ch01_001-018 16/07/13 2:42 PM Page 14
environment and through internal reorganization Ecologically Sound

(De Bot, Lowie, & Verspoor, 2007). Relationships An ecological approach considers the client em-
among variables in dynamic systems are governed by bedded in and interacting with a variety of envi-
heterarchy. “Heterarchy” refers to “the relation of ronments and contexts. This perspective requires
elements to one another when they are unranked, or the occupational therapy practitioner to consider
when they possess the potential for being ranked in both the client’s capabilities and constraints and
a number of different ways, depending on systemic the environmental enablers and barriers. Client
requirements” (Crumley, 2005, p. 39). capabilities may include psychological, physiologi-
Throughout history (Green & Anderson, 1982, cal, cognitive, neurobehavioral, and spiritual assets.
p. 22), “people have organized themselves into fam- Environmental enablers may include cultural and
ilies, institutions, communities, and societies to social, policy, socioeconomic, and built and natu-
exercise more control over the environment and over ral environmental resources (Baum, Bass-Haugen,
the behavior of each other. Rules of behavior become & Christiansen, 2005). Client constraints may
community norms that are transmitted from one include poor health status, occupational risk fac-
generation to another as culture. Culture defines tors, and occupational performance limitations.
acceptable social organization (family interaction Environmental barriers may include poverty, lack
patterns, roles and responsibilities of institutions and of natural and built environmental resources,
leaders, and the functions of government) as well as economic recession, high unemployment rates,
individual behavior. The influence of all these cul- inadequate public transportation, and lack of access
tural, economic, organizational, and institutional to social and occupational participation. Recogniz-
forces on the environment, on individual behavior, ing the interdependence between the client and the
and on health may be referred to as the social history social and physical environment is critical to effec-
of health.” tive community practice.
A dynamical systems approach recognizes the
complexity of the social history of health and pro- Strengths-Based
vides a framework for assessment and intervention Finally, a community paradigm for occupational
at various levels of systems, including individual, therapy is strengths-based, meaning that the focus
interpersonal, organizational, community, and is on what the client can do—his or her assets,
public policy levels. The focus of intervention in talents, resources, and capabilities—and not simply
community practice might be the individual recip- the client’s deficits or functional limitations.
ient of service. However, just as frequently, if not A strength is the ability to consistently perform in a
more frequently, the focus of intervention is the high-quality manner in a particular activity. A talent
family or the community as a whole. Individuals is a naturally occurring pattern of thought, feeling,
are embedded in a number of systems that must be or behavior that can be used productively. A
addressed even when the focus of intervention is at strengths-based approach to intervention assesses
the individual level. For example, an individual’s the client’s inherent strengths and talents and then
level of self-fulfillment and independence in the incorporates these into the therapeutic process to
community may well be more a function of envi- facilitate occupational engagement and empower-
ronmental, institutional, and social barriers than ment. A strengths-based model avoids the use of
the individual’s disability itself. Therefore, interven- stigmatizing labels; reduces the sense of victimiza-
tion may focus on several levels of systems simulta- tion; and fosters hope, growth, and self-efficacy. The
neously. According to dynamic systems theory, development of strengths can be conceptualized as
if one component of a system changes, “a chain a three-step process:
reaction of adaptations and adjustments is created
1. identifying strengths and talents,
in other parts of the system” (Scaffa & Brownson,
2. incorporating these strengths and talents into
2005, p. 482). Interventions to improve health and
the client’s view of himself or herself, and
well-being are most effective when multiple com-
3. changing behavior.
ponents of a dynamic system are targeted. This cre-
ates a synergistic effect that resonates throughout Behavior change may include acquiring knowl-
all aspects of a community. edge to enhance strengths and talents, sharing
2580_Ch01_001-018 16/07/13 2:42 PM Page 15
one’s talents with others, and creating and imple- The occupational therapy profession must rein-
menting strategies to maximize one’s strengths terpret and expand its knowledge base to support
and utilize them more consistently. A focus on the community-based initiatives as well as think cre-
development of strengths increases life satisfaction atively and develop new models of practice appro-
and productivity (Hodges & Clifton, 2004). priate for community-based settings. As occupational
The basic underlying tenets of the emerging therapy services in the community increase and as
community practice paradigm can be summarized practitioners become more comfortable with indirect
as follows: service provision and designing interventions for
populations, the paradigm of community practice
• Occupational therapy is best provided “in will evolve.
vivo” where people play, work, go to school,
participate in social interactions, and engage
in activities of daily living (Scaffa, 2001). Conclusion
• Participation in occupation that structures
everyday life is health promoting and It is time to start living out of our imagination, not out
enhances quality of life (AOTA, 2008). of our memory alone.
• Occupational risk factors—for example, Over 25 years ago, Dasler (1984) stated that
occupational deprivation, occupational occupational therapists, regardless of their area of
alienation, and occupational imbalance— practice, should focus their attention on creating
predispose individuals, families, groups, and and filling more positions in community-based
communities to illness, disability, and dys- settings than in the traditional clinic environment.
function (AOTA, 2008; Wilcock, 2006). She believed that practitioners should adapt their
• The physical, social, cultural, and temporal roles and skills to fit with the “outside” community
environments influence occupational choice, environment. Dasler (1984) referred to this as the
priorities, and organization, as well as quality “deinstitutionalization of the occupational thera-
and satisfaction with occupational perform- pist” (p. 31). Fidler (2000) echoed this sentiment
ance (AOTA, 2008). when she stated, “as a profession, our single focus
• Habits, routines, roles, and rituals are on and identity as a therapy, as a remedial rehabil-
performance patterns that impact occupa- itation service, has, I believe, significantly ham-
tional participation (AOTA, 2008). pered our development. This narrow identity has,
• Engagement in occupation contributes over many years, hindered our discovery and
to self-identity and self-efficacy (AOTA, validation of the rich and broad dimensions of
2008). occupation” (p. 99).
• People have the right to fully participate in For the future, Fidler (2000) envisioned an “oc-
their communities and engage in occupations cupationalist” who, in addition to rehabilitation
of their choice that provide purpose and services, provides health promotion services and
meaning in their lives (AOTA, 2008). programs of prevention, lifestyle counseling, and
• Health and health behaviors are influenced learning enhancement, and participates in organi-
by a variety of factors: personal, social, zational, institutional, and community planning
economic, and ecological (USDHHS, 2011). and design. If occupational therapy practitioners
• Social isolation, low educational attainment, continue to resist the move into community-based
poverty, violence, pollution, crime, and settings, where their services are most needed, in
discrimination are all threats to individual favor of hospital and clinic environments, then the
and community health and well-being future of the profession will surely be unnecessarily
(Scaffa & Brownson, 2005). limited.
• The reduction of occupational risk factors In 1972, Finn suggested a number of issues
and the enhancement of occupational that need to be addressed as the profession moves
resilience factors can improve the health from an emphasis on medical and clinical services
and well-being of individuals, families, and to health promotion and community-based
communities. (Scaffa & Brownson, 2005). services. An updated interpretation of these
2580_Ch01_001-018 16/07/13 2:42 PM Page 16
issues follows. Occupational therapy practitioners Learning Activities

need to:
1. Interview an occupational therapist in
• Gain knowledge about community organiza- community practice regarding the skills,
tions and institutions and how they operate. abilities, and characteristics a person needs to
• Acquire a thorough understanding of the be successful in providing community-based
unique services they can offer in community services. Assess your own readiness to practice
settings and be able to communicate these in community settings. What do you need to
services clearly. learn to be able to make this transition?
• Develop strategies to translate knowledge 2. In pairs or small groups, write a brief article
into actual programs that are responsive to for OT Practice describing the benefits
community needs. for clients and practitioners of providing
• Prepare to take risks when faced with community-based services and the barriers
challenges in unfamiliar environments. to developing occupation-based community
• Learn to relate to and communicate effec- programs.
tively with non-medical personnel and avoid 3. Read the local newspaper for a week and identify
the use of professional jargon. at least two community health problems that
• Offer services to a community rather than could be addressed by occupational therapists.
waiting for services to be solicited. Describe the populations and communities
• Develop the role of health agent while main- affected and the environmental and contextual
taining professional identity, and appreciate characteristics that contribute to the health
the opportunities for personal and profes- problems. Who would you contact in order
sional growth in the experience. to investigate volunteer or paid employment
opportunities to help solve one or both
Occupational therapy philosophy and services are
of the health problems?
very compatible with community-based service
provision. However, the paradigm of direct-service
provision to individuals in clinical settings is inade- REFERENCES
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identifying relevant issues and solving the problems occupational therapy manager, 5th edition (pp. 331–347).
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Stalker, K., Jones, C., & Ritchie, P. (1996). All change? The American Journal of Occupational Therapy, 23, 226–231.
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104–108. tional Therapy, 24, 323–328.
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Chapter 2
Public Health, Community Health,

and Occupational Therapy
Marjorie E. Scaffa, PhD, OTR/L, FAOTA, and Courtney S. Sasse, MA EdL, MS, OTR/L
If you do not know where you are going, you are likely to end up someplace else.
—Lao Tsu
Learning Objectives
• Describe the basic constructs associated with community and public health, prevention, and health promotion.
• Identify the determinants of health in a community.
• Discuss strategies for primary, secondary, and tertiary prevention.
• Describe the contributions occupational therapy can make to achieve the goals of Healthy People 2020.
• Discuss occupational therapy’s role within the context of health promotion, community, and public health.
Key Terms
Community Incidence
Community health Prevalence
Community health interventions Preventive occupation
Determinants of health Primary prevention
Epidemiology Public health
Health disparities Secondary prevention
Health promotion Tertiary prevention
Introduction just a few of the outcomes that can result from the
application of occupational therapy to public health
The profession’s participation in public and com- problems.
munity health efforts is affirmed in the Occupational Although having a sound knowledge base in
Therapy Framework: Domain and Process (American occupational therapy is likely, the reader may be less
Occupational Therapy Association [AOTA], 2008). familiar with the areas of public health and commu-
In this document, health promotion and disability nity health. The underlying constructs and principles
prevention are described as intervention approaches, of public health and community health as a founda-
and examples of the application of these approaches tion for providing occupational therapy from a pop-
are provided focusing on performance skills, per- ulation perspective are presented in this chapter. Key
formance patterns, contexts, activity demands, and public and community health constructs such as health
client factors. In addition, health management and promotion, prevention, risk factors, and epidemiol-
maintenance are identified within the domain of ogy are discussed in this chapter. Roles that may be
occupational therapy as instrumental activities of assumed by occupational therapy practitioners and
daily living. Health and wellness, participation, pre- measures that may be implemented to improve the
vention, quality of life, and occupational justice are health of the community also are described.
19
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Public Health Epidemiologists use health statistics, including

measures of incidence and prevalence, to estimate dis-
Public health is concerned with optimizing the ease, injury, and disability in a variety of population
health status of populations. Detels and Breslow groups; analyze health trends; plan and evaluate pub-
(1997, p. 3) stated that public health is “the process lic health initiatives; and make informed health policy
of mobilizing local, state, national, and international decisions. Incidence refers to the number of new cases
resources to ensure the conditions in which people of disease, injury, or disability within a specified time
can be healthy.” To achieve these healthy conditions, frame, typically a year. Prevalence refers to the total
four public health strategies are used: promoting number of cases of disease, injury, or disability in a
health and preventing disease, improving medical community, city, state, or nation existing at one point
care, promoting health-enhancing behaviors, and in time (Pickett & Hanlon, 1990).
controlling the environment (Detels & Breslow, According to Pickett and Hanlon (1990), preven-
1997). These authors also identified three principles tive interventions attempt to reduce the incidence
of public health that must be considered before any rate of a disease or an injury, and early detection pro-
action can be taken to alleviate health concerns: cedures and rapid treatment attempt to reduce the
duration of illness. Either strategy would result in a
• The specific problems affecting the commu- decreased prevalence rate. Combining the two strate-
nity’s health must be assessed. gies of prevention and early detection is the most
• Any strategies implemented must be based on effective approach to reducing overall prevalence.
scientific knowledge and available resources. Public health practitioners also are very interested
• The level of social and political commitment in risk factors, both modifiable and nonmodifiable,
that currently exists must be determined. that compromise health. Risk factors are those pre-
A comprehensive definition of public health was cursors that increase an individual’s or population’s
put forth by Winslow in 1920: “Public health is the vulnerability to developing a disease or disability or
science and art of preventing disease, prolonging life, sustaining an injury (Scaffa, 1998). Often when peo-
and promoting physical health and efficiency through ple hear or use the term “risk factor,” they are think-
organized community efforts for the sanitation of the ing of a physical condition that contributes to a
environment, the control of communicable infec- disease. For example, high cholesterol, hypertension,
tions, the education of the individual in principles of and obesity are risk factors that can contribute to
personal hygiene, the organization of medical and cardiovascular disease. However, risk factors are not
nursing service for the early diagnosis and preventive just physical, behavioral, or genetic. They can also be
treatment of disease, and the development of the social, economic, political, and environmental. Some
social machinery which will ensure to every individual risk factors are considered causal because the health
in the community a standard of living adequate for problem cannot occur in the absence of the risk
the maintenance of health” (p. 30). factor. Other risk factors are considered contributory
Public health is often defined in terms of its aims because they interact with other risk factors leading
and goals rather than being grounded in a specific to the development, exacerbation, or maintenance
body of knowledge (Detels, Holland, McEwen, of disease, injury, or disability (Scaffa, 1998).
& Omenn, 1997; Fee, 1997). Winslow’s broad defi- In addition to risk factors, public health profes-
nition accurately implies that many disciplines con- sionals attempt to increase resiliency or protective
tribute to the field of public health, including factors that contribute to improved health and well-
epidemiology, the biological and clinical sciences, bio- being. Resiliency factors are those precursors that
statistics, nursing, health education, sanitation, indus- appear to increase an individual’s or population’s
trial hygiene, sociology, psychology, economics, law, resistance to developing a disease or disability or
and engineering. However, the fundamental scien- sustaining an injury (Scaffa, 1998). Resiliency fac-
tific basis of public health is epidemiology, the study tors may include the individual’s genetic composi-
of the distribution, frequencies, and determinants of tion, personality, and health behavior patterns and
disease, injury, and disability in human populations social factors such as peer and family relationships
(MacMahon & Trichopoulos, 1996). and environmental and institutional supports for
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Chapter 2 | Public Health, Community Health, and Occupational Therapy 21
health. Public health interventions attempt to mod- prevention is implemented when a person is already
ify all types of risk factors and strengthen resiliency ill or impaired, and the initial damage has already
or protective factors to enhance the overall health occurred. The goal is to restore as much functional-
and well-being of populations. ity as possible, rehabilitate the individual, and
attempt to prevent further damage. This level of pre-
vention is the most familiar to occupational therapy
Prevention practitioners. For example, occupational therapists
routinely teach joint protection techniques to indi-
Prevention refers to “anticipatory action taken to viduals with rheumatoid arthritis to prevent defor-
reduce the possibility of an event or condition from mity and to enhance their ability to complete
occurring or developing, or to minimize the damage desired occupations with less pain. Energy conser-
that may result from the event or condition if it does vation techniques are taught to individuals with
occur” (Pickett & Hanlon, 1990, p. 81). When cardiac conditions to prevent overexertion during
applying the term to public health, prevention refers the performance of occupations.
to reducing the likelihood of the occurrence of
disease/disability or inhibiting its progression to
enhance optimal health and quality of life. Specifi- Health Promotion
cally, there are three levels of prevention: primary,
secondary, and tertiary. Each level focuses on pre- Health promotion, a key public health strategy, is
venting health problems at a particular point along defined as any planned combination of educa-
the continuum of the illness/injury process. tional, political, regulatory, environmental, and
Primary prevention focuses on healthy individu- organizational supports for actions and conditions
als who potentially could be at risk for a particular of living conducive to the health of individuals,
health problem. The goal is to prevent the health groups, or communities (American Hospital Asso-
problem from occurring by taking steps to maintain ciation, 1985; Green & Kreuter, 1991). More sim-
one’s current healthy status and reduce susceptibility. ply, it is “the process of enabling people to increase
For example, an already healthy person could con- control over, and to improve, their health” (World
tinue to eat nutritious foods in the proper quantities Health Organization [WHO], 1986, para. 3).
and exercise regularly. Doing so could potentially Health promotion encompasses strategies impact-
avert obesity, diabetes, or cardiovascular disease. ing all societal levels, including individuals, groups,
Another primary prevention strategy is to always organizations, communities, and government pol-
wear a seat belt while in a motor vehicle, possibly icy makers. A key purpose of health promotion is
avoiding injury if a crash occurred. the prevention of disease and injury in individuals
Secondary prevention focuses on the detection and populations.
and treatment of disease early in its preclinical or
clinical stages. The goal is to slow the progression,
attempt to cure or control it as soon as possible, and Community Health
prevent complications and disability. Arresting or
reversing communicability also is a focus because Typically, when people use the terms “community”
early treatment of an infectious disease will limit and “health,” they assume others define the words in
exposure to others. An example of secondary pre- the same manner. In reality, definitions can vary
vention is an individual with hypertension exercis- widely. To avoid misunderstandings, these two words
ing and maintaining an optimal weight so he or she are defined here for this discussion. Community refers
can achieve normal blood pressure readings and thus to “noninstitutional aggregations of people linked
reduce the risk of myocardial infarction (MI) and together for common goals or other purposes” (Green
cerebrovascular accident (CVA). & Raeburn, 1990, p. 41). Inherent is the idea that
Tertiary prevention, the third level, refers to a community does not have to be composed of
measures used in the advanced stages of disease to individuals within a particular geographical region.
limit disability and other complications. Tertiary Communities may be “religious, professional, cultural,
2580_Ch02_019-030 16/07/13 2:42 PM Page 22
political, recreational, and a myriad of others based on are health services provided in community settings
groups of people with common bonds” (Rhynders & targeted at individuals and families in order to
Scaffa, 2010, p. 209). Communities are dynamic improve health and facilitate health behavior
entities that evolve with the changing characteristics change. Community-level interventions seek to
of their members. Community health refers to the modify the norms and behaviors of a population
physical, emotional, social, and spiritual well-being of and improve health through sociocultural, political,
a group of people who are linked together in some economic, and environmental changes. Community-
way, possibly through geographical proximity or centered interventions are population-based ap-
shared interests. proaches that are initiated and driven by the
A community-based approach can be optimal community itself using existing resources and seek-
when providing prevention and health care services ing external support as needed. The goal of com-
to individuals. Social support, the ability to reach munity health promotion is that every member of
many consumers, targeted interventions that meet the community experiences a level of well-being
specific community needs, active community and vitality, enabling him or her to choose, partic-
involvement, community-driven priorities, and the ipate in, and enjoy the activities of the community
potential for a systems approach where problems (Scaffa & Brownson, 2005).
can be addressed at multiple levels are included.
A systems-oriented approach allows all involved to
see the big picture and better understand relation- National Health Goals and
ships, connections, and dependencies. Because con-
sequences and interactions are integral components, Objectives for the United
employing a systems view is helpful when trying to States
prioritize community needs and determine solutions
to problems. In 1979, the Surgeon General’s office, in the
Community health interventions can be U.S. Department of Health, Education, and
defined as “any combination of educational, Welfare (now the U.S. Department of Health and
social, and environmental supports for behavior Human Services [USDHHS]), published a docu-
conducive to health” (Green & Anderson, 1982, ment titled Healthy People. This document was
p. 3). Also, according to Green and Anderson designed to identify national health goals and
(1982, pp. 3–4): “Educational interventions may discuss health promotion and disease prevention
be directed at high-risk individuals, families, or in the United States so increasingly scarce health-
groups or at whole communities through mass care resources could be used most efficiently and
media, schools, worksites, and organizations. effectively. The concept underlying Healthy People
Social interventions may include economic, politi- came from Canada’s LaLonde Report, a document
cal, legal and organizational changes designed to published in 1974 describing the health status
support actions conducive to health. Environmen- of Canadians. The authors of this framework pro-
tal supports include the structure and distribution posed that all morbidity and mortality can be
of physical, chemical and biological resources, and attributed to four primary elements:
facilities and substances required for people to pro-
• inadequacies in the existing health care
tect their health. The health behavior of a commu-
system,
nity includes the actions of the people whose health
• behavioral factors or unhealthy lifestyles,
is in question and the actions of community deci-
• environmental hazards,
sion makers, professionals, peers, teachers, employ-
• human biological factors (LaLonde, 1974).
ers, parents and others who may influence health
behaviors, resources or services in the community.” The Healthy People document (U.S. Depart-
Community health interventions can be de- ment of Health, Education, and Welfare, 1979)
scribed on a continuum from community-based to emphasized the importance of lifestyle changes in
community-level to community-centered (Scaffa & reducing morbidity and mortality rates. Five major
Brownson, 2005). Community-based interventions health goals for the nation were identified and
2580_Ch02_019-030 16/07/13 2:42 PM Page 23
categorized according to life span; that is, one Healthy People 2020, released in November 2010,
major goal was identified for each age group (i.e., represents the fourth decade of goals and objectives
infants, children, adolescents and young adults, that can be used to provide structure for prevention,
adults, and older adults). Goals, several subgoals, health promotion, and well-being across a variety of
and other problems experienced by each age group population groups. The overarching goals outlined
also were presented. in Healthy People 2020 are to:
A new document, Healthy People 2000, was
• “Attain high-quality, longer lives free of
released in 1990. With this document, the focus
preventable disease, disability, injury, and
became the improvement in quality of life and
premature death.
people’s sense of well-being rather than solely the
• Achieve health equity, eliminate disparities,
reduction of mortality rates. The new health goals
and improve the health of all groups.
for the United States were to:
• Create social and physical environments that
• Increase the span of healthy life. promote good health for all.
• Reduce health disparities. • Promote quality of life, healthy development,
• Achieve access to preventive health services and healthy behaviors across all life stages”
for all (USDHHS, 1990). (USDHHS, 2011a, para. 5).
In Healthy People 2000, 22 priority areas were According to Healthy People 2020, the range of
identified for the focus of the nation’s health pro- factors that influence health status, or the determi-
motion and disease prevention efforts. These areas nants of health, fall into five broad categories: policy
were listed under the same three broad categories making, social factors, health services, individual
used in the 1979 document (i.e., health promotion, behavior, and biology and genetics. Individual and
health protection, and preventive health services) population health are influenced by the interrela-
with the addition of another category, surveillance tionships among these factors. Interventions that
and data systems. The purpose of adding this last target multiple determinants of health are likely to
category was to improve data collection methods. be more effective than programs that address single
Additionally, social and environmental factors were factors.
emphasized as it became obvious that focusing on A major focus of the Healthy People 2020 ini-
individual behaviors was insufficient. tiative is to eliminate health disparities and achieve
Ten years later, due to advances in preventive health equity. The term health disparities refers
therapies, vaccines and pharmaceuticals, assistive to “a particular type of health difference that
technologies, and computerized systems, the context is closely linked with social, economic, and/or
in which Healthy People 2010 was developed dif- environmental disadvantage. Health disparities
fered from that in which Healthy People 2000 was adversely affect groups of people who have system-
framed (USDHHS, 1998). Healthy People 2010, atically experienced greater obstacles to health
released in January 2000, had two comprehensive based on their racial or ethnic group; religion; so-
goals: to increase the quality and years of healthy life cioeconomic status; gender; age; mental health;
and to eliminate health disparities. Progress toward cognitive, sensory, or physical disability; sexual
these goals was measured by 467 objectives orga- orientation or gender identity; geographic loca-
nized into 28 focus areas. “Healthy People in tion; or other characteristics historically linked to
Healthy Communities” was the underlying premise discrimination or exclusion” (USDHHS, 2011b,
of Healthy People 2010 as individual health is de- para. 6).
pendent, to some degree, on the physical and social Achieving health equity will require a coordi-
environments that exist in the community. Like- nated and concerted effort to address the complex
wise, community health is affected by the collective social, economic, educational, and environmental
attitudes and behaviors of community members. factors that produce health disparities, as well as to
Healthy People 2010 provided a framework for increase access to health care.
interdisciplinary collaboration in prevention and Three new features have been added to Healthy
health promotion activities. People 2020 to support the vision of the initiative,
2580_Ch02_019-030 16/07/13 2:42 PM Page 24
“a society in which all people live long, healthy lives” A significant number of the health objectives for
(USDHHS, 2010a, p. 1). These include: the nation outlined in Healthy People 2020 address
the needs of persons with disabilities specifically.
• an increased emphasis on achieving health equity
Box 2-2 contains examples of these objectives, many
through a determinants of health approach
of which are directly relevant for occupational
• an interactive Web site that enables users to
therapy intervention.
tailor information to their needs as the main
Ultimately, the goal of Healthy People 2020 is to
vehicle for dissemination
provide data and tools to enable practitioners and
• a collection of evidence-based resources to
communities across the nation to easily integrate serv-
facilitate implementation
ices and intervention efforts. In order to meet public
The long-range goals, topic areas, and measures health goals, a framework for implementation is
of progress included in Healthy People 2020 provide included in Healthy People 2020: MAP-IT, or Mobi-
an action-oriented foundation for occupational lize, Assess, Plan, Implement, and Track (USDHHS,
therapy practitioners to consider in all phases of 2010b). The MAP-IT guide, available online, includes
evaluation and intervention. There are 42 topic areas information on conducting a community needs
identified in the Healthy People 2020 document assessment, a brief overview of Healthy People 2020,
(Box 2-1). These topical areas are sets of health and tools for assessing and tracking progress.
objectives that have been grouped to bring attention Throughout the decade, the Healthy People 2020
and focus to the needs of certain populations or initiative will assess the general health status of the
needs specific to each condition. Health objectives population, health-related quality of life, determi-
are assigned to particular federal agencies to develop, nants of health, and health disparities. Health-related
track, monitor, maintain, and periodically report to quality of life measures are particularly relevant
the public the status of each. for occupational therapists as they include physical,
Box 2-1 Healthy People 2020 Focus Areas
Access to health services Heart disease and stroke

Adolescent health HIV
Arthritis, osteoporosis, and chronic back conditions Immunization and infectious diseases
Blood disorders and blood safety Injury and violence prevention
Cancer Lesbian, gay, bisexual, and transgender health
Chronic kidney disease Maternal, infant, and child health
Dementias, including Alzheimer’s disease Medical product safety
Diabetes Mental health and mental disorders
Disability and disability health Nutrition and weight status
Early and middle childhood Occupational safety and health
Educational and community-based programs Older adults
Environmental health Oral health
Family planning Physical activity
Food safety Preparedness
Genomics Public health infrastructure
Global health Respiratory diseases
Health care–associated infections Sexually transmitted diseases
Health communication and health information Sleep health
technology Social determinants of health
Health-related quality of life and well-being Substance abuse
Hearing and other sensory or communication Tobacco use
disorders Vision
Data from: Healthy People 2020 by the U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion, 2010, ODPHP Publication No. B0132. Retrieved from http://
healthypeople.gov
2580_Ch02_019-030 16/07/13 2:42 PM Page 25
Box 2-2 Selected Objectives Addressing the Needs of People with Disabilities
The overall goal in this focus area is to promote the health and well-being of people with disabilities. Objectives
designed to address this goal include:
• DH-1: Include in the core of Healthy People 2020 population data systems a standardized set of questions that
identify “people with disabilities.”
• DH-2: Increase the number of Tribes, States, and the District of Columbia that have public health surveillance
and health promotion programs for people with disabilities and caregivers.
• DH-3: Increase the proportion of U.S. master of public health (M.P.H.) programs that offer graduate-level
courses in disability and health.
• DH-4: Reduce the proportion of people with disabilities who report delays in receiving primary and periodic
preventive care due to specific barriers.
• DH-7: Reduce the proportion of older adults with disabilities who use inappropriate medications.
• DH-8: Reduce the proportion of people with disabilities who report physical or program barriers to local health
and wellness programs.
• DH-9: Reduce the proportion of people with disabilities who encounter barriers to participating in home, school,
work, or community activities.
• DH-10: Reduce the proportion of people with disabilities who report barriers to obtaining the assistive devices,
service animals, technology services, and accessible technologies that they need.
• DH-11: Increase the proportion of newly constructed and retrofitted U.S. homes and residential buildings that
have visitable features.
• DH-13: Increase the proportion of people with disabilities who participate in social, spiritual, recreational,
community, and civic activities to the degree that they wish.
• DH-14: Increase the proportion of children and youth with disabilities who spend at least 80% of their time in
regular education programs.
• DH-16: Increase employment among people with disabilities.
• DH-17: Increase the proportion of adults with disabilities who report sufficient social and emotional support.
• DH-18: Reduce the proportion of people with disabilities who report serious psychological distress.
• DH-19: Reduce the proportion of people with disabilities who experience nonfatal unintentional injuries that
require medical care.
• DH-20: Increase the proportion of children with disabilities, birth through age 2 years, who receive early
intervention services in home or community-based settings.
Data from: Healthy People 2020 by the U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion, 2010, ODPHP Publication No. B0132.
mental, and social aspects of quality of life, well-being are due mainly to policy failures, and inequities in
and life satisfaction, and participation in common daily living conditions, access to power, and partici-
activities. Participation measures reflect how commu- pation in society.
nity members, regardless of functional limitations, The CSDH proposed three comprehensive goals:
participate in education, work, social, civic, and to improve daily living conditions; address the
leisure activities (USDHHS, 2010c). inequitable distribution of power, money, and other
resources; and measure and understand the problem
and evaluate the outcomes of intervention (WHO,
A Global Perspective 2008). Nine key themes with implementation
strategies were identified, including:
In 2005, the WHO established the Commission on
Social Determinants of Health (CSDH) to develop • early child development
strategies on reducing health inequities. Health • globalization
inequities exist both within and between countries, • health systems
with a 40-year life expectancy difference between the • employment conditions
richest and poorest countries. The CSDH concluded • social exclusion
that health inequities are not inevitable; instead they • women and gender equity
2580_Ch02_019-030 16/07/13 2:42 PM Page 26
• urbanization social integration, support and justice, all within and

• priority public health conditions as part of a sustainable ecology.”
• measurement and evidence Seligman (2011) proposes that well-being con-
sists of five elements: positive emotion, engagement,
At the 2011 World Conference on Social
positive relationships, meaning, and accomplish-
Determinants of Health in Brazil sponsored by
ment. This perspective suggests that occupation is a
the WHO, heads of governments and govern-
fundamental process for achieving health and well-
ment representatives reaffirmed the belief that
being by facilitating engagement, meaning, and
“health inequities within and between countries
accomplishment. According to Wilcock (2005), the
are politically, socially and economically unac-
“occupations that will have the most obvious effects
ceptable, as well as unfair and largely avoidable,
on wellbeing are those that are socially sanctioned
and that the promotion of health equity is essen-
and valued and that enable people freedom to effec-
tial to sustainable development and to a better
tively use physical and mental capacities in combi-
quality of life and well-being for all, which in
nation with social activity” (p. 153).
turn can contribute to peace and security”
A variety of risk factors to health can result from
(WHO, 2011, para. 4). The participants pledged
less than optimal use, choice, opportunity,
to collectively take global action on the social de-
or balance in occupation. Risk factors for occupa-
terminants of health in order to create vibrant,
tional dysfunction include occupational imbal-
inclusive, and healthy communities.
ance, occupational deprivation, and occupational
alienation (Wilcock, 1998) as well as occupational
Improving Health delay, occupational interruption, and occupational
disparities (Bass-Haugen, Henderson, Larson, &
and Well-Being Through Matuska, 2005). These risk factors are described in
Occupation Box 2-3.
Occupational therapy practice is based on the
Wilcock (1998, p. 110) defines health from an occu- premise that participation in meaningful occupa-
pational perspective as “the absence of illness, but not tions can improve occupational performance and
necessarily disability; a balance of physical, mental and overall health and well-being. Therefore, preventive
social wellbeing attained through socially valued and occupation can be characterized as the application
individually meaningful occupation; enhancement of of occupational science in the prevention of disease
capacities and opportunity to strive for individual and disability and the promotion of health and
potential; community cohesion and opportunity; and well-being of individuals and communities through
Box 2-3 Occupational Risk Factors
• Occupational alienation: a lack of satisfaction in one’s occupations. Tasks that are perceived as stressful,
meaningless, or boring may result in an experience of occupational alienation (Wilcock, 1998).
• Occupational delay: occupational development that does not follow the typical schedule for the acquisition of
occupational skills and is associated with occupational performance deficits (Bass-Haugen, Henderson, Larson,
& Matuska, 2005)
• Occupational deprivation: circumstances or limitations that prevent a person from acquiring, using, or enjoying
an occupation. Conditions that lead to occupational deprivation may include poor health, disability, lack of
transportation, isolation, homelessness, etc. (Wilcock, 1998)
• Occupational disparities: inequalities or differences in occupational patterns among populations, often the result
of occupational injustice (Bass-Haugen, Henderson, Larson, & Matuska, 2005)
• Occupational imbalance: occupational patterns that fail to meet an individual’s physical or psychosocial needs,
thereby resulting in decreased health and well-being (Wilcock, 1998)
• Occupational interruption: a temporary interference with occupational performance or participation as a result of
a change in personal, social, or environmental factors (Bass-Haugen, Henderson, Larson, & Matuska, 2005)
2580_Ch02_019-030 16/07/13 2:42 PM Page 27
meaningful engagement in occupations. An excel- • Promote healthy living practices, social partic-
lent example of the power of preventive occupation ipation, occupational justice, and healthy com-
was demonstrated in a comprehensive research munities, with respect for cross-cultural issues
project commonly referred to as the “Well Elderly and concerns (Scaffa et al., 2008, p. 695).
Study” conducted at the University of Southern
Occupational therapy practitioners may assume
California (Clark, Azen, Zemke, Jackson, Carlson,
any combination of these three major roles in health
Mandel, Hay, Josephson, Cherry, Hessel, Palmer,
promotion and disease/disability prevention:
& Lipson, 1997). This randomized, controlled trial,
involving 361 men and women aged 60 years or 1. Promoting healthy lifestyles for all clients
older living independently in the community, was and their families regardless of disability
designed to evaluate the effectiveness of a preventive status. Lifestyle risk factors, such as tobacco
occupational therapy program. The main outcome use, unhealthy diet, physical inactivity, and
measures of interest were “physical and social func- substance abuse, are often overlooked
tion, self-rated health, life satisfaction and depres- among persons with disabilities. Standard
sive symptoms” (Clark et al., 1997, p. 1321). Older health promotion programs and services
adults receiving occupational therapy services may be inappropriate for persons with dis-
demonstrated improved vitality, physical and social abilities. Occupational therapy practitioners
functioning, life satisfaction, and general mental are capable of adapting these programs to
health. A six-month follow-up assessment indicated meet the special needs of individuals living
that 90% of the therapeutic gains had been main- with disabling conditions.
tained (Clark, Azen, Carlson, Mendale, LaBree, 2. Incorporating occupation in existing health
Hay, et al., 2001). promotion efforts developed by experts in
areas such as health education, nutrition,
and exercise. For example, in working with
Practitioner Roles in Health a person with a lower-extremity amputation
Promotion and Community due to diabetes, the occupational therapy
practitioner may focus on the occupation
Health of meal preparation using foods and prepa-
The AOTA supports and promotes the involvement ration methods recommended in the nutri-
of occupational therapy professionals in the design tionist’s health promotion program. This
and implementation of health promotion and pre- enables the achievement of the goal of func-
vention services (Scaffa, Van Slyke, & Brownson, tional independence in the kitchen while
2008). Health promotion services may address the reinforcing the importance of proper nutri-
needs of individuals, families, groups, organizations, tion for the prevention of further disability.
communities, and populations. The goals of occu- 3. Developing and implementing occupation-
pational therapy in health promotion and preven- based health promotion programs, targeting
tion are to: a variety of constituencies and levels of soci-
ety, including individuals (both with and
• Prevent or reduce the incidence of illness or without disabilities), groups, organizations,
disease, accidents, injuries, and disabilities in communities, and governmental policies.
the population
• Reduce health disparities among racial and A variety of examples of occupation-focused health
ethnic minorities and other underserved promotion interventions are listed in Box 2-4.
populations
• Enhance mental health, resiliency, and
quality of life Conclusion
• Prevent secondary conditions and improve
the overall health and well-being of people Philosophically, occupational therapy and public
with chronic conditions or disabilities and health are quite compatible and even complemen-
their caregivers and tary. Occupational therapy practitioners can learn
2580_Ch02_019-030 16/07/13 2:42 PM Page 28
Box 2-4 Occupation-Based Health Promotion Interventions
Occupation-focused health promotion interventions at each level may include but are not limited to:
Individual-level interventions
• Adaptation of physical activities/exercises for persons with disabilities
• Education of caregivers about proper body mechanics for lifting to prevent back injuries
• Driving evaluation and training for persons with physical or cognitive impairments
Group-level interventions
• Repetitive strain injury education and prevention and management programs for workers
• Parenting skills training for adolescent mothers
• Education of day-care providers regarding normal growth and development, handling behavioral problems,
and identifying children at risk for developmental delay
Organizational-level interventions
• Consultation with industrial managers regarding the benefits of ergonomic workspace design and worksite
injury prevention strategies
• Disability awareness training for service-industry personnel such as those who work for airlines, hotels,
restaurants, etc.
Community-level interventions
• Modification of community recreational facilities to increase accessibility for persons with disabilities
• Consultation with contractors, architects, and city planners regarding accessibility and universal design
Governmental-policy interventions
• Promotion of full inclusion of children with disabilities in schools and day-care programs
• Lobbying for public funds to support programs to improve the quality of life for at-risk populations
much from collaboration with public health, health underpinning for Healthy People 2020 objectives
promotion, and health education professionals in related to the training of health professionals.
terms of primary and secondary prevention strate- The Clinical Prevention and Population Health
gies and community health initiatives. Public health Curriculum Framework consists of four compo-
programs can benefit from the unique contribution nents: evidence-based practice, clinical preventive
of occupation and an occupational science perspec- services and health promotion, health systems
tive that occupational therapy practitioners can pro- and health policy, and population health and
vide. The focus of Healthy People 2020 on quality of community aspects of practice (APTR, 2009).
life, satisfying relationships, and functional capacity Adoption of this framework by occupational ther-
to work and play invites the participation and apy educational programs could enhance the
inclusion of the occupational therapy profession in knowledge and skills of students needed for future
public health, health promotion, prevention, and health promotion practice.
community health initiatives. Changes in demographics, including the rapid
In order for occupational therapists and other growth in the number of elderly who are at risk for
health care professionals to effectively participate injuries, illnesses, and disabilities, provide an oppor-
in individual and population-based health promo- tunity for occupational therapy practitioners to
tion and prevention efforts, educational programs expand their role in health promotion and
need to facilitate the development of competencies disease/disability prevention. As in all areas of prac-
for this area of practice. The Association for tice, health promotion interventions should be
Prevention Teaching and Research (APTR) has based on clear evidence. Although occupational
developed a curriculum framework for health pro- therapy practitioners have the basic competencies to
fessions education that focuses on interprofes- design and implement occupation-based health
sional collaboration and serves as the educational promotion interventions, continuing education to
2580_Ch02_019-030 16/07/13 2:42 PM Page 29
acquire specialized knowledge and skills is recom- changes into the daily lives of independent-living older
mended for this practice area (Scaffa et al., 2008). adults: Long-term follow-up of occupational therapy
intervention. Journal of Gerontology: Psychological Sciences,
56, 60–63.
Learning Activities Detels, R., & Breslow, L. (1997). Current scope and concerns
in public health. In R. Detels, W. W. Holland, J. McEwen,
1. Interview several individuals of various ages & G. S. Omenn (Eds.), Oxford textbook of public health.
to ascertain their ideas, definitions, and per- New York: Oxford University Press.
Detels, R., Holland, W. W., McEwen, J., & Omenn, G. S.
spectives on health and well-being. How are (1997). Oxford textbook of public health. New York:
their perspectives on health and well-being Oxford University Press.
different and how are they similar? Ask them Fee, E. (1997). The origins and development of public health
to describe their current state of health and in the United States. In R. Detels, W. W. Holland, J.
how participation in everyday activities McEwen, and G. S. Omenn (Eds.), Oxford textbook of pub-
lic health (pp. 35–54). New York: Oxford University Press.
(occupations) impacts their well-being. Green, L. W., & Anderson, C. L. (1982). Community health.
2. Select a population in a specific geographic St. Louis, MO: Mosby.
area and search for newspaper and magazine Green, L. W., & Kreuter, M. W. (1991). Health promotion
articles on the health needs of this population. planning: An educational and environmental approach
Identify potential occupational risk factors (2nd ed.). Mountainview, CA: Mayfield.
Green, L. W., & Raeburn, J. (1990). Contemporary develop-
for this population and occupational therapy ments in health promotion, definitions and challenges.
interventions to address these risk factors. In N. Bracht (Ed.), Health promotion at the community
3. Compare your occupational therapy educa- level. Newbury Park, CA: Sage.
tional program to the Clinical Prevention and LaLonde, M. (1974). A new perspective on the health of
Population Health Curriculum Framework Canadians: A working document. Ottawa: Ministry of
National Health and Welfare.
(APTR, 2009) to determine content areas that MacMahon, B., & Trichopoulos, D. (1996). Epidemiology
need to be enhanced for effective participation principles and methods. Boston: Little, Brown.
in health promotion services. Pickett, G., & Hanlon, J. J. (1990). Public health: Administra-
tion and practice. St. Louis, MO: Times Mirror/Mosby.
Rhynders, P. A., & Scaffa, M. E. (2010). Enhancing commu-
nity health through community partnerships. In M. Scaffa,
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Bass-Haugen, J., Henderson, M. L., Larson, B. A., & Scaffa, M. E., Van Slyke, N., & Brownson, C. A. (2008).
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U.S. Department of Health and Human Services. (2000). health promotion/disease prevention (Publication No. 79-
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Chapter 3
Theoretical Frameworks
for Community-Based Practice
S. Maggie Reitz, PhD, OTR/L, FAOTA, Marjorie E. Scaffa, PhD, OTR/L, FAOTA,
and M. Beth Merryman, PhD, OTR/L, FAOTA
We envision that occupational therapy is a powerful, widely recognized, science-driven,

and evidence-based profession with a globally connected and diverse workforce meeting
society’s occupational needs.
—Centennial Vision of the American Occupational Therapy Association [AOTA], 2007, p. 614)
Learning Objectives
• Appreciate the need for occupational therapists to be knowledgeable and competent in the use of theory in
community-based practice.
• Identify and define terms related to theory and the relationships among these terms.
• Define the term “community organization,” and describe strategies for organizing communities to meet health
needs.
• Describe the general characteristics and principles of theories from related disciplines that could be used in
community-based practice.
Key Terms
Community assets Outcome expectations
Community organization Paradigm
Concept Principle
Conceptual model of practice Reciprocal determinism
Construct Self-efficacy
Human agency Theory
Model
Introduction of reasons. Theories and models provide the foun-

dation and context for basic and applied research,
In preparation for its 100th anniversary in 2017, program design, implementation, and evaluation.
the American Occupational Therapy Association A brief review of terminology is provided to help
(AOTA) developed its Centennial Vision, which establish a common basis for understanding the
highlights the importance of evidence-based practice. theoretical discussion. This review is followed by a
The utilization of theory is the first step in a profes- description of a few select theoretical frameworks
sion’s quest to be both science-driven and evidence- from public health, health education, and occupa-
based. A well-developed theoretical foundation for tional therapy that can be applied to community-
community-based practice is essential for a variety based practice. Theoretical frameworks such as these
31
2580_Ch03_031-050 16/07/13 2:43 PM Page 32
and others can be used to assist communities in their combination of constructs and concepts. Some
efforts to improve residents’ occupational perfor- writers use the term “postulate” interchangeably
mance, health, participation, and quality of life. with the term “principle.” Related principles can
These four outcomes are consistent with those of oc- then be organized into theories (Miller & Schwartz,
cupational therapy, as detailed in the AOTA Practice 2004; Payton, 1988). Examples of principles from
Framework: Domain and Processes (AOTA, 2008). Nelson’s Conceptual Framework of Therapeutic
In the current climate of rapid change and the Occupation (Nelson, 1997, p. 13) include:
need to justify and substantiate the role of occupa-
• “Occupation influences the world around the
tional therapy, knowledge of theory is essential.
person.”
Established and evolving theoretical models are well
• “The person can affect his or her own future
suited to support occupational therapy’s role in
occupational forms.”
health care institutions and in the community.
• “A person can literally change his or her own
However, before models can be fully implemented,
nature by engaging in occupation.”
it is important to understand the terminology used
in the application of theory. These same principles can be adapted for use in
the community as follows:
Review of Terminology • Occupation influences the world around
people and their community.
The following terms will be defined and described: • The community can affect its own future
concept, construct, principle, model, theory, para- occupational forms.
digm, and conceptual model of practice. These terms • A community can literally change its own
are presented in sequence beginning with the basic nature through occupational engagement.
building blocks of theory and then moving on to
terms that describe higher levels of conceptualization.
Model
Concepts and Constructs A model can be defined as a semantic or diagram-
matic representation of concepts and/or constructs
Some authors and theorists simply use the term “con-
and their interrelationships. This representation al-
cept,” while others use both “concept” and “con-
lows for operationalization, experimental assessment,
struct” in order to differentiate between types of ideas.
and application of a theory (Parcel, 1984). Models
A concept “describes some regularity or relationship
can be viewed as a subclass of theories (McKenzie,
within a group of facts” (Payton, 1988, p. 12). The
Neiger, & Thackeray, 2009). However, not all theo-
term “construct” may be used to represent a specific
ries possess corresponding models, and not all models
type of concept. When this distinction is made, the
are founded on specific, well-defined theories.
term “concept” is employed to describe tangible phys-
ical objects such as a table or ball, while the term con-
struct is used to refer to intangible ideas (Miller Theory
& Schwartz, 2004), such as health or quality of life.
A theory “is a systematic way of understanding events
Occupational therapy uses a variety of constructs, for
or situations” that describes the relationships between
example, competence, mastery, achievement, adap-
the constructs, concepts, and principles on which
tation, self-efficacy, and emotional regulation. It is
it is built (National Cancer Institute [NCI], 2005,
essential that these and other constructs are examined,
p. 4). Humans use theory to link an event or behavior
defined, and explained in terms of their potential con-
to antecedent factors whether or not those factors
tribution to occupational therapy community-based
are directly observable (Miller & Schwartz, 2004).
practice outcomes.
A well-constructed theory satisfies four basic criteria:
• Fit,
Principle • Understanding,
A principle describes the relationship between two • Generality, and
or more concepts, two or more constructs, or a • Control.
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Chapter 3 | Theoretical Frameworks for Community-Based Practice 33
For a theory to have a good fit, it must reflect Box 3-1 Conceptual Practice Model
the everyday reality of the phenomenon it is Components
designed to represent. Understanding refers to the
need for the theory to be rational, be logical, and • Theory specific to phenomena seen in practice
make sense both to the researcher/theorist and to • Resources for practice (e.g., equipment,
the individuals who were studied. Generality means assessments)
• Research and evidence on utility of theory
that a well-developed theory is comprehensive and
includes sufficient variation to provide applicability Developed from “The Kind of Knowledge Needed to Support
to a diversity of contexts. Lastly, it should allow Practice?” by G. Kielhofner, 2009, in G. Kielhofner (Ed.),
for a degree of control over the phenomenon in Conceptual Foundations of Occupational Therapy Practice
(pp. 8–14). Philadelphia, PA: F.A. Davis.
question (Strauss & Corbin, 1990).
Paradigm
A paradigm guides the thinking and development
Theories Related to
of new knowledge for the use of a discipline. The Community-Based Practice
term is used by theorists in a variety of disciplines
to describe both the overall vision of the discipline There are many theoretical supports available to oc-
and the practical knowledge employed in daily cupational therapy practitioners as they engage in
activities of the discipline. A paradigm, according community-based occupational therapy practice.
to Kuhn, is a “collective vision...a set of perspec- These supports include the academic discipline of oc-
tives, ideas, and values that constitute a unique cupational science as well as occupational therapy
perspective shared by members of the discipline” conceptual practice models. Theories and models
(Kielhofner, 2004, p. 16). Kielhofner (2009) ex- from health education, health psychology, public
pands on this idea by identifying three elements health, and communication studies, as well as theo-
of a paradigm: ries directly related to community organization, can
also be helpful guides for community-based practice.
• core constructs, which are broad ideas
about the need, selection, and rationale of
interventions,
• focal viewpoint, which provides a common
Community Organization
lens to view practice possibilities, and Approaches
• values and priorities of the profession.
Community organization has been defined as “the
process by which community groups are helped to
Conceptual Model of Practice identify common problems or goals, mobilize re-
A conceptual model of practice “presents and or- sources, and in other ways develop and implement
ganizes theory used by therapists in their work.... strategies for reaching goals they have set” (Minkler
Each model explains an area of functioning and & Wallerstein, 2005, p. 26). The goals of commu-
specifies the interventions pertaining to particular nity organization include solving current commu-
kinds of problems in that area” (Kielhofner, 2004, nity problems, building permanent organizational
p. 20). The elements of a well-developed concep- and community capacity for ongoing problem solv-
tual practice model are displayed in Box 3-1. ing, and empowering individuals and neighbor-
Ideally these parts work together to support the hoods to act collectively in their own best interest
continued development of best practice. Examples (Rubin & Rubin, 2005). Before initiating a com-
of conceptual models of practice identified by munity organization effort, familiarity with the
Kielhofner (2009) include the biomechanical community, as well as the language of community
model, cognitive model, functional group model, development and the values and assumptions of
intentional relationship model, model of human community organization, is important. Terms asso-
occupation, motor control model, and sensory ciated with community organization are listed and
integration model. defined in Box 3-2 (McKenzie et al., 2009).
2580_Ch03_031-050 16/07/13 2:43 PM Page 34
Box 3-2 Terms Associated With Community Organization
Citizen Participation: The bottom-up, grassroots mobilization of citizens for the purpose of
undertaking activities to improve the condition of something in the
community.
Community Capacity: “The characteristics of communities that affect their ability to identify,
mobilize, and address social and public health problems” (Goodman,
Speers, McLeroy, Fawcett, Kegler, Parker, & Wallenstein, 1999, p. 259).
Community Development: “A process designed to create conditions for economic and social progress
for the whole community with its active participation and the fullest possible
reliance on the community’s initiative” (United Nations, 1955, p. 6).
Empowered Community: “One in which individuals and organizations apply their skills and resources
in collective efforts to meet their respective needs” (Israel, Checkoway,
Schulz, & Zimmerman, 1994).
Grassroots Participation: “Bottom-up efforts of people taking collective actions on their own behalf,
and they involve the use of a sophisticated blend of confrontation and
cooperation in order to achieve their ends” (Perlman, 1978, p. 65).
Macro Practice: The methods of professional change that deal with issues beyond the
individual, family, and small group level.
Social Capital: “Relationships and structures within a community that promote cooperation
for mutual benefit” (Minkler & Wallerstein, 2005, p. 35).
Participation and Relevance: “Community organizing that ‘starts where the people are’ and engages
community members as equals” (Minkler & Wallerstein, 2005, p.35).
From McKenzie, J. F., Neiger, B. L., & Thackeray, R., Planning, Implementing, and Evaluating Health Promotion
Programs: A Primer (5th ed., p. 239). Copyright © 2009 by Pearson Benjamin Cummings. Reprinted
with permission.
Ross (1967) describes several important principles (2005) propose a strengths-based approach that in-
underlying community organization. These include: volves identifying and mobilizing all of the existing
and potential, but often unrecognized, assets in a
• Communities can develop strategies to re-
community. Community assets include personal
spond to their specific needs and problems.
attributes and skills, relationships among people, local
• Individuals have the ability to change and
associations, and informal networks. Connecting
want to change.
community assets and strengths creates a synergy and
• Community members should be involved in
multiplies their power and efficacy.
the change-making process.
The models used in community organizing have
• Changes that are internally motivated have
been classified into different systems. One frequently
more meaning and are more lasting than
cited classification method, developed by Rothman
changes imposed from the outside.
(Minkler & Wallerstein, 2005), separates the models
• A “holistic” approach to change is more effec-
into three categories:
tive than a “fragmented” approach.
• Democracy requires the “cooperative partici- 1. locality development, which is heavily
pation and action” of community members process-dominated;
and the requisite skills that make this possible. 2. social planning, which is heavily task-
• Communities may need assistance to effec- oriented; and
tively organize to meet their needs. 3. social action, which incorporates task and
process.
The majority of theoretical approaches to commu-
nity organization are need- or problem-based, and Community organizing strategies take many
involve identification and remediation of deficits in forms but typically involve consensus, collaboration,
a community. However, Kretzmann and McKnight and advocacy. Examples of effective strategies include
2580_Ch03_031-050 16/07/13 2:43 PM Page 35
developing critical awareness, creating community to working with the community as the point of
identity, building relationships, mapping commu- service. These steps provide the basic road map of
nity assets, organizing coalitions, identifying com- tasks that are required to enter and organize a com-
munity successes, and leveraging resources and munity. However, they do not provide sufficient
investments from outside the community, as well as guidance to develop and evaluate an intervention.
leadership development, and political and legislative These principles, combined with one or more of the
action (Mathie & Cunningham, 2003; Minkler & other theoretical models discussed later in this chap-
Wallerstein, 2005). ter, provide an excellent framework for the develop-
McKenzie et al. (2009, p. 242) provide a generic ment of an empowered community. Community
approach to community organization that combines organizing involves “transforming individual and
the three types of models, with social planning being collective values to build support for social justice
the most heavily used (Fig. 3.1). The steps, described and social equity” (Rubin & Rubin, 2005, p. 189)
by McKenzie et al. (2009), can serve as useful guides and as such is a useful tool for occupational therapy
for occupational therapy practitioners who are new practitioners advocating occupational justice.
Selected Health Education

Recognizing the problem and Public Health Models
and Theories
Getting entry into the community
Since the 1950s, the fields of health education, pub-
lic health, and health psychology have been devel-
Organizing the people oping and employing models to explain why people
do or do not engage in health behaviors. Many the-
ories have been referred to in the health education
Identifying the specific problem and public health literature, but one of the most fre-
quently cited is social cognitive theory (Bandura,
1977). This theory, as well as four additional mod-
Determining the priorities and setting goals els, will be described briefly, including: the health
belief model (Rosenstock, Strecher, & Becker,
1994), Prochaska and DiClemente’s transtheoretical
Arriving at a solution and selecting intervention activities model of health behavior change (1983, 1992),
the PRECEDE-PROCEED framework (Green &
Implementing the plan
Kreuter, 1991, 2005) and the Diffusion of Inno-
vation model (Rogers, 2003). The health belief
model (HBM) is a model of the precursors of health
Evaluating the outcomes of the plan of action behavior, while the transtheoretical model of health
behavior change explains the stages people experi-
ence as they seek to change their health behavior
Managing the outcomes in the community (McKenzie et al., 2009). The PRECEDE-PROCEED
framework is a program planning and evaluation
tool, while Diffusion of Innovation is a health
Looping back communications approach.
Fig. 3•1 Steps of Community Organization. (From
McKenzie, James F., Neiger, Brad, L., and Thackery, Rosemary,
Social Cognitive Theory
Planning, Implementing, and Evaluating Health Promotion Bandura (2004) described the core determinants of
Programs: A Primer [5th ed., p. 242]. Copyright ©2009 by health behaviors, the mechanisms through which
Allyn & Bacon.) these core determinants work, and the application
2580_Ch03_031-050 16/07/13 2:43 PM Page 36
of social cognitive theory (SCT) to prevention and expectations are the individual’s belief that a given
health promotion practices. The core determinants behavior will lead to specific outcomes. There are
of health behaviors include: knowledge of the health three types of outcome expectations: physical out-
risks and benefits of various behaviors, perceived comes, the pleasurable and/or aversive effects of the
self-efficacy, outcome expectations, self-determined health behavior; social outcomes, the social approval
health goals and strategies, and perceived facilitators and/or disapproval the behavior evokes; and self-
and impediments to health behavior change. In ad- evaluative outcomes, the degree of satisfaction and/or
dition, the SCT relies on the postulate of reciprocal self-worth the person derives from his or her health
determinism, which is present when there is a behavior and/or health status (Bandura, 2004).
continuous reciprocal, interdependent interaction Finally, health behavior is affected by personal
of the person, the person’s behavior, and the envi- values and goals, as well as perceived facilitators and
ronment. The relative contribution of each of these barriers. Human agency, or the ability to intention-
factors in the determination of an outcome differs ally create and influence one’s future, enables goal
according to the setting and the behavior in question setting, behavior change, and environmental adap-
(Bandura, 1977). tation (Bandura, 2006). Barriers, obstacles, and
Knowledge of the health effects of various behav- impediments to health behavior and health behavior
iors is a necessary, but not sufficient, precondition change may be personal, social, economic, and en-
for change. Other factors also are involved. The in- vironmental. Persons with high levels of self-efficacy
dividual’s perception that he or she will be able to are more likely to perceive obstacles as surmount-
successfully perform a specific behavior, or perceived able, while persons with low levels of self-efficacy
self-efficacy, plays a central role in motivation for will quickly become discouraged in the face of
change (Bandura, 2004). Self-efficacy is the belief adversity (Bandura, 2004). Behavior change, in the
in one’s own competence and power to execute an SCT paradigm, can be achieved in the following
action that will achieve the desired outcome. These ways:
efficacy beliefs have a profound impact on goal set-
• directly, by reinforcement of particular
ting and aspirations. According to Bandura (2004,
behaviors;
p. 145), “the stronger the perceived self-efficacy, the
• indirectly, through social modeling or observ-
higher the goals people set for themselves and the
ing someone else being reinforced for the
firmer their commitment to them.”
behavior; and
Self-efficacy, whether or not an individual believes
• through self-management or by having the
in his or her ability to perform a given behavior, is
individual monitor and self-reward (Parcel &
derived from personal performance attainments,
Baranowski, 1981).
vicarious experiences, verbal persuasion, and emo-
tional arousal. Successful accomplishment of a be- Bandura (2004) recommends the use of a stepwise
havior enhances one’s expectation for future approach to the development of health behavior in-
endeavors. The more similar the current task to tasks terventions, tailoring the strategies to the particular
performed successfully in the past, the greater the level of self-efficacy and outcome expectations of
efficacy expectations will be. Observations of others the client. For example, persons with high levels of
who are perceived as similar to oneself, engaging in self-efficacy and positive outcome expectations will
activities and achieving the desired outcome can also require minimal guidance to achieve health behavior
increase one’s expectations for accomplishment. Ac- change. However, persons who have doubts about
cording to SCT, verbal encouragement, receipt of their self-efficacy and the outcomes of their behaviors
permission to attempt a specific behavior, and a per- will need more guidance, support, and modeling.
ceived physiological and emotional state that is con- Persons with low levels of self-efficacy and negative
ducive to successful execution of the task will also outcome expectations will require considerable struc-
enhance an individual’s confidence and self-efficacy ture and personal guidance, as well as the incorpora-
relative to that behavior. tion of the occupational therapy principle of “the just
Health behavior change also is mediated by ex- right challenge” in order to build confidence through
pectancies. According to Bandura (1977), outcome experiences of behavioral success.
2580_Ch03_031-050 16/07/13 2:43 PM Page 37
In general, the SCT provides a unique perspec- • the individual is exposed to cues for action,
tive for community-based practice. The constructs • then it is likely that the health behavior will
of self-efficacy, outcome expectations, behavioral occur (Rosenstock, 1974).
capability, modeling, reciprocal determinism, and
The HBM has been used with a variety of popu-
self-control appear to be particularly relevant for the
lations and a diversity of health topics, including:
development of occupational therapy interventions.
• Breast self-examination (Champion, 1985)
and mammogram screening (Wang, Liang,
Health Belief Model Schwartz, Lee, Kreling, & Mandelblatt, 2008),
• Contraceptive behavior (Herold, 1983; Hester
The health belief model describes the relationships
& Macrina, 1985),
between a person’s beliefs about health and his or
• Diabetes self-management regimen (Becker
her health-specific behaviors. The beliefs that medi-
& Janz, 1985; Bereolos, 2007),
ate health behavior are, according to the model, per-
• Health habits of college students (Deshpande,
ceived susceptibility, severity, benefits, and barriers.
Basil, & Basil, 2009; Juniper, Oman, Hamm,
In addition to the beliefs just mentioned, cues to ac-
& Kerby, 2004),
tion are viewed as necessary triggers of behavior.
• Medication compliance among psychiatric out-
• Perceived susceptibility is the individual’s patients (Kelly, Mamon, & Scott, 1987), and
subjective impression of the risk of a disease, • Osteoporosis prevention (Johnson, McLeod,
illness, or trauma. Kennedy, & McLeod, 2008).
• Perceived severity refers to the convictions a
Perceived threat, which encompasses perceived
person holds regarding the degree of serious-
susceptibility, has been suggested to be an important
ness of a given health problem.
first cognitive step in the health-action link described
• Perceived benefits are the beliefs a person has
by this model. Figure 3.2 presents an adapted
regarding the availability and effectiveness of
schematic representation of the updated HBM as
a variety of possible actions in reducing the
applied to the goal of increasing physical activity.
threat of illness or trauma.
Within occupational therapy, the HBM has been
• Perceived barriers are the costs or negative as-
used to support a program evaluation of CarFit®, a
pects associated with engaging in a specific
community-based program directed at educating
health or preventive behavior.
older drivers about proper positioning while driving.
• Cues to action are defined as instigating events
CarFit was jointly developed by AOTA, AARP, and
that stimulate the initiation of behavior. These
the American Automobile Association to enhance
cues may be internal, such as perceptions of
driving safety among older adults. Results from this
pain, or external, such as feedback from a
study indicated that this type of community-based
health care provider (Rosenstock, 1974) or
program can result in self-reported behavior change
the media.
and the dissemination of educational content be-
According to the model, in order for a person to yond the original participants (Stav, 2010).
take action to avoid illness or trauma, the positive
forces need to outweigh the negative forces. If an
individual believes the following, that: Transtheoretical Model of Health
• he or she is personally susceptible to the Behavior Change
disease, illness, or trauma; The transtheoretical model of health behavior
• occurrence of the health problem is severe change (TMHBC), also referred to as the Stages of
enough to negatively impact his or her life; Change Model, is a complex model consisting of
• taking specific actions would have beneficial stages (precontemplation, contemplation, prepara-
effects; tion, action, maintenance, and relapse/re-cycling)
• barriers to such action do not overwhelm the and processes of change (Prochaska, Norcross, &
benefits; DiClemente, 1994). The stages are depicted in
2580_Ch03_031-050 16/07/13 2:43 PM Page 38
Background Perceptions Action
Threat
Perceived susceptibility
to disease or chronic Cues to Action
conditions secondary to Media
obesity or lack of Personal influence
physical activity Reminders
Perceived severity of
disease or chronic
condition
Sociodemographic Institute program of
Factors regular physical activity
(e.g., education, age, with friends
sex, race, ethnicity)
Expectations
Perceived benefits of
action (minus)
Perceived barriers to
action
Perceived self-efficacy
to engage in regular
physical activity
Fig. 3•2 Adapted from The Revised Health Belief Model as a Framework to Investigate
Compliance with Required Physical Activity. (From Rosenstock, I. M., Strecher, V. J., and Becker, M. H.
[1994]. The health belief model and HIV risk behavior change. In R. J. DiClemente and J. L. Peterson [Eds.],
Preventing AIDS: Theories and methods for behavioral interventions [p. 11]. New York: Plenum.)
Figure 3.3 and the processes are described in

Table 3-1.
Precontemplation
The precontemplation stage refers to the individ-
ual’s inability to identify that she has a problem,
and, as a result, she has no intention of changing her
behavior. In the contemplation stage, the individual Contemplation
can identify and acknowledge a problem behavior
and is motivated to remedy it. The preparation stage
is characterized by planning for change, acquiring
needed resources to facilitate the behavior change, Relapse/
Preparation
Recycling
and making declarations about intentions to change
to family and friends. The action stage involves
overtly changing one’s behavior and modifying the
environment to facilitate and maintain the change.
The maintenance stage requires long-term commit- Maintenance Action
ment to sustain the behavior change and to incor-
porate it into one’s lifestyle permanently (Prochaska,
Norcross, & DiClemente, 1994). Fig. 3•3 Stages of Change from the Transtheoretical
Relapse is included as many health behavior Model. (Data from: Prochaska, Norcross, & DiClemente
changes, such as smoking, follow a pattern of initiation, (1994).)
2580_Ch03_031-050 16/07/13 2:43 PM Page 39
Table 3-1 Processes Associated With the Transtheoretical Model

Process Description
Consciousness-raising Increasing one’s level of awareness of the problem and its conse-
quences, providing information that can be useful in the behavior
change process
Social liberation Alternatives to the behavior that the environment provides that free the
person from having to make an individual decision
Emotional arousal Similar to consciousness-raising, but works on a deeper feeling level
in order to experience and express emotions about the problem and
behavior change, as well as to understand one’s resistance to change
Self-reevaluation A thoughtful and emotional reappraisal of the problem that enables
people to see when and how their behavior conflicts with their goals
and values
Commitment (or self-liberation) Accepting responsibility for the changes needed and announcing one’s
decision to change, which increases accountability for taking action
Countering Substituting healthy responses and behaviors for unhealthy ones, for
example, going for a walk instead of eating a piece of cake
Environment control Restructuring the physical and social environment to maximize poten-
tial for effective behavior change; avoiding stimuli that elicit unhealthy
behaviors
Rewards Behaviors that are reinforced are repeated and maintained. Finding
rewards for behavior change that are personally meaningful is critical
for success.
Helping relationships Soliciting, accepting, and receiving support and other types of assis-
tance from significant others in one’s life including friends, family,
colleagues, clergy, and health-care professionals
Data from: Prochaska, Norcross, & DiClemente (1994). Changing for Good: A Revolutionary Six-Stage Program
for Overcoming Bad Habits and Moving Your Life Positively Forward. New York, NY: Avon Books.
relapse, and re-initiation of change. It is important • individuals who believe they have the auton-
not to interpret relapse as a failure but to acknowledge omy and power to change their lives are
it as a natural element in the long-term process of the most likely to initiate and maintain a
health behavior change. Following a relapse, an indi- change, and
vidual typically will re-enter the change process at • tailoring the techniques employed to the
the contemplation, preparation, or action stages. The individual’s preferences and needs enhances
National Cancer Institute (NCI, 2005) identified this the probability of successful long-term be-
model’s circular nature as a strength, whereby an indi- havior change (Prochaska, Norcross, &
vidual can enter the cycle at any point and repeated DiClemente, 1994).
attempts to change behavior or “re-cycle” are possible.
There has been limited use of this model within
The broad change processes listed in Table 3-1
the occupational therapy literature. One exception
should not be confused with techniques. There are
is the work of Stoffel and Moyer (2004), in which
potentially hundreds of techniques associated with
they identify motivational strategies, based on the
the processes of change. Research indicates that:
transtheoretical model, as one of four effective
• many methods for implementing change methods occupational therapy practitioners can use
processes can be effective to assist persons with substance use disorders to
2580_Ch03_031-050 16/07/13 2:43 PM Page 40
eliminate use of risky substances. Hammond, the acronym PRECEDE stands for predisposing,
Young, and Kidao (2004) conducted a study on the reinforcing, and enabling causes in educational
effectiveness of a pragmatic occupational therapy diagnosis and evaluation (Green, Kreuter, Deeds, &
program that was developed over a period of years Partridge, 1980). A set of steps called PROCEED
for clients with rheumatoid arthritis. From this (policy, regulatory, and organizational constructs in
experience, the researchers came to realize that the educational and environmental development) were
program may have been more effective had it been later superimposed on the original model (Green &
theory-based and matched to the client’s readiness Kreuter, 1991). The framework has since been re-
for change, an important construct of the transthe- vised in order to accommodate the evolving nature
oretical model. and broadening ecological perspective of health
promotion. The complete PRECEDE-PROCEED
framework is illustrated in Figure 3.4.
PRECEDE-PROCEED Planning Model The PRECEDE portion of the framework is
The PRECEDE model, developed by Green, Kreuter, readily applicable across a variety of settings, pro-
Deeds, and Partridge (1980) with financial support viding structure and organization to health educa-
from the National Institutes of Health, is a planning tion program planning and evaluation. Application
model for health education based on principles, of this approach occurs in several phases and in-
both theoretical and applied, from epidemiology, volves the diagnoses of variables in four domains:
education, administration, and the social/behavioral social, epidemiological, educational and ecological,
sciences. In the PRECEDE-PROCEED framework, and administrative and policy (Green & Kreuter,
PRECEDE
Phase 5 Phase 4 Phase 3 Phase 2 Phase 1
Administrative Educational and Behavioral and Epidemiological Social
and policy organizational environmental diagnosis diagnosis
diagnosis diagnosis diagnosis
Predisposing
factors
Health
promotion
Health Reinforcing Behavior

education factors and lifestyle
Quality
Health
of life
Policy
Enabling
regulation Environment
factors
organization
Phase 6 Phase 7 Phase 8 Phase 9

Implementation Process Impact Outcome
evaluation evaluation evaluation
PROCEED
Fig. 3•4 The PRECEDE-PROCEED Model. (From Health Promotion Planning: An Educational
and Ecological Approach [4th ed., p. 17], by Lawrence W. Green and Marshall W. Kreuter. Copyright © 2005
by McGraw Hill.)
2580_Ch03_031-050 16/07/13 2:43 PM Page 41
2005). The approach is unique in that it begins completed, the PROCEED portion of the model is
with the desired final outcome and works backward, activated.
taking into account factors that must precede a The PROCEED phase follows the four phases of
certain result. the PRECEDE portion and includes the implemen-
Phase 1, social assessment, is an analysis of the tation of the program (i.e., phase 5) as well as three
social problems that exist in a community, which is phases of evaluation. The goal of the PROCEED
a necessary step in assessing the quality of life of the portion is to monitor the program processes in order
target population. The purpose of this phase is to as- to make adjustments as needed to ensure quality
certain the relationship between a given health prob- as program implementation continues. The three
lem and the social problems and priorities of the types of evaluation include process (phase 6), impact
population. Phase 2, epidemiological, behavioral, and (phase 7), and outcome (phase 8) evaluations (Green
environmental assessment, is an evaluation of the & Kreuter, 2005).
health problems associated with the community’s The PRECEDE-PROCEED planning frame-
quality of life. It includes a review of vital indicators work has been used to develop a wide variety of
such as morbidity, mortality, fertility, and disability community and population health programs, with
rates along with behavioral and environmental in- over 950 applications of the use of the framework
dicators (Green & Kreuter, 2005). being published (Green & Kreuter, 2005). While
In phase 3, educational and ecological assessment, this planning framework has not been used widely
resources and barriers are differentiated by three in occupational therapy, it has been used by an in-
categories of influence: predisposing, enabling, and terdisciplinary team with members from a variety
reinforcing factors. Predisposing factors provide the of health professions and disciplines, among them
motivation or rationale for the behavior(s); for ex- occupational therapy, to conduct a systematic
ample, knowledge, attitudes, values, and beliefs. Re- literature review. The team used the PRECEDE
inforcing factors supply the reward, incentive, or portion of the PRECEDE-PROCEED framework
punishment of a behavior that contributes to its to systematically investigate the literature and re-
maintenance or extinction. Enabling factors include port risk and protective factors related to driving
personal skills and assets as well as community re- safety among older adults (Classen, Awadzi, &
sources and barriers. Predisposing and enabling fac- Mkanta, 2008).
tors are antecedent to the health behavior and allow
for the behavior to occur. Each group of factors is
analyzed in terms of importance and changeability, Diffusion of Innovations Model
and priorities are established for the intervention. The diffusion of innovations model developed by
Based on the nature of the targets for intervention, Rogers (2003) is a very useful adjunct to specific oc-
educational methodologies are selected (Green & cupation or health theories (Reitz, Scaffa, Campbell,
Kreuter, 2005). & Rhynders, 2010). Whereas specific health or
The final phase (phase 4) of the process is ad- occupation theories inform the development of an
ministrative and policy assessment, and intervention effective structure and content for the program, the
alignment, which includes: reviewing budgetary im- diffusion of innovations model provides a guide on
plications; identifying and allocating other types of how to most efficiently communicate the availability
resources, including time; defining the nature of any of the intervention and the adoption of new behav-
cooperative agreements; and assessing the availabil- iors. The factors that influence the speed of behavior
ity of and gaps in policies and regulations. Gaps in adoption appear in Table 3-2, together with ques-
and barriers to the implementation of the health tions to address in order to maximize success in
promotion program need to be addressed at this communicating the message. In the AOTA’s back-
stage, prior to program implementation. This step pack awareness program, developed by Jacobs
and the steps proceeding are essential for the devel- (Yamkovenko, 2010), the answer to each of these
opment of an ethical, evidence-based program. Neg- questions would be yes. The innovation (e.g., limit-
lect of this important step can doom an otherwise ing weight and using both padded shoulder straps),
viable intervention to failure. After this phase is once tried, is more comfortable and will impact the
2580_Ch03_031-050 16/07/13 2:43 PM Page 42
Table 3-2 Key Attributes Affecting Selected Occupational

the Speed and Extent of an
Innovations Diffusion Therapy Models
Attribute Key Question Descriptions of models found in the occupational
Relative advantage Is the innovation better than therapy professional literature and application in
what it will replace? community-based practice follows. This descrip-
Compatibility Does the innovation fit with tion is not meant to be an exhaustive account of
the intended audience? relevant approaches but rather a sampling to illus-
trate how models within occupational therapy re-
Complexity Is the innovation easy to use?
late to community-based practice. Of the many
Trialability Can the innovation be tried occupational therapy models available to assist in
before making a decision to community health program planning, three have
adopt? been selected for analysis in this chapter. However,
Observability Are the results of the innova- various other models also are potentially useful in
tion observable and easily community-based practice. It is hoped that readers
measurable? will explore other models and conduct an inde-
From Theory at a glance (2nd ed., p. 28), by National Cancer
pendent analysis to determine the most appropri-
Institute, 2005, Bethesda, MD: National Institutes of ate model to address the health needs of their
Health. unique community. The three models discussed in
this chapter were selected due to their applicability
daily lives of the intended participants; the innova- for use either individually or in conjunction with
tion is easy to use and easy to try, and it is easy to models and approaches from other disciplines pre-
see other influential people adopting the innovation. sented earlier in this chapter. The models described
According to Rogers, people vary in their readi- include:
ness to adopt new behaviors (NCI, 2005; Rogers, • model of human occupation (MOHO),
2003). Rogers found that people, following a nor- • ecology of human performance (EHP), and
mal distribution, would fall in one of five categories • person-environment-occupation model (PEO).
of adopters: innovators, early adopters, early major-
ity adopters, late majority adopters, or laggards.
Most people fall into the early majority adopters or Model of Human Occupation
late majority adopters categories. Fewer individuals The model of human occupation (MOHO) was
are classified as early adopters or laggards. The rarest developed by Kielhofner and Burke (1980) to pro-
categories are those on either end of the distribution, vide a link between practice and Reilly’s theory of
the innovators (i.e., those first to adopt) and the lag- occupational behavior (Scott, Miller, & Walker,
gards (i.e., the last to adopt). Early adopters are 2004). In 1980, a four-part article describing the
often seen as trendsetters; once a trend becomes MOHO was published in the American Journal of
popular, people who often lag in trying new things Occupational Therapy. Kielhofner either authored
may eventually adopt the innovation. or coauthored each of these articles and has been
Whereas there is tremendous potential to use this the catalyst for the model’s further development.
theory to disseminate occupational therapy health However, “scholars and clinicians worldwide now
promotion strategies (Reitz et al., 2010), there is little contribute to its development and application”
to no evidence in the literature. However, the theory (Kielhofner, 1997, p. 187). Originally the human
has been used to develop recommendations for in- system was portrayed as interacting with the en-
creasing the compatibility of reported research evi- vironment via a cycle of input, throughput, out-
dence for use by occupational therapists (Sudsawad, put, and feedback (Kielhofner & Burke, 1980).
2005) and to explore adherence to intervention The traditional application of this model views the
guidelines for low back pain by physical therapists individual as receiving input from the environ-
(Harting, Rutten, Rutten, & Kremers, 2009). ment as well as being the site of the throughput
2580_Ch03_031-050 16/07/13 2:43 PM Page 43
process. Throughput is a process composed of three The habituation subsystem functions to maintain
subsystems: the organism by providing “everyday patterns of
behaviors without ongoing conscious choices”
1. Volitional,
(Kielhofner & Burke, 1985, p. 24). This maintenance
2. Habituation, and
is done through the development and refinement of
3. Performance capacity.
habits and internalized roles (e.g., worker, student,
This process was originally portrayed as being mother, and spouse). Habits and internalized roles
hierarchical in nature, where the higher subsys- provide humans with a sense of order and pre-
tems “command lower ones and...lower ones con- dictability. In addition, they allow humans to be
strain the higher” (Kielhofner, 1985, p. 504). energy and time efficient.
Later the model was described as a heterarchy, The volitional subsystem, the third component of
where each of the subsystems works in unison to the throughput process, motivates the individual to
perform occupational behaviors “according to the “enact” a behavior. This subsystem, which originally
demands of the situations in which they are per- was viewed as the subsystem that governed the other
forming, not according to a preordained or fixed subsystems, is composed of three “structural compo-
structure” (Kielhofner, 1995, p. 34). A heterarchical nents: personal causation, values, and interests”
process seems better suited to community-based (Kielhofner & Burke, 1980, p. 576). Kielhofner
practice. and Burke (1985) defined “personal causation” as “a
The output of the system is occupational behav- collection of beliefs and expectations which a person
ior (Kielhofner, 1997), or purposeful interaction holds about his or her effectiveness in the environ-
with the environment. This interaction, which is ment” (p. 15). These beliefs include “belief in skill,
termed feedback, produces additional information belief in efficacy of skill, expectancy of success/failure,
to the individual regarding his or her performance. and internal/external control” (Kielhofner & Burke,
A thorough understanding of the role of the three 1985, p. 16). In addition, Kielhofner and Burke view
heterarchical subsystems of throughput is necessary values as “images of what is good, right and/or im-
before applying or adapting this model to community- portant” (p. 17), whereas interests concern the self-
based practice. These subsystems, when working in knowledge of activities or occupations that provide
unison, serve to organize the individual’s response pleasure to the individual. This self-knowledge in-
to the environment. cludes the ability to recognize patterns of enjoyed
Through the years, the description of the compo- activities and an understanding of which activities
nents of the environment has been modified to re- evoke more potency of interest than others.
flect both the continued development of the model Two related constructs that explain how the
and the influence of other theorists. In the current human system changes within, and in response to,
language of the MOHO (Kielhofner, 1997), the en- the environment over time also are important to con-
vironment consists of physical aspects (i.e., objects sider when applying this model in the community.
and spaces) as well as social aspects (i.e., occupational These constructs are the trajectory of change and
forms and groups). The environment both “affords” adaptive and maladaptive cycles. The trajectory of
and “presses” the individual (Kielhofner, 1997), change is the self-transformation of the system over
meaning it simultaneously facilitates and constrains time. An adaptive cycle supports the individual in sat-
the human system. isfying internal demands as well as the demands of
The throughput subsystems play important roles. the environment (Kielhofner & Burke, 1980). Kiel-
The performance capacity subsystem involves the “in- hofner described a maladaptive cycle as failing “to
terplay of the musculoskeletal, neurological, percep- meet one or both” of the internal or environmental
tual, and cognitive phenomena” (Kielhofner, 1997, demands just mentioned (1980, p. 737). It is possi-
p. 194), which allows the individual to meet the ble, however, to reverse a maladaptive cycle and
demands of both the environment and the remain- encourage the development of an adaptive cycle.
ing two subsystems. The primary function of this The MOHO has been applied to intervention
subsystem is to produce “the actions required to ac- with individuals with a variety of disorders. This
complish occupation” (Kielhofner, 1997, p. 194). model also has potential use for well individuals in
2580_Ch03_031-050 16/07/13 2:43 PM Page 44
an occupational therapy community-based pro- potentially conflicting values. For example, the com-
gram. In addition, it is believed that it can be used munity will need to weigh the value it places on per-
in community-based health promotion program- sonal freedom against the value it places on student
ming where the recipient of services is the commu- safety and comfort when deciding whether to re-
nity rather than an individual or family. Figure 3.5 quire students to wear identification or to install
illustrates a simplified adaptation of the MOHO security cameras.
for use as a community empowerment model In addressing the habituation level of this model,
(Reitz, 1990). the practitioner identifies potentially dangerous
The following fictional example illustrates the habits (e.g., propping open exterior doors on balmy
possible use of the adapted MOHO, depicted in days) and roles (e.g., identification of disengaged
Figure 3.5, to community-based practice. In this students with no apparent role in the school com-
scenario, an occupational therapy practitioner munity). In addition, the community’s skills and
employed by a school system has been asked by skill constituents would be identified. This analysis
the Parent-Teacher-Student Association (PTSA) to would then be used to facilitate the community’s
assist with the development of a violence (i.e., per- current skills to maximize habit and role perform-
petrators from outside the school community) and ance as well as identify necessary skills requiring
bullying (i.e., perpetrators from within the school development in order to achieve the goals of the
community) prevention program in the county’s program.
only high school. In this example, the commu-
nity’s volitional subsystem has already motivated
the community to make the decision to seek assis- Ecology of Human Performance
tance. Thus, the community is already exhibiting The ecology of human performance (EHP) model
“community causation” by identifying the prob- was developed by the faculty at the University of
lem and believing it has the power to take steps Kansas to address their concerns regarding the “lack
to accomplish the goal of improving school and of consideration for the complexities of context” in
student safety. both evaluation and intervention (Dunn, Brown, &
The actual steps the community or PTSA decides McGuigan, 1994, p. 595). Figure 3.6 depicts the
to take will be greatly influenced by the commu- major components of this conceptual model of
nity’s cultural norms (e.g., values and interests) as practice—the person and his or her skills, abilities,
well as the habits and roles of its members. The prac- tasks, and performance range.
titioner can assist the community in identifying val- A human’s skills and abilities, in combination
ues and interests that will influence decision making with a perception of his or her context, support the
relative to changes in the structure of the school and selection and performance of specific tasks, defined
community habits. The community may need to in the model as “objective sets of behaviors necessary
collectively determine the relative priorities of to accomplish a goal” (Dunn et al., 1994, p. 599).
Environment
Occupational
Volition Participation
Identity
Habituation Performance Occupational

Fig. 3•5 The Model of Human Occupation as a Adaptation
Framework for Use in Community-Based Practice.
(Adapted from Model of Human Occupation: Theory and Performance Occupational
Skill
Capacity Competence
Application (3rd ed., p. 121), by G. Kielhofner, 2002, Baltimore,
MD: Lippincott Williams & Wilkins. Copyright 2002 by
Lippincott Williams & Wilkins.)
2580_Ch03_031-050 16/07/13 2:43 PM Page 45
T T
T T T
T T T
T
T T
T
T Performance
T T
T
Fig. 3•6 The Major Components
T
T
of the EHP. (From Dunn, W., Brown,
C., and McGuigan, A. [1994]. The ecology
T T T
T T
of human performance: A framework for
T
T T considering the effect of context. American
T T Journal of Occupational Therapy, 48,
T
T p. 600.)
Each individual’s performance range depends on maladaptive performance in context” (p. 604). The
both past experience and current resources. Limited last level of intervention in the EHP is the create
resources, possibly due to a temporary state of level. This level has great potential for community-
affairs or a more permanent situation, may impact a based practice since its goal is to create “circum-
human’s performance range even if he or she has a stances that promote more adaptable or complex
variety of skills and abilities. For example, a compe- performance in context” (p. 604). Policy initiatives,
tent parent of a toddler may find his or her parenting program development, community development,
repertoire (i.e., performance range) significantly hin- and community empowerment are all activities at
dered by a change of context brought about by the this level of intervention.
cramped confines of an airplane seat. If the same When using the EHP model, regardless of the
competent parent were sentenced to serve a 10-year level of intervention chosen, intervention should
prison term, the change in resources for parenting always be guided by the culture of the individual
would obviously be of longer duration. However, in or the community. Tasks that an individual or com-
this scenario, even though the parent had a variety munity selects to pursue are determined by its skills
of skills and abilities, he or she would not have access and abilities, as well as personal choices, priorities,
to resources to support a broad performance range. and values that are often guided by both life experi-
The EHP model provides “five alternatives ence and cultural values. For example, a child’s
for therapeutic intervention” (Dunn et al., 1994, choice to play soccer may at first be influenced by
p. 603). The first of these five levels is identified as his or her family’s cultural background, which
the establish/restore level. This level includes inter- highly values the sport. Continued interest may be
ventions that seek to restore function via the devel- influenced by natural aptitude and early skill devel-
opment and improvement of skills and abilities. opment, coupled with pride for a grandfather’s past
Another level of intervention is that of adapt. At this achievements as a semiprofessional player overseas.
level, the therapist adapts “the contextual features These five levels of intervention can be readily
and task demands to support performance in con- adapted to facilitate the development of community-
text” (p. 604). Yet another intervention level is the based health promotion activities. An intervention
alter level where the therapist changes the actual at the prevent level may, for example, include the
context rather than adapting the current one. An development of an interdisciplinary program to
example of such an intervention would be moving educate seniors with diabetes in healthy eating
an individual who uses a walker to a street-level habits and cooking techniques to avoid complica-
apartment so the individual would not be forced tions of an uncontrolled disease process (Lutz,
to climb stairs. The prevent level of intervention 1998). Forming a daily walking group at a senior
seeks to “prevent the occurrence or evolution of center to promote exercise, leisure skills, and a
2580_Ch03_031-050 16/07/13 2:43 PM Page 46
healthy lifestyle is an example of a create level inter- Rigby, & Letts, 1996). In the PEO model, activities,
vention. As stated earlier, the fifth level, create, tasks, and occupations are differentiated by describ-
appears to be particularly well suited for community- ing them as nested within one another, with activi-
based program development since it “does not ties being the smallest unit and occupations being
assume a disability is present” and it focuses on the largest unit. An occupation is a group of tasks
“providing enriched contextual and task experiences in which an individual engages across a period of
that will enhance performance” (Dunn et al., 1994, time or his or her life span. Occupational perform-
p. 606). ance is understood as a “dynamic, ever-changing
An example of a community that may request as- experience of a person engaged in purposeful activ-
sistance from an occupational therapy practitioner ities, tasks, and occupations within an environment”
might be a homeless shelter (i.e., a community of (Stewart, Letts, Law, Cooper, Strong, & Rigby,
individuals). In this example, the community has 2003, p. 229). The major assumption of the PEO
acted based on concern for the healthy development model is that the greater the “fit” among the three
of its children. The community has already taken key areas—person, environment, and occupation,
the first two necessary steps by recognizing the prob- in terms of matching the strengths and capacities of
lem and inviting the occupational therapy practi- the person and the supports and demands of the en-
tioner into the community. The practitioner can use vironment and occupation—the better the person’s
the EHP model to define the scope of the problem or community’s occupational performance.
from an occupation-based perspective and then One of the strengths of this model is its applica-
work with the community to determine priorities bility across settings. For example, the proponents
and set goals. Interventions are then selected from of this model assume that an intervention can occur
the model’s five intervention levels. The occupa- at the person, program, or system level. This lends
tional therapy practitioner and the community then it to use in community practice, where a consulta-
jointly implement the agreed-upon activities and tive approach or broader than person level interven-
evaluate the outcomes. The community then takes tion is the norm. Another strength is its relative
responsibility for continued monitoring, consulting simplicity and lack of jargon, lending to ease of use
the occupational therapy practitioner for assistance in interdisciplinary settings, such as community
in program evaluation or expansion as desired. agencies. Because the roots of this model lie in an
ecological framework, others in community health
practice may be familiar with its basic tenets, such
Person-Environment-Occupation as the influence of the environment on engagement
Model and participation. Those who work in the commu-
The person-environment-occupation (PEO) model nity are faced very directly with the effects of the en-
was initially conceptualized by Law and colleagues vironment in people’s everyday lives, so this model
(1996) to operationalize client-centered practice is easily understood and applied in such settings.
across settings and populations. The model expands
the awareness of the relationship between a person
and his/her environment present in ecological mod-
Examples of Research Using
els in order to recognize the transactive relationship the PEO Model
among the three constructs—person, environment, The PEO model was used to structure community-
and occupation (Strong & Rebeiro-Gruhl, 2011). based research in which occupational engagement
In addition to explicitly identifying the person as and time use relative to recovery were examined
the focus of intervention, this model also identifies from the perspective of people with serious mental
the environment as a modality. Four aspects of the illness living in the community. A specific research
environment that have an influence on occupational question addressed participants’ views of environ-
performance are detailed in the model. These are ex- mental supports and barriers to recovery, using the
ternal to the person and include cultural, institu- PEO to guide questions on a semi-structured inter-
tional (including political and economic), social, view about the physical, social, cultural, and insti-
and physical aspects (Law, Cooper, Strong, Stewart, tutional aspects of the environment (Merryman,
2580_Ch03_031-050 16/07/13 2:43 PM Page 47
Magaha, Mullins, Pollock, & Waters, 2003). Find- Although the positive youth development model
ings from this population revealed that the social as- was the primary driver of the program, the PEO
pects of the environment were the most critical to model encouraged researchers to use specific strate-
support recovery. These primarily included the sup- gies to enhance occupational performance and op-
port of family and friends. The aspects of the envi- portunities for skill development and competence
ronment that most served as a barrier to recovery to aid efficacy.
were predictable: social and financial (Merryman &
Sheffield, 2011).
The PEO model was used to structure other Conclusion
community-based research using participatory action
methods (McIntyre, 2008) in designing sessions for Community-based practice often involves a team
a Photovoice project with fifth and sixth graders in approach wherein the membership of the team does
a Youth Empowerment Program (Wilson, Dashio, not conform to the familiar, traditional, hospital-
Martin, Wallerstein, Wang, & Minkler, 2007). The based interdisciplinary team. Public health experts,
grant used positive youth development (Damon, health educators, community developers and organ-
2004) as the overarching framework, and employed izers, and politicians are all examples of potential
the PEO in the design and implementation of community-based team members who may work to-
intervention sessions. Sessions were designed by gether on a community initiative. Many of these
occupational therapy graduate students using the professionals share a common language that is rep-
model’s principles in decisions regarding the resented in the models from other disciplines pre-
amount of structure, support, enrichment, and sented in this chapter. It is hoped that exposure to
adaptation of approach, task, and environment. An these models will facilitate interdisciplinary work in
example of a session in which participants selected the community by practitioners. For occupational
photographs and generated quotes reflecting their therapy to reach its potential in the community,
responses to directions to take nine photos each its practitioners must possess the knowledge and
of their daily life, their environment, and things skill to join together with a varied group of stake-
they liked to do or wanted to share about what they holders, gatekeepers, community members, and other
liked, is presented in Table 3-3. health professionals to creatively and cost effectively
Table 3-3 Photovoice Storyboard Captions Using PEO to Reflect Themes of Self-Efficacy
P = Daily Life E = My Environment O = Things I Like to do
“This one I chose because my CDs “The playground. It’s fun to “This is my brother and he is pos-
are my most important possession be playing on the playground ing with earphones in his ears.
because if you’re bored and your because you can let out all He’s in my room and I took this
friends are punished, you can just your feelings there.” picture he encourages me to do
sit back, get some popcorn, and things like sing and don’t let no-
watch a movie.” body tell me I can’t do anything.”
“I took this picture because every “I took a picture of the grass “My best friend, (participant), is in
day I come home I have to do because me, my neighbor, the picture. She is smiling. I took
homework and do all my chores. and my mom helped it grow the picture because she is one of
I think this picture is very important by planting seeds and water- my best friends. I think that it is
because without homework you ing it everyday. When I first nice of me to encourage her to be
will have very low grades. This moved in it was dirt. The a wonderful student. The picture
picture makes me feel very picture made me feel good makes me feel great to have a
successful.” because I helped it grow.” friend to take care of me.”
Data from Day, Y., DeHart, R., Grant, A., Kwebetchou, N., Lowther, S., & Weisburger, M. (2010) under the
direction of Dr. Beth Merryman, Photovoice: Engagement through action research with fifth graders in
a Youth Empowerment Program. Unpublished graduate project.
2580_Ch03_031-050 16/07/13 2:43 PM Page 48
facilitate the achievement of the health goals of would use constructs from one or more theo-
diverse communities. ries in your program. Draw a sketch of the
As in all areas of occupational therapy practice, theory and the corresponding constructs.
outcomes research is needed to evaluate the efficacy
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An application of the model of human occupation. Occupational therapy in mental health: A vision for
Unpublished paper for Health 688—p, Community participation (pp. 31–44). Philadelphia: F.A. Davis.
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Maryland, College Park. conceptual framework to increase usability of outcome
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tion practice. In M. E. Scaffa, S. M. Reitz, & M. A. Pizzi United Nations. (1955). Social progress through community
(Eds.), Occupational therapy in the promotion of health and development. New York: United Nations.
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Rogers, E. M. (2003). Diffusion of innovations (5th ed.). & Mandelblatt, J. S. (2008). Development and evaluation
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Rosenstock, I. (1974). Historical origins of the health belief breast cancer-related behaviors in Chinese women. Health
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The health belief model and HIV risk behavior change. social action through Photovoice: The youth empowerment
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and practice. New York, NY: Harper and Row. Backpack-Day.aspx
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Chapter 4
Legislation and Policy Issues

M. Beth Merryman, PhD, OTR/L, FAOTA, and Nancy Van Slyke, EdD, OTR/L, FAOTA
Legislation that affects the lives of people with disabilities should be of more than just a
passing interest to those who are involved with the disability community. Not only does
legislation articulate who is to receive the services, but it also articulates what and how
services are to be delivered.
—Fifield & Fifield, 1995, p. 38
Learning Objectives
• Discuss the need for a basic understanding of federal legislation pertinent to community-based practice.
• Compare and contrast legislation supporting reimbursement for services with those providing support and
funding for programs.
• Identify specific legislation that focuses on issues related to each of the following categories: education and
development, medical rehabilitation, consumer rights, and environmental issues.
• Compare and contrast federal and state policy environments and potential methods of influence for community
practice.
Key Terms
Americans with Disabilities Act (ADA) of 1990 Individuals with Disabilities Education Act (IDEA)
Civil rights referenced legislation Medical rehabilitation referenced legislation
Consumer referenced legislation Protection and care referenced legislation
Educational and developmental referenced legislation Social Security Act of 1935
Environment referenced legislation Technology Related Assistance Act of 1988
Introduction and Law (1998), occupational therapists must

understand the mechanisms of service delivery for
Occupational therapists practicing in the medical social programs, including the legislative policies
model have expected payment from, and therefore and funding (i.e., provision of money for a specified
have been influenced by, the medical insurance purpose) resources that support them.
providers, including programs offered by federal, Globally, health and social policies have shifted
state, and private sources. Although this reimburse- away from institutional care and towards support-
ment for services will continue to influence the prac- ing inclusion and community participation.
tice of occupational therapy within the medical For example, the World Health Organization
model, the current shift from the fee-for-service adopted the International Classification of Func-
delivery model to community-based practice will tioning, Disability and Health (ICF) (2001) to
require practitioners to broaden their perspectives replace the International Classification of Impair-
to include knowledge of legislation that impacts ments, Disabilities and Handicaps (ICIDH), sup-
community service programs. According to Baum porting a shift from a biomedical to a social
51
2580_Ch04_051-060 16/07/13 2:45 PM Page 52
paradigm. This occurred in recognition of the role populations. Changing views of health and the
of the environment in determining a person’s environment have also influenced policy and
health and disability status (Stewart & Law, funding decisions (Stewart & Law, 2003). The
2003). In 2004, the World Federation of Occu- influence of federal legislation and regulation on
pational Therapists approved a position paper on the increased availability of community programs
community-based rehabilitation that supports full for persons with disabilities has been part of the
community participation by people with disabili- impetus for the interest and shift in occupational
ties worldwide (Kronenberg, Algado, & Pollard, therapy practice from the medical model to a variety
2005). In the United States, it has been recog- of other environments within the community
nized that many people with serious mental illness (Jacobs, 1996).
live productive lives in the community. Mental In this chapter, the legislation and policies
health policy has shifted to support recovery by that might influence community-based practice
putting the person at the center of care decisions. are presented. The legislation described is not
Examples include the Surgeon General’s Report on intended to be all-inclusive. It should be empha-
Mental Health (1999) and the President’s New sized that policy is constantly changing and prac-
Freedom Commission/Initiative (2001; 2003), in titioners must be alert to both existing and
which it is recommended that the entire mental pending legislation that impacts the practice set-
health delivery system be transformed to support ting as well as the client population served. The
consumer recovery. basic themes described are an amalgamation
Historically, special-interest groups have influ- of those described in publications by Fifield and
enced legislation and policies, resulting in the Fifield (1995) and Reed (1992). An extensive
development of the majority of community serv- outline of the relevant legislation is provided in
ices and programs currently available for special Box 4-1.
Box 4-1 Outline of Major Legislation Influencing Community Practice
Protection and care referenced legislation/policy

• Social Security Act
• Aid to the permanently and totally disabled
• Supplemental security income program
• Maternal and Child Health and Mental Retardation Planning Amendments (P.L. 88-156)
• Mental Retardation and Community Mental Health Center Construction Act (P.L. 88-164)
• National Institute of Mental Health Community Support Program
• Omnibus Reconciliation Act of 1981 (P.L. 97-35)
• Reauthorization of P.L. 102-321 ADAMHA Re-Organization Act Substance Abuse Prevention and Treatment
Services Block Grant
Educational and developmental legislation for persons with disabilities
• Education
• National Defense Education Act (P.L. 85-864)
• Maternal and Child Health and Mental Retardation Planning Amendments (P.L. 88-156)
• Mental Retardation and Community Mental Health Center Construction Act (P.L. 88-164)
• Education for All Handicapped Children Act (P.L. 94-142)
• Part H Amendment to P.L. 94-142
• Developmental referenced legislation/policy
• Developmental Disabilities Act of 1970 (P.L. 91-517)
• 1973 Amendments to the Rehabilitation Act (P.L. 93-112)
• Education for All Handicapped Children Act of 1975 (P.L. 94-142)
• Part H of P.L. 94-142, Early Intervention Provisions
2580_Ch04_051-060 16/07/13 2:45 PM Page 53
Chapter 4 | Legislation and Policy Issues 53
Box 4-1 Outline of Major Legislation Influencing Community Practice—cont’d
Legislation establishing reimbursement and funding for rehabilitation programs

• Rehabilitation Act of 1973 (P.L. 93-112)
• Subsequent Amendments to the Rehabilitation Act
• 1965: P.L. 89-97 created Medicare and Medicaid
• 1972: P.L. 92-223 established intermediate-care facilities for persons with mental retardation
• 1972: P.L. 92-603 established supplemental security income to persons on standardized assistance programs
• 1986: P.L. 99-506 clarified supportive employment
• Mental Retardation Facilities and Community Mental Health Center Construction Act of 1963 (P.L. 88-164)
Civil rights referenced legislation
• Civil Rights Act of 1964 (P.L. 88-352) and 1988 Civil Rights Restoration Act
• Architectural Barriers Act of 1968 (P.L. 90-480)
• Amendments to Developmental Disabilities Act
• Section 504 of the Rehabilitation Act of 1973 (P.L. 93-112)
• Americans with Disabilities Act of 1990 (P.L. 101-336)
Environment referenced legislation
• Architectural Barriers Act of 1986 (P.L. 90-480)
• Independent Living Provisions of the 1973 Vocational Rehabilitation Act (P.L. 93-112)
• Technology Related Assistance Act of 1988 (P.L. 100-407)
• Technology Assistance Act of 2004 (P.L. 108-364)
Consumer referenced legislation
• Developmental Disabilities Act of 1970
• 1977 Rehabilitation Act Amendments
• Technology Related Assistance Act of 1988 (P.L. 100-407)
• Americans with Disabilities Act of 1990 (P.L. 101-336)
Sources: Reed, K. L. (1992). History of federal legislation for persons with disabilities. American Journal of Occupational Therapy, 46,
397–408.
Fifield, B., & Fifield, M. (1995). The influence of legislation on services to people with disabilities. In O. C. Karan and S. Greenspan (Eds).
Community rehabilitation services for people with disabilities (pp. 38–70). Boston: Butterworth-Heinemann.
National Collaborative on Workforce and Disability for Youth. (2008). Disability Legislation Retrieved from http://ncwd-youth.info/
resources_&_Publications?disability_Legislation/all_legislation.shtml
Legislation and Disabilities moved beyond the medical management of the

client to addressing other societal and environ-
To facilitate the shift in practice to the commu- mental factors that affect health.
nity model and promote the role of occupational Fifield and Fifield (1995, p. 38) state that “leg-
therapy effectively, the practitioner must have a islation not only articulates who is to receive serv-
basic understanding of the historical background ices, but it also articulates what and how services
of legislation that affects the lives of people with are to be delivered and reflects the values, philoso-
disabilities. Although most practitioners are gen- phies, and concerns of society.” According to these
erally aware of legislation affecting reimbursement authors, much of the early legislation provided
for services, this knowledge has been traditionally compensation programs for military and work
based on the location of service provision (e.g., in- injuries, which later led to the emergence of reha-
patient hospital, outpatient rehabilitation facility, bilitation and education legislation that provided
public school). According to Brownson (1998), funding for services rather than compensation
current legislation and funding mechanisms have for injury. Fifield and Fifield (1995) state that a
2580_Ch04_051-060 16/07/13 2:45 PM Page 54
majority of the current federal programs for community-based settings (Fifield & Fifield,
persons with disabilities has evolved from legisla- 1995; Reed, 1992).
tion that was initiated under the administration
of President John F. Kennedy. Although the work
of the President’s Panel on Mental Retardation of
Educational and Developmental
1962 focused on mental retardation, it outlined Referenced Legislation
legislative needs and programs that applied to Educational and developmental referenced legis-
almost all disabilities. These needs included pre- lation is intended to provide for the instructional
vention, education, public resources, research, co- and training needs of those constituencies covered
ordination of services, and consumer participation. by the legislation. The focus of this type of legisla-
Subsequently, legislation has been developed in tion is on increasing the productivity and enriching
almost all of these areas. Fifield and Fifield (1995) the lives of people with disabilities. Because public
categorized the legislation that emerged into five education was primarily considered the responsibil-
social concerns or themes: ity of the state, the early education laws for children
with disabilities came from the individual state leg-
(1) protection and care,
islatures. The first significant federal support for
(2) development and opportunities,
public education for people with disabilities was
(3) civil rights,
provided through the National Defense Education
(4) environmental issues, and
Act in 1957. Amended versions of the National De-
(5) consumer responsiveness.
fense Education Act (Public Law 85-864 and Public
Law 85-926) provided funds for mental retardation
research and authorized the first federally supported
Protection and Care programs to train teachers of children who were
Referenced Legislation mentally retarded (Fifield & Fifield, 1995). Addi-
Protection and care referenced legislation is in- tional public policies, such as the Mental Retarda-
tended to provide for the safety of those con- tion Facilities and Community Mental Health
stituencies covered by the legislation. The focus Center Construction Act of 1963 (Public Law
of this type of legislation is on guardianship or 88-164) and the Developmental Disabilities Act of
protection of the citizenry. Legislation related to 1970 (Public Law 91-517), have attempted to better
protection and care was initially introduced with meet the needs of at-risk populations and individu-
the Social Security Act of 1935. This act was als with developmental disabilities by addressing
designed as a federally financed program that gaps in services.
would be managed by the state to provide relief The Education of the Handicapped Act Amend-
and assistance to indigent dependent children, ments of 1986 (Public Law 99-457) was the most
elderly adults, and the blind. The Social Security influential piece of legislation for children with
Act originally provided old-age assistance (Title I) disabilities and their families. Part H and Part B of
and aid to families with dependent children (Title IV). this legislation established services for children from
In addition, the act provided programs for the birth through 2 years of age and 3 to 21 years of age,
blind (Title VI), established state and public respectively. Subsequent amendments to that law,
health authorities (Title X), and authorized grants the Individuals with Disabilities Education Act
to states for maternal and child health and crip- of 1990 (IDEA) (Public Law 101-476) further de-
pled children services (Title V). The Social Secu- fined implementation of these services and rein-
rity Act has been amended numerous times (1956, forced the importance of prevention rather than
1972, and 1980) to allow workers with disabilities remediation (Stephens & Tauber, 1996). IDEA leg-
to receive pensions before reaching retirement, islation was updated in 2004 (Public Law 108-446)
to provide income maintenance for those who are with key components of interest to occupational
permanently and totally disabled, and to provide therapists. Among these are increased emphasis on
income maintenance and health benefits (Medic- transition services, involvement of parents, and sup-
aid and Medicare) to families and individuals port for emotional needs related to education of
with disabilities living in non-institutional and students. IDEA Part B conceptualizes occupational
2580_Ch04_051-060 16/07/13 2:45 PM Page 55
therapy as a “related service,” an intervention that Social Security Act) and a statewide waiver that
supports the educational goals of the child with proposes a redesign of Medicaid services that is
a disability, not a medical service. IDEA Part C comprehensive in scope (section 1115) (CMS,
enables occupational therapy services from birth 2005). Due to specific criteria about population
through 36 months as primary services that occur access to institutional care, the populations that
in the child’s natural environment (Sandstrom, are most often targeted for 1915(c) waivers are
Lohman, & Bramble, 2009). children and adolescents, and the elderly.
The Deficit Reduction Act of 2005 has made it
easier for states to provide services typically avail-
Medical Rehabilitation Referenced able only by applying for a waiver, without getting
Legislation the formal waiver, if the services are for people with
Medical rehabilitation referenced legislation is disabilities who meet the income criteria or for peo-
intended to provide for the health of those con- ple over the age of 65 (Kaiser Family Foundation,
stituencies covered by the legislation. The focus of 2006). For example, the Money Follows the Person
this type of legislation is on medical care and the Demonstration (MFP) is a Medicaid initiative that
development of programs to meet the special health provides enhanced funding to states to provide
needs of persons with disabilities. more long-term care services in the community and
Public funds for rehabilitation services are typ- fewer in institutional settings. An evaluation of the
ically available through either insurance or grant initiative identified successes with moving people
programs. “Between 1965 and 1975, legislation from institutional to community settings and
separated itself from protection and care legislation expanded services to facilitate transition. However,
by redefining and broadening these concepts to “identifying safe, affordable and accessible commu-
include intervention, treatment, and therapy nity housing for MFP participants is a major chal-
which focused on maintaining and restoring phys- lenge for states” (Kaiser Family Foundation, 2009,
ical, social, vocational, and cognitive skills” (Fifield p. 2). Therapists can research state Web sites or
& Fifield, 1995, p. 58). Most significant were the identify key policy makers on the state level to
Title XVIII (Medicare) and Title XIX (Medicaid) advocate a role for community-based occupational
Amendments to the Social Security Act because therapy services in these types of federal and state
they provided health insurance coverage to bene- programs.
ficiaries for services delivered in a wide range of set- The Mental Retardation Facilities and Commu-
tings, including hospitals, outpatient facilities, nity Mental Health Center Construction Act of
skilled nursing facilities, comprehensive rehabilita- 1963 (Public Law 88-164) authorized construction
tion facilities, home health agencies, hospices, and of specially designed state facilities for the diagnosis,
clinics (Reed, 1992). treatment, education, and training of people with
Among other rehabilitation-related policy op- disabilities, specifically individuals with mental
portunities that can impact occupational therapy retardation or mental illness. In addition, this act
services are Medicaid Home and Community- provided funding to establish community mental
Based Waivers. Designed as demonstration proj- health centers, and to increase the accessibility and
ects that eventually pay for themselves, such availability of mental health services to the public
waivers involve a state application for portions of (Ellek, 1991; Reed, 1992).
the Social Security Act to be “waived” to support The Workforce Investment Act (WIA) (P.L.
innovative policy to enable community rather 105-220, 404, 112 Stat. 936, 1148–49) supports
than institutional care (Centers for Medicare & many services that enable productive activity. These
Medicaid Services, 2009). States may have several include vocational rehabilitation, training pro-
of such waivers that address specific populations, grams, and consultation to educational systems
such as the elderly who would be institutionalized to support the transition of youth with disabilities
without services enabled by the waiver, persons to adulthood. States vary in which services they
with autism, or other disabilities. There are provide and program eligibility, so although there
waivers that propose alternatives to institutional may be opportunities for occupational therapists,
care (typically section 1915(b) or 1915(c) of the it is recommended that therapists communicate
2580_Ch04_051-060 16/07/13 2:45 PM Page 56
with the relevant state agency for specific information agencies receiving federal support (Fifield & Fifield,
on which services are funded (Workforce Investment 1995; Reed, 1992; Stephens & Tauber, 1996). The
Act, 1998). Olmstead v. L.C. Supreme Court (Olmstead v. L.C.
(98-536), 527 U.S. 581 [1999]) decision found that
unnecessary segregation of people with disabilities
Civil Rights Referenced Legislation in institutions could constitute discrimination based
Civil rights referenced legislation is intended to on disability (Center for an Accessible Society,
protect the lawful privileges of those constituencies 1999). This decision has spurred all levels of gov-
covered by the legislation. The focus of this type of ernment to address access to community services.
legislation is on equal protection under the law for There are implications for persons with disabilities
all citizens. Social conflict during the 1960s resulted of all ages, including transition-aged youth moving
in an initial piece of legislation (Civil Rights Act of from special education or government-sponsored
1964) that asserted fundamental human rights and mental health services to the broader community.
guaranteed numerous protections for all citizens. Occupational therapists may be involved in direct
Subsequent legislative activities, such as the Archi- or indirect community-based services relative to
tectural Barriers Act of 1968, Rehabilitation Act Olmstead issues of housing, employment, and reha-
of 1973, and the Americans with Disabilities Act of bilitation needs.
1990, included provisions to ensure the rights
of people with disabilities. The Architectural Barriers
Act of 1968 required all federal buildings to be Environment Referenced Legislation
accessible to persons with disabilities and included Environment referenced legislation is intended to
standards for accessibility that were later revised and provide physical access to a variety of settings for
incorporated into Section 504 of the Rehabilitation those constituencies covered by the legislation. The
Act of 1973. Section 504, which provided the foun- focus of this type of legislation is on the accessibility
dation for the Americans with Disabilities Act of and usability of programs for all persons but partic-
1990, prohibits discrimination on the basis of a dis- ularly for those with disabilities. Since the imple-
ability by any program receiving or benefiting from mentation of the Architectural Barriers Act of 1968
federal financial aid. It also provided the first federal (Public Law 90-480), legislative provisions have
statutory definition of a disability, which has been extended the original focus of eliminating environ-
used extensively in subsequent legislation. mental barriers to buildings to include better access
Other legislation that incorporated civil rights to information, services, and opportunities. Often,
provisions include the 1974 amendments to the important community services were provided in
Developmental Disabilities Act and the Education locations and at times inconvenient to consumers
for All Handicapped Children Act (Public Law but convenient to providers. The ideology for
94–142). The 1974 amendments to the Develop- change has progressed from normalization and
mental Disabilities Act established protection and mainstreaming to full inclusion of persons with
advocacy agencies in every state to ensure that disabilities. The shift in the focus of control from
state, public, or private service agencies did not the providers to the consumers was a direct result of
violate the rights of persons with disabilities. The the Independent Living Provisions of the 1973
Education for All Handicapped Children Act of Vocational Rehabilitation Act.
1975 (Public Law 94-142) established the right of In the 1980s, the Education for All Handicapped
children with handicaps to a free and appropriate Children Act (Public Law 94-142) focused on
public education. improving the fit between the person with a disability
Perhaps the most significant disabilities legisla- and the regular education environment. As a result,
tion was the Americans with Disabilities Act increased attention was placed on mainstreaming chil-
(ADA) of 1990 (Public Law 101-336). It expanded dren with special needs and providing placement in
the nondiscrimination provisions primarily associ- the least restrictive environment.
ated with the Rehabilitation Act of 1973 to include The Technology Related Assistance Act of 1988
the private sector and public services. Previous (Public Law 100–407) expanded the definitions of
legislation affected only government agencies and assistive technology introduced and defined in the
2580_Ch04_051-060 16/07/13 2:45 PM Page 57
Older Americans Act (1986) and in the Develop- of these pieces of legislation has aggressively strength-
mental Disabilities Act (1985) to include devices ened the level and depth of consumer participation
and services used to achieve independence, produc- in planning, monitoring, setting priorities, and
tivity, and integration (Fifield & Fifield, 1995, making decisions in the development of service
p. 63): “Since 1988, assistive technology has been delivery. Both the Technology Related Assistance
an expanding provision included in the Individuals Act of 1988 and the Americans with Disabilities Act
with Disabilities Education Act of 1990 and the of 1990 also strengthened consumer responsiveness
1992 amendments to the Rehabilitation Act. Ad- by “using ‘people first’ language that addressed
vancements in assistive technology have made it dignity, choice, and participation” (Fifield & Fifield,
feasible to implement many of the provisions of the 1995, p. 64).
Americans with Disabilities Act.”
The Assistive Technology Act of 2004 (Public
Law 108-364) was designed to increase access Federal and State-Level
by persons with disabilities to technology devices
and services. Among other things, it requires states Policy and Community
to have an advocacy council to assure consumer Practice
directedness as well as to establish and monitor
measurable goals. The roles of the federal and state governments vary
The specific inclusion of environment relative to in the policy making process. Traditionally, the role
supporting health of populations is evidenced in the of the federal government has been to set broad
overarching goals of Healthy People 2020. In addi- parameters, such as overall policy goals and direc-
tion to goals related to prevention and removal of tions, with the role of the states to design and imple-
health disparities, Healthy People 2020 supports ment programs and services that meet federal
goals that “create social and physical environments guidelines according to population needs. The state’s
that promote good health for all” (U.S. Department role in health policy historically involves financing
of Health and Human Services, 2008, ¶11). some services, regulating health-care providers and
organizations, and coordinating and implementing
public health initiatives (Lipson, 1997). Additional
Consumer Referenced Legislation health-related roles of the states include environmen-
Consumer referenced legislation is intended to tal protection, regulation of the sale of health insur-
provide for representation in decision making of ance, state rate setting and licensing, and cost control
those constituencies covered by the legislation. The (Weissert & Weissert, 2006). Occupational therapy
focus of this type of legislation is on autonomy and practitioners need to be aware of both federal and
the individual’s right to self-determination. state initiatives that may impact community practice.
Historically, society has viewed people with dis- Federal policy may shape the direction of funding
abilities as different, often using negative descrip- in terms of population, setting, and services. Exam-
tors. Throughout the 1970s and 1980s, the terms ples of federal policy changes and their impacts have
“handicapped” and “client” were used interchange- been identified in this chapter and include the Amer-
ably when referring to people with disabilities. Both icans with Disabilities Act of 1990, and the Olmstead
terms implied a dependent relationship in which the decision of 1999. Occupational therapists need to
provider was the decision maker. The Developmen- be aware of these changes so that they can assist
tal Disabilities Act of 1970 and the 1977 Rehabili- populations to access needed services or rights/
tation Act amendments outlined provisions for entitlements. In the case of the ADA, occupational
increased consumer representation on policy and therapists working with persons with disabilities in
advisory councils, thus introducing the term “con- the community on employment or housing need to
sumer” (Fifield & Fifield, 1995; Reed, 1992). The be aware of the appropriate federal department to
Education for All Handicapped Children Act access in case of a client complaint that may be a
strengthened the role of parents through the indi- violation of the law. In the case of the Olmstead deci-
vidual education plan process. According to Fifield sion, occupational therapists working with persons
and Fifield (1995), each successive reauthorization with disabilities on aging in place need to be aware
2580_Ch04_051-060 16/07/13 2:45 PM Page 58
of how the state evaluates individuals relative to safety services, and many optional services. Among op-
and resources that may be available, such as through tional services are occupational therapy, case man-
state Medicaid waivers. In the case of state health agement, personal care services, and home and
policy, occupational therapists in community community-based services. States differ in which op-
practice may provide services that are financed by tional services they provide, and many of the op-
the state through a waiver, such as services for people tional services include those provided in the
with autism, and so need to be aware of how to be community.
included as a provider. Community occupational
therapists may wish to be involved in public health
initiatives such as disaster planning and again may Advocacy Activities That Support
benefit from volunteering on a local planning task Community Practice
force. Another area in which occupational therapists Key leadership roles, such as board membership
are affected daily by state policy is through the regu- or volunteering to chair a community committee,
lation of the profession. Occupational therapists can enhance visibility of the professional and strengthen
volunteer to serve on the state board of practice or potential partnerships. Involvement with state and
relevant subcommittees. national professional associations can assist the com-
State government is structured similarly to the munity occupational therapist to stay abreast of key
federal government. Both have three branches of state and federal initiatives and assist the profession
government: each state has a governor whose duties to participate in the policy making process. Collabo-
are similar to the president; both have a legislature ration or coalitions with other groups with a common
that passes laws, allocates resources, and oversees the interest can also assist with influence—the greater the
executive branch; and both have a similar process numbers, the greater the potential impact. Examples
for a bill to become a law (Weissert & Weissert, of potential partners for community-based occupa-
2006). Differences include revenue sources, the fact tional therapists might be community health centers
that states are required to have a balanced budget, or their advocacy group, community behavioral
and the fact that state elected officials have more health centers or their advocacy group, professional
direct responsibility to their constituents. The top provider organizations, educational advocacy groups,
two state funding areas are K–12 education and disease-specific advocacy groups, consumer advocacy
Medicaid. The fact that states must operate on a groups, and Centers for Independent Living.
balanced budget may lead to cuts during times of
economic challenge. Occupational therapists relying
on state funding for community practice need to be Conclusion
informed about the process for influencing resource
allocation to assure access to their services. For Historically, federal legislation concerning persons
example, each state has a designated agency to pro- with disabilities has developed from a focus on adults
vide vocational rehabilitation services through the to a focus on children and policies that emphasize
department of education. Occupational therapists secondary prevention. Federal legislation has pro-
working with persons with disabilities on employ- gressed from concerns primarily for physical disabil-
ment goals need to be aware of state priorities and ities to concerns for all types of disabilities, and
funding challenges to advocate for access to critical expanded from assistance primarily for medical man-
services and supports for this population. agement to assistance that also includes non-medically
It is important for occupational therapists to be based programs for citizens with disabilities that sup-
aware that although there are some consistencies, port them in the community context (Reed, 1992).
state policies can vary widely. This requires occupa- Because community-based programs are unique to
tional therapy practitioners to develop key relation- the community served and are often based financially
ships at the local and state levels to monitor and and programmatically on a variety of local, state, and
advocate for issues of importance to community federal policies, practitioners shifting from the more
practice. For example, there are some mandated traditional practice arena must research the environ-
services, such as physician visits and hospital care, ment of their intended practice to ensure optimum
that must be provided by states offering Medicaid service provision to their clients. A readily accessible
2580_Ch04_051-060 16/07/13 2:45 PM Page 59
source for researching both current state and federal Center for an Accessible Society. (1999). Supreme Court
legislation that might impact occupational therapy upholds ADA ‘Integration Mandate’ in Olmstead decision.
Retrieved from http://accessiblesociety.org/topics/ada/
practice is the American Occupational Therapy olmsteadoverview.htm
Association’s Web site (www.aota.org). Centers for Medicare & Medicaid Services (CMS). (2009).
In many community-based programs, the role of Section 1915(b) Authority [Online]. Retrieved from
occupational therapy may not be clearly defined. http://cms.hhs.gov/MedicaidStWaivProgDemoPGI/04_
It is then incumbent upon the practitioner to deter- Section1915(b)Authority.asp
Civil Rights Act of 1964. Retrieved from http://ourdocu-
mine the role of occupational therapy. Both the roles ments.gov/doc.php?flash=old&doc=97
and responsibilities should be based on the needs of Ellek, D. (1991). The evolution of fairness in mental health
the program recipients, the scope of occupational policy. American Journal of Occupational Therapy, 45,
therapy practice, and applicable legislation/policy. 947–951.
In changing times and with changing societal needs, Fifield, B., & Fifield, M. (1995). The influence of legislation
on services to people with disabilities. In O. C. Karan &
occupational therapists must be responsive to the S. Greenspan (Eds.), Community rehabilitation services for
needs of consumers and the community programs people with disabilities (pp. 38–70). Boston: Butterworth-
that serve them. According to Powell (1992, p. 562), Heinemann.
“Occupational therapists must forge stronger bonds Jacobs, K. (1996). The evolution of the occupational therapy
with consumers, increase consumer independence, delivery system. In The occupational therapy manager
(pp. 3–48). Bethesda, MD: American Occupational
and hasten consumer community integration to Therapy Association.
refocus and develop new programs.” Kaiser Family Foundation. (February 2006). Deficit Reduction
Learning Activities Act of 2005: Implications for Medicaid. Retrieved from
http://kff.org/medicaid/upload/7465.pdf
1. Discuss the differences in the terms “reim- Kaiser Family Foundation. (2009). Money follows the person:
bursement” and “funding.” For each, identify An early implementation snapshot. Retrieved from
http://kff.org/medicaid/7928.pdf
an example of federal legislation that provides Kronenberg, F., Algado, S., & Pollard, N. (2005). Occupa-
this type of financial resource. tional therapy without borders. New York: Elsevier.
2. Describe key features of the Social Security Act, Lipson, D. J. (1997). State roles in health care policy: Past as
the Americans with Disabilities Act (ADA), the prologue? In T. J. Lipman & L. S. Robins (Eds.), Health
Individuals with Disabilities Education Act politics and policy, (3rd ed., pp.176-197). Albany, NY:
Delmar Publishers.
(IDEA), and the Technology Related Assistance National Collaborative on Workforce and Disability for
Act that have implications for community- Youth. (2008). Disability Legislation. Retrieved from
based occupational therapy practice. http://ncwd-youth.info/resources_&_Publications/
3. Identify a community-based setting and dis- disability_Legislation/all_legislation.shtml
cuss the policies that may affect practice in Powell, N. J. (1992). Supporting consumer-mandated pro-
gramming for persons with developmental disabilities.
this setting. American Journal of Occupational Therapy, 46, 559–562.
4. Identify a community-based program and dis- President’s New Freedom Commission on Mental Health.
cuss the factors that an occupational therapy (2003). Achieving the promise: Transforming mental
practitioner might consider in determining his health care in America. Retrieved from http://mental-
or her role in that setting. healthcommission.gov/reports/FinalReport/
FullReport.htm
5. What resources are available to research legisla- Reed, K. L. (1992). History of federal legislation for persons
tive changes at the federal and state levels that with disabilities. American Journal of Occupational
may impact occupational therapy practice? Therapy, 46, 397–408.
Sandstrom, R. W., Lohman, H., & Bramble, J. D. (2009).
Public policies addressing social disablement. In Health
REFERENCES
services: Policy and systems for therapists, 2nd ed.
Americans with Disabilities Act of 1990, Pub. L. 101-336, (pp. 63–70). Upper Saddle River, NJ: Pearson.
July 26, 1990, 104 Stat. 327 (42 U.S.C. 12101 et seq.). Stephens, L. C., and Tauber, S. K. (1996). Early interven-
Baum, C., & Law, M. (1998). Community health: A tion. In J. Case-Smith, A. Allen, & P. Pratt (Eds.),
responsibility, an opportunity, and a fit for occupa- Occupational therapy for children (pp. 648–653). St. Louis:
tional therapy. American Journal of Occupational Mosby.
Therapy, 52, 7–10. Stewart, D., and Law, M. (2003). The environment: Para-
Brownson, C. (1998). Funding community practice: Stage 1. digms and practice in health, occupational therapy and
American Journal of Occupational Therapy, 52, 60–64. inquiry. In L. Letts, P. Rigby, & D. Allen (Eds.),
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Using environments to enable occupational performance format of Healthy People 2020. Retrieved from http://
(pp. 3–13). Thorofare, NJ: Slack. healthypeople.gov/hp2020/advisory/PhaseI/summary.htm
U.S. Department of Health and Human Services. (1999). Weissert, C., & Weissert, W. G. (2006). States and health care
Mental health: A report of the surgeon general. Rockville, reform. In Governing health: The politics of health policy,
MD: U.S. Department of Health and Human Services, 3rd ed. Baltimore, MD: Johns Hopkins University Press.
Substance Abuse and Mental Health Services Administra- Workforce Investment Act of 1998, Pub. L. No. 105-220,
tion, Center for Mental Health Services, National Insti- 404, 112 Stat. 936, 1148–49 (codified as amended at 29
tutes of Health, National Institute of Mental Health. O.S.C. 723 Supp. IV 1998).
Retrieved from http://surgeongeneral.gov/library/ World Health Organization. (2001). International classifica-
mentalhealth/home.html tion of functioning, disability and health. Geneva,
U.S. Department of Health and Human Services. (2008). Switzerland: Author.
Phase I report: Recommendations for the framework and Box 4-1
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SECTION II
Community-Based
Program Development
Chapter 5
Program Planning and

Needs Assessment
Marjorie E. Scaffa, PhD, OTR/L, FAOTA, and Carol A. Brownson, MSPH
Planning is bringing the future into the present so that you can
do something about it now. Failing to plan is planning to fail.
—Alan Lakein, author of How to Get Control of Your Time and Your Life (1989)
Learning Objectives
• Describe the processes of environmental scanning and trend analysis.
• Define the key steps in community health/health promotion program development.
• Describe three sources of data for needs assessments.
• Identify four factors that impact the selection of needs assessment strategies.
• Demonstrate understanding of the role of health behavior theories in community health/health promotion
program planning.
• Define “goal” and “objective.”
• Develop program objectives.
• Describe the five levels of the ecological approach to community health/health promotion programs.
• Develop implementation strategies at the different levels of intervention.
• Identify the purposes for each of the three levels of program evaluation.
61
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62 SECTION II | Community-Based Program Development
Key Terms
Capacity assessment Outcome
Ecological perspective Preplanning
Environmental scanning Process evaluation
Evidence Program
Evidence-based planning for health Program development
Formative evaluation Program planning
Goal Secondary data
Group processes Societal levels
Impact Stakeholders
Interventions Summative evaluation
Key informant Systematic reviews
Needs assessment Theory
Objectives Trend
Introduction Jaffe, 1989, pp. 63–65). However, this lack of

training should diminish as a result of occupational
Program development, including planning and therapy educational institutions ensuring their cur-
developing implementation and evaluation strategies, riculums are in compliance with current Accredita-
emerged in the 1980s as a key component of health tion Council for Occupational Therapy Education
education and health promotion (Timmreck, 1995, (ACOTE) standards, which became effective in
p. xv). With growing concerns about health care costs 2008 (American Occupational Therapy Association
and access to care, health promotion and disease/ [AOTA], 2006) and reflect the AOTA Centennial
injury prevention activities will likely play a major Vision (Baum, 2006).
role in the future of health services. Planning, imple- The steps involved in developing community
mentation, and evaluation skills are essential to health and health promotion programs, beginning
the delivery of successful health promotion, health with trend analysis and environmental scanning,
education, and prevention services. are described in this chapter. This is followed by a
Programs are distinguished from clinical services review of theoretical foundations and models on
in that programs are primarily educational. A pro- which programs can be based.
gram is a “planned, coordinated group of activities,
procedures, etc., often for a specific purpose or out-
come; it addresses a specific need, problem or situa- Environmental Scanning
tion, shows what activities have taken place and and Trend Analysis
reports what measurable changes have occurred”
(Rutgers Cooperative Extension, 2007, p. 5). Some- Environmental scanning is “the acquisition and
times referred to as interventions, programs are sys- use of information about events, trends, and rela-
tematic efforts to achieve preplanned objectives such tionships in an organization’s external environment,
as changes in knowledge, attitudes, skills, and behav- the knowledge of which would assist management
iors to maintain or improve function and/or health. in planning the organization’s future course of
These interventions can occur in a number of settings action” (Choo, 2001, p. 1). The goal of scanning is
such as schools, work sites, community agencies, and to gain data, information, and knowledge to enable
health care environments. action. Environmental scans are often used as part
Among the barriers to occupational therapists of a strategic planning process. In its simplest form,
developing and/or providing health education and environmental scanning is identifying one’s infor-
health promotion programs were lack of training in mation needs, searching for relevant information,
health promotion and in designing and implement- and then using that information in decision making
ing effective educational interventions (Johnson & (Choo, 2001).
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Chapter 5 | Program Planning and Needs Assessment 63
Environmental scanning is a tool for collecting 5. Sort remaining articles, trend information, and
data that can be used to design health programs notes into two groups, those that are likely to
tailored for specific communities (Rowel, Moore, have a positive impact and those that are
Nowrojee, Memiah, & Bronner, 2005). Contextual likely to have a negative impact on community-
factors can inhibit or facilitate individual and com- based occupational therapy practice.
munity health and are therefore an important aspect 6. Predict probable futures based on the trends
of a comprehensive needs assessment. This is partic- discovered.
ularly true for marginalized populations in which
In order to plan and develop a viable and effec-
many health problems are related to environmental
tive community program, environmental scanning
conditions.
and trend analysis is an important starting point.
Typically, an environmental scan examines a broad
The information gathered through this process pro-
range of economic, social, political, and technological
vides the basic foundation for the remainder of the
issues. Information is gathered from a variety of
program planning process.
sources, and leading thinkers in the field are recruited
to interpret the information and develop a variety of
future scenarios. There is no single standardized
methodology for conducting environmental scans. Program Planning Principles
However, Choo (2001) identifies four modes of scan-
Program planning has been described as a process
ning, including undirected viewing, enacting, condi-
of establishing priorities, diagnosing causes of prob-
tioned viewing, and searching. The “viewing” modes
lems, and allocating resources to achieve objectives
are more passive, whereas enacting and searching
(Green, 1980). People have always planned, with or
modes are purposefully active. Undirected viewing is
without a systematic method. As knowledge accumu-
noticing general characteristics or changes in the
lates, planning continues to become more sophisti-
environment through informal information-seeking
cated. Although no one perfect model exists,
mechanisms. Conditioned viewing is value- and belief-
Breckon, Harvey, and Lancaster (1994) point to
driven and involves watching for specific characteris-
seven principles common to all planning models.
tics or changes in the environment through routine
information-seeking mechanisms. Enacting refers to
exploring specific issues of concern through testing Plan the Process
and experimentation and thereby gaining tacit knowl-
Preplanning is an important step that, if overlooked,
edge. Searching refers to discovering detailed
can undermine the success of an otherwise effective
information through formal information-seeking
intervention strategy. During the preplanning phase,
mechanisms.
consideration is given to who should be involved,
Analyzing trends allows one to anticipate change,
when the planning should occur, what resources
recognize the implications, and take effective action.
are needed, and what process will be followed. Internal
A trend is a general direction, tendency, or pre-
and external resources are assessed, including atti-
dictable sequence of events. Fazio (2008) outlines
tudes, policies, available expertise, time, space, money,
six steps in trend analysis:
priorities, and fit with the organization’s mission.
1. Locate and gather sources of trend informa-
tion, such as national and local newspapers,
the Internet, television, magazines, etc. Plan With People
2. Identify relevant articles and trend informa- Experience has demonstrated the importance of
tion, and take notes. involving clients in the planning process. Two com-
3. Categorize articles, trend information, and munity health promotion principles are encompassed
notes into broad categories, such as health, here: (1) the principle of relevance and (2) the prin-
education, scientific research, economics, ciple of participation. Similar to the concept of client-
and local events. centeredness in occupational therapy, the principle
4. Remove any items that you believe are not of relevance, or “starting where the people are,” exists
likely to impact occupational therapy practice. when program planners begin by considering the
2580_Ch05_061-079 16/07/13 2:46 PM Page 64
perceived needs of community residents rather than Plan for Priorities

those of the planners or their organizations.
The most effective programs are those that address the
Participation is considered essential for develop-
greatest need and are designed or known to have the
ing effective programs and is considered health
greatest effect within given resources. Prioritization
enhancing. People meet and sustain their goals
should flow naturally from planning with people and
more effectively when they are actively involved
planning with data. Time for this activity needs to be
in the process (Green & Kreuter 2005; Baker
built in to ensure continued community participation.
& Brownson, 1998; Minkler & Wallerstein, 1997).
A comprehensive needs assessment and input from all
Participation can range from responding to requests
stakeholders helps to ensure that prioritization is
for feedback on program plans to taking an active
directed by the stakeholders. Stakeholders are “per-
role in designing, implementing, and evaluating
sons who may or may not benefit directly by being
program activities.
involved in the potential program, but who may have
Planning with people also encompasses the concept
a stake in the program’s outcome and often the ability
of collaboration. Program planning generally begins
to influence that outcome” (Scaffa, Reitz, & Pizzi,
with a group of people who have a vested interest in
2010, p. 204).
the issues. Working with people and agencies who
have shared interests and goals offers many advantages:
resources and workload can be shared, duplication of Plan for Evaluation
effort can be minimized, and more creative problem Evaluation is a continuous process of asking questions,
solving can occur. The end result is a program that such as “Are we doing the right thing?” and “Are we
provides better service to the community. doing things right?” and “What do we need to measure
to know what and how we’re doing?” These questions
are usually answered through the systematic collection
Plan With Data and analysis of program outcome data. Evaluation
Sound planning decisions are based on a thorough methods, depending on the goals and objectives of the
knowledge of the health issue and associated factors, program, should be built into the program design and
the service area or site, the target population, social spelled out in the program plan. Once the needed
and environmental support systems, and existing information is determined, record-keeping systems and
or former programs addressing the same issue. Much evaluation instruments need to be selected and put in
of the quantitative information can be gathered from place to ensure that data are properly collected. The
existing sources, such as health departments, libraries, planning process should address who will be responsi-
the National Center for Health Statistics, Chambers ble for both data collection and analysis. It should also
of Commerce, and health systems. Planners may also establish time frames for all steps.
identify the need for additional data, perhaps more
qualitative data that would help to identify attitudes, Plan for Measurable Outcomes
beliefs, or barriers. A review of available and gathered
data provides a context in which planning and prior- The last of the seven planning principles is to match
itizing can occur logically. clearly articulated and measurable program objectives
with data against which to judge program accom-
plishments. The format for the objective and the eval-
Plan for Performance uation should match. For example, if the objective of
a program is to reduce the risk of falling, then the out-
This principle speaks to long-range planning. Given come would be stated in terms of risk reduction, not
that most serious health challenges will not com- reduced mortality or reduced hospitalization.
pletely disappear with one program, approaching
the planning process with the idea of permanence,
or sustainability, makes sense. This includes con- The Planning Process
sidering how the program might be staffed and
financed after the initial intervention or how it A typical program planning process follows steps
might ultimately become incorporated as an integral that are very similar to the occupational therapy
part of an agency’s services. process (Table 5-1). Program planning is a process
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Table 5-1 Comparison of the Program Planning Process and Occupational Therapy Process
Program Planning Process Occupational Therapy Process
Preplanning (Exploration) Chart Review
• Identify/state the problem and the target population (also called
“issue identification”).
• Identify existing information regarding issue of concern.
• Assess the internal and external resources and barriers.
• Determine the goals of, and an approach for, the needs assessment.
Needs Assessment (Data Gathering and Analysis) Client Evaluation
• Collect relevant data.
• Analyze and synthesize data.
• Determine priorities.
• Identify and evaluate alternative solutions.
• Formulate an action plan.
Program Planning Intervention Planning
• Establish goals and objectives.
• Develop the details of the intervention strategies, procedures,
and time lines.
• Develop a plan for evaluation.
• Pretest materials and procedures.
Program Implementation Intervention
• Implement/offer the program or service.
Program Evaluation Re-evaluation and modification of
• Monitor and evaluate the program process, its impact, and intervention plan as appropriate
ultimately the outcome.
• Revise program as indicated and plan next steps (e.g., continue,
terminate, and expand).
Sustainability Plan Discharge Planning and Carryover to
• Identify future sources of funding. Home and Community
• Build community capacity.
• Cultivate supportive relationships.
Dissemination Plan Documentation
• Share the results with stakeholders, peers, and clients
involving continuous cycles of needs assessment, assessed, and the goals of the needs assessment are
planning the intervention, implementation, and established. Identifying an issue to address can come
evaluation (Dignan & Carr, 1992). Although these from data, professional judgment, observation, existing
planning subtasks have discrete roles, in good pro- literature, concerned individuals, or agencies.
grams they are interdependent and interwoven, Key questions of who, what, and why are an-
using feedback at each step to revise or improve swered. For example, who are the key players (e.g.,
previous steps, as depicted in Figure 5.1 (Simons- service receivers, service providers, experts in the
Morton, Greene, & Gottlieb, 1995). field, policy makers, agency representatives) with a
vested interest in the issue; what do they hope will
come from the needs assessment; and why—what
Preplanning prompted their concern, and how important is it
The pre-assessment or preplanning phase is an (Soriano, 1995)? Answers to these questions will
exploratory step during which existing data on the help define the key questions for the needs assess-
issue are identified and reviewed, resources are ment. Planning often occurs through a group of
2580_Ch05_061-079 16/07/13 2:46 PM Page 66
Preplanning Needs Assessment

The occupational therapist evaluates needs of clients
Share daily in the delivery of direct care. In the context of
results
Needs program planning, however, a needs assessment is
assessment not intended to provide diagnostic information
Revise,
about individuals. Instead, the purpose is to make
Determine
expand, or
priorities decisions about priorities for programs and services
terminate
that affect groups of people.
Impact/ A “need” is generally defined as the gap between
outcome Program plan
evaluation development the present state of affairs (what is) and some desired
future state for a particular group with an identified
issue (McKillip, 1987; Witkin & Altschuld, 1995).
Needs assessment is “the regular systematic collec-
tion, assembly, analysis and dissemination of infor-
mation on the health of a community” (Rowel
Process Implementation et al., 2005, p. 527). Needs assessments are designed
evaluation to prioritize issues and facilitate the development
of interventions to address community concerns.
Fig. 5•1 The Cycle of Program Development. In addition to identifying needs, this process also
identifies available resources in a given population,
discovers factors that contribute to the identified
problem, establishes priorities, and devises criteria
stakeholders forming a planning committee. How-
for interventions that will address the need (Witkin
ever broad or narrow the group, the perspectives of
& Altschuld, 1995). If done properly, the needs
all stakeholders—particularly those of potential
assessment will lead to a clear set of program goals
clients—must be considered and integrated into the
and objectives.
planning process.
Every program planning initiative is influenced
by factors that can support or inhibit the process. Profiling the Population and Community
Considering these internal and external factors One aspect of a needs assessment involves profiling
early in the process is important to avoid unnec- the community in which the program is to be lo-
essary pitfalls. First, a need must be analyzed for cated. A community profile includes collecting both
consistency or “fit” with the organization’s mis- population demographics and social demographics.
sion. Assuming it fits, how important is the need Population demographics refer to data about per-
relative to other issues? Is there a commitment of sons who reside within the selected community,
time and resources to see the project through? such as age, race, ethnicity, education, religion, and
What is the potential for effecting a positive income. Social demographics refer to data on the
change? What do the other stakeholders want or social and health problems of the population and
expect? Are there other programs addressing this existing resources in the community. Data collected
issue of concern? may include housing, employment, crime, and
Assessment of resources goes beyond the question health statistics (Fazio, 2008).
of whether or not there is funding. Depending The next step in the community profiling process
on the nature of the program being planned, other is to identify the service needs of the population. Un-
considerations may include location, space, materi- derstanding the problems in the community and the
als, appropriately trained personnel, transportation existing resources allows us to identify the gaps in
for clients, and access to experts for certain phases services and develop a service profile. The service pro-
of the process. Finally, preplanning should include file consists of a description of the population, data
an assessment of existing regulations and policies on the problem or unmet need, and information
that might have an impact on the issue or the about the context in which the problem or unmet
approach(es) being pursued. need occurs (Fazio, 2008). Positive community
2580_Ch05_061-079 16/07/13 2:46 PM Page 67
attributes and assets should also be identified. This perspective, they are best used in conjunction with
is referred to as a community capacity assessment qualitative data.
in which the capacities, skills, and strengths of indi- Surveys, the most frequently used tool for gath-
vidual community members, community organiza- ering information for the needs assessment, are a
tions, and the community as a whole are identified cost-effective method for gathering information
(Scaffa, Reitz, & Pizzi, 2010). The community pro- from large numbers of people who represent the tar-
file and the service profile provide the foundation for get population. They may take the form of written
program development. questionnaires or interviews (in person, by tele-
phone, or Web-based). Surveys should be adminis-
Data Collection tered to obtain information that does not exist
Key to the needs assessment process is the gathering elsewhere and should be designed so that inferences
of accurate and comprehensive information for can be drawn about priorities and seriousness of
making decisions about the best use of resources needs. The most effective type of survey for a needs
to resolve high-priority needs. Typically, in a needs assessment asks people for their opinions based on
assessment, information is gathered from key in- their own experiences, background, expertise, or
formants and stakeholders within the community. knowledge or for facts about themselves and others
Key informants are persons, typically formal or about whom they have direct knowledge (Witkin &
informal leaders, who have expert knowledge Altschuld, 1995).
about a phenomenon of interest. In the case of The specifics of survey methodology are beyond the
needs assessment, key informants provide informa- scope of this chapter. While surveys look deceptively
tion about the community, the population, local simple to construct, obtaining meaningful and reliable
resources, and unmet needs. Key informants may be information requires considerable expertise in ques-
political figures, clergy, educators, social service tionnaire development and administration. Questions
providers, health care workers, school administra- need to be simple, straightforward, and carefully
tors, business leaders, and others who are influential worded to elicit the desired information. The survey
in the community (Ritzer, 2007). also must include people who are representative of the
Methods for gathering data vary. Only a few of target audience and the stakeholders. Additionally, ef-
the potential methods will be briefly described here. fort must be made to ensure that the method itself
Before collecting new data, a review of the scientific doesn’t exclude segments of the population. Decisions
and intervention literature for background on the need to be made about how the results will be ana-
issue of concern and identification of strategies that lyzed. The survey also should be pretested on a sample
have been used in similar situations are necessary. of respondents. These tasks may require additional
Some common data sources and methods, such study (recommended is Witkin & Altschuld, 1995,
as secondary data, surveys, and group processes, Chapter 6) or the input of professionals with expertise
are outlined in Table 5-2. The use of secondary in survey methodology.
data is one of the simplest and most cost-effective Aside from surveys, group processes are the most
methods. Secondary data, also called archival frequently used method of collecting qualitative data
data, are existing data collected by agencies for for needs assessments (Witkin & Altschuld, 1995).
other purposes. Examples include birth and death Group processes provide face-to-face interactions
records; census data; prevalence data on diseases, with groups of stakeholders in a variety of discussion
disability, illness, injury, and risk; demographic formats, most commonly open forums, focus groups,
data; social indicators; and special surveys and re- and nominal group processes. Group processes also
ports. Secondary data are generally easy to obtain provide direct interaction between the agency repre-
and particularly useful in the exploratory phase of sentatives and the target population, which can serve
the needs assessment process to determine what is to build rapport. Like the other methods, group
already known about an issue. These data give a processes are most valuable when used in conjunc-
sense of the current status and give the planner an tion with other methods and sources. For further
idea of what further information to gather. By explanation of these techniques, the reader is referred
themselves, secondary data do not constitute a to Witkin and Altschuld (1995), Krueger (2009),
needs assessment. To provide context and client and Dignan and Carr (1992).
2580_Ch05_061-079 16/07/13 2:46 PM Page 68
Table 5-2 Overview and Comparison of Commonly Used Data Collection Methods for
Needs Assessment
Data Source/ Resulting
Method Description Information Advantages Disadvantages
Secondary Existing data Quantitative Relatively low in No client input;
(archival) data, usually found in data that help cost; generally possibly not repre-
i.e., records and city, county, state, determine the available; minimal sentative for given
logs, prior studies, and national status of a target investment of time target audience;
demographic data, organizations population with or staff; unbiased; technical assistance
social indicators, and government regard to a need; complements other for statistical interpre-
risk-factor data, bureaus may furnish infor- sources of data tation possibly
epidemiologic mation on causal needed
studies, census or contributing
data, and rates factors
under treatment
Survey methods, Techniques for Mainly qualitative— Client input Generally more time-
i.e., written gathering informa- values, percep- achieved; and labor-intensive
questionnaire, tion directly from tions, opinions, quantitative data than using secondary
face-to-face individuals using judgments of complemented data sources
interview, structured forms importance, and
telephone or protocols observations
interview,
and key informant
interview
1. Written Easy to administer; Possible low return
questionnaire relatively low in cost; rates; may not be
time efficient; quan- representative; not
tifiable; broad reach useful for people
into community/ who are illiterate or
target population not fluent in English;
prone to design
problems; technical
assistance for ques-
tionnaire construc-
tion and data
processing/analysis
possibly necessary
2. Face-to-face High response Smaller sample size;
interview rate; greater flexibil- costly in terms of
ity for answers and time and travel;
interviewer probing; trained interviewers
opportunity to required; possible
observe non-verbal difficulty with sched-
responses; ability uling; time consum-
to include people ing; opportunity for
who are illiterate bias; possibility to
or who have vision raise client expecta-
problems; rapport tions; data more
building difficult to interpret
and summarize;
2580_Ch05_061-079 16/07/13 2:46 PM Page 69
Needs Assessment—cont’d
technical assistance
for questionnaire
construction and
data processing/
analysis possibly
necessary
3. Telephone Easy to administer; Sampling challenges;
interview no travel time and may not be
cost; perceived representative; not
anonymity; fairly as suitable for long
good response rate questionnaires;
inability to observe
non-verbal reactions;
possible rise in client
expectations; trained
interviewers neces-
sary to avoid bias;
computer capability
and technical assis-
tance for question-
naire construction
and data processing/
analysis possibly
needed
4. Key informant Surveys (written Limited number Possible difficulty
and/or interview) of participants in identifying infor-
of a select group necessary mal leaders; biased
of key commu- results possible;
nity leaders, participants may
informal lay have vested interests
leaders, and pro-
fessional persons
who are aware of,
and in touch
with, the target
population and
the given issue
Group processes, Techniques that Mainly qualitative— Opportunity for
i.e., community involve small opinions and fluid, natural discus-
forums, focus or large groups expert judgments; sion around an
groups, and of stakeholders group perceptions issue; complemen-
nominal group (e.g., service and perspectives tary to other data
processes receivers, service regarding values,
providers, importance of
experts in the need; information
field, policy on causes/
makers, and barriers; decisions
Continued
2580_Ch05_061-079 16/07/13 2:46 PM Page 70
Needs Assessment—cont’d
agency represen- on priorities; feed-
tatives) in vary- back or consensus
ing degrees of on goals or
interaction courses of action
1. Community An open public Ideas and input Broad range Possibly not reflec-
forum meeting with all from a broad of views and tive of opinions of
interested parties segment of the concerns provided; general population;
invited; a large population natural discussion participation possibly
group discussion format; facilitation low; domination by a
of dialogue among few possible; difficult
people with differ- to analyze; logistics
ent viewpoints
2. Focus groups Groups of 8 to Individual and Possible in-depth Skilled facilitators
12 clients/ group perspectives probing of themes needed; technical
potential clients on a focused area assistance in data
responding to a or theme analysis possibly
structured set of required; logistical
questions challenges getting
group together;
groups variable,
thus, more than one
needed for reliable
results
3. Nominal group The most Ranking by the Highly effective for Expensive in terms
process structured of the group members of getting at a large of time and results;
group methods; what they perceive number of issues skilled leadership
a combination of to be the most in a short amount required; limited
written responses, important issues of time; equitable ability to generalize
voting, and dis- and/or solutions participation
cussion used in
small groups of
10 or less
Data from: Simons-Morton, B. G., Greene, W. H., and Gottlieb, N. H. (1995). Introduction to health educa-
tion and health promotion. Prospect Heights, IL: Waveland. Soriano, F. L. (1995). Conducting needs
assessments: A multidisciplinary approach. Thousand Oaks, CA: Sage. Witkin, B. R., and Altschuld, J. W.
(1995). Planning and conducting needs assessments: A practical guide. Thousand Oaks, CA: Sage.
There is no inherently perfect or best method of may influence the manner in which informa-
data collection for needs assessment. The selection tion is gathered.
of methods depends on several factors (Soriano, • The type of information desired. It makes
1995; Witkin & Altschuld, 1995), including: sense to choose a combination of methods
that yield different types of information, both
• The characteristics of the target group and qualitative and quantitative.
the survey respondents. For example, socioe- • Resources available (e.g., time, financial and
conomic factors, literacy, language, availability, human resources, and expertise). Trade-offs
and level of ability are among the factors that between the desired comprehensiveness of
2580_Ch05_061-079 16/07/13 2:46 PM Page 71
the needs assessment and the resources behind the choice of intervention, then there is no
available may be necessary. way to link the intervention to the intended out-
• The amount of interaction desired with come (Posavac & Carey, 1997). As a result, program
the audience. Some methods offer greater design would be much less effective and evaluation
opportunity for dialogue with members of would be less informative.
the target audience. Those same methods Simply stated, a theory is an explanation of why
may be more costly or harder to analyze. a phenomenon occurs the way it does (Freudenberg
Advantages and disadvantages of each et al., 1995). Good theories complement practical
approach should be considered. skills and technologies by taking the program be-
yond simply conducting activities to actually solv-
Data Analysis and Interpretation ing problems. Theories can provide answers to a
The data-gathering methods yield raw data. The next program developer’s questions about why people
step is to analyze the data and use them in a practical engage or do not engage in specific health behav-
way for planning. Even though the needs assessment iors and how to engage people in changing and
is a form of survey research, the analysis is more of a maintaining behaviors. Programs devised to
planning tool than a statistical exercise. As such, the address expected behaviors according to a theory
needs assessment relies less on inferential statistics help to determine what factors to focus on in the
and more on identification of need, risk, seriousness evaluation (Posavac & Carey, 1997; van Ryn &
of a problem, and access to services (Timmreck, Heaney, 1992).
1995). Once analyzed, the data should be presented No single theory exists on which to base health
to stakeholders in an easily understandable manner. education and health promotion programs. Popu-
Charts, graphs, and tables are useful techniques. lations, environments, cultures, and health issues
Interpretation of the data for planning purposes is vary broadly, so different theories or different com-
the last step in the needs assessment process. The goal binations of theories may be useful in addressing a
of this intermediate step is not to make final decisions particular issue. Some theories focus on individual
about the intervention strategy but to interpret find- behavior; others focus on groups, organizations, or
ings, set priorities regarding needs, suggest ways of communities as the unit of change. The dominant
addressing needs, weigh the alternatives based on a theories currently used in health education have
set of predetermined criteria, and propose a plan to roots in social psychology and focus on health
implement the best solution (Witkin & Altschuld, behavior at the individual level. These include the
1995). This final step in the needs assessment process health belief model and the transtheoretical model.
provides the direction and rationale for program Bridging the individual, group, and community lev-
planners to develop an effective intervention. els is social learning theory, also called social cogni-
tive theory. (See Chapter 3 for a discussion of these
and other theories that are useful for community
Program Plan Development program planning.)
While needs assessments focus on the ends to be at- Theories that address organizations and communi-
tained, the development of a program plan focuses ties include organizational change theory (Butterfoss,
on the means or solutions (Witkin & Altschuld, Kegler, & Francisco, 2008), community organiza-
1995). Ideally, the development of program com- tion and empowerment (Minkler, Wallerstein, &
ponents is based on a merging of the findings of the Wilson, 2008), diffusion of innovations (Oldenburg
needs assessment, theories, and available resources & Glanz, 2008), and media studies (Finnegan &
(Simons-Morton et al., 1995). Viswanath, 2008). These are not described here due
to space constraints but are well described in the
The Role of Theories references noted.
Any time a program or service is planned, planners Learning how to analyze a theory’s fit with the
make assumptions about the causes of the problem issue or problem identified is challenging. Accord-
and the best ways to effect change. If those assump- ing to Glanz and Rimer (2005, p. 6), “a working
tions are not made in terms of an explicit theory or knowledge of specific theories, and familiarity with
theories, and there is no conceptual framework how they have been applied in the past improves
2580_Ch05_061-079 16/07/13 2:46 PM Page 72
skill in this area.” When selecting the best model, based. “They specify who, to what extent, under
it is important to consider the characteristics out- what conditions, by what standards, and within
lined in Box 5-1 rather than prematurely selecting what time period certain activities are to be per-
a theory that may be temporarily in vogue or a performed and completed” (Timmreck, 1995, p. 32).
sonal favorite. For more detail on the theories just They outline the tasks and activities essential to
described and others, and for a better understand- accomplish the established goals. One goal may have
ing of their applications, the reader is referred to several objectives, with each objective representing
Glanz, Rimer, and Viswanath (2008) and Glanz one aspect of accomplishing the goal. Well-written
and Rimer (2005). objectives typically answer the following questions:
Program Components • Who (clients/participants)?
• What (action/performance)?
The general form of the written program plan
• When (time frame)?
includes:
• How much (to what degree/standard of
• Goals performance/level)?
• Objectives
For example, an objective might read: Within
• Strategies
6 months of completing the fall prevention course,
• Evaluation plan
75% of participants will be continuing their balance
Goals exercises. Using the questions listed,
Despite commonality of plan components, terminol- • “Who” refers to the participants of the fall
ogy is often confusing and used differently from one prevention course.
discipline to another. In health and social services • “What” refers to the action of continuing
planning, a goal is a quantified statement of a desired their balance exercises.
change in the status of a priority health need. Goals • “When” is identified as within 6 months of
are long-term and broad in scope. As such, they are completing the course.
not directly measurable but should be considered • “How much” is denoted as 75% of participants.
attainable. Programs may have more than one goal.
Programs that employ multiple approaches to
Objectives reaching their goals may have different types
of objectives. Some are directed at changes in
Objectives are used to reach goals. Unlike goals, ob-
the participants—their knowledge, behavior, or
jectives are specific, measurable, and performance
health status. Others may be directed at changes
in resources or services. Examples of different
types of objectives that pertain to the same goal
Box 5-1 A Good Fit: Characteristics of a are listed in Table 5-3.
Useful Theory Program plans may identify objectives by type
and group them as such. Others may consider one
A useful theory makes assumptions about type of objective as a “sub-objective” of another. The
a behavior, health problem, target population, important element is that the program plan clearly
or environment that are: identify its health objective(s); what the program
• Logical; will do to accomplish the objective(s); and what
• Consistent with everyday observations;
change in knowledge, skill, or behavior is expected
• Similar to those used in previous successful
programs; and
in participants.
• Supported by past research in the same area
Strategies
or related ideas.
The next task is to develop specific strategies for
From Theory at a Glance: A Guide for Health Promotion accomplishing the objectives that will be effective
Practice (2nd ed., p. 7), K. Glanz & B. K. Rimer, (2005). with the intended audience. Participation by mem-
Washington, DC: National Cancer Institute, U.S.
Department of Health and Human Services, National bers of the intended audience in the selection
Institutes of Health. of methods is crucial to ensure that the methods are
2580_Ch05_061-079 16/07/13 2:46 PM Page 73
Table 5-3 Different Types of Objectives for One Goal

Goal: By 2020, reduce injury from falls by half among older adults in Johnson County.
Objectives Type
Within 2 years of the program’s inception, This is an example of a health objective. This objective
admissions due to injury from falls in adults specifies a change in health status (i.e., fewer injuries
over age 60 will be reduced by 15% at Johnson from falls). Health objectives define the specific health
County Hospital. outcomes the program aims to accomplish and are
sometimes referred to as “outcome objectives.” There
may be several for each goal.
By January 2015, the occupational therapist will This is an example of a program objective. It deals with
reach 300 adults over age 60 through a fall the new service that is planned. These often address the
prevention course taught in 15 senior housing “process” of the intervention.
complexes and nutrition centers in Johnson
County.
By the end of the course, participants in the This is an example of a learning objective. It addresses
fall prevention program will be able to identify knowledge, attitudes, or skills the program will attempt
at least four risk factors for falls and develop an to effect to encourage specific behaviors in the intended
action plan for addressing their personal risks. population.
Within 6 months of completing the course, This is an example of a behavioral objective. Behavioral
75% of participants will be continuing their objectives, closely related to learning objectives, describe
balance exercises at their goal level. what the program will encourage people to do to reduce
risk or improve health. Learning and behavioral objectives
are sometimes called “impact objectives”; they do not
directly address the health outcome but deal with factors
that affect outcomes. They reflect the specific program
strategies.
Home assessments will be provided to all This is an example of a resource objective. It addresses
interested clients who attend the fall prevention material support or essential services the program plans
course. to provide.
acceptable and effective. Other factors to consider person-environment-occupation that guide occupa-
include literacy of the potential participants; degree tional therapy practice (Law et al., 1997). In an
of auditory or visual stimulation in their everyday ecological health promotion planning model, Simons-
lives; ways they customarily obtain information; Morton et al. (1995) described five societal levels
cost; convenience; cultural relevance feasibility; and in which planners could intervene:
anticipated effectiveness (Dignan & Carr, 1992).
The most comprehensive programs go beyond 1. Intrapersonal: individual characteristics that
the individual level, addressing systems that affect the influence behavior, such as knowledge,
ability of an individual to achieve work, leisure, and attitudes, beliefs, values, and personality
social participation goals. Socioecologic approaches 2. Interpersonal: family, friends, peers, and
to improving health recognize the interrelationships groups that provide social identity, support,
between people and their physical, social, cultural, and role definition
economic, and political environments. Key to the 3. Organizational: agencies and their rules,
ecological perspective in health promotion is that regulations, policies, procedures, programs,
health behavior both influences and is influenced and resources
by the environment, known as reciprocal causation. 4. Community: social networks, norms,
This construct is well recognized in occupational trends, and standards that constrain or
therapy and evident in the theories and models of promote desired action
2580_Ch05_061-079 16/07/13 2:46 PM Page 74
5. Public policy: local, state, and federal poli- Trying to address all levels in one program initia-
cies, laws, and programs that regulate or tive may not be feasible or even desirable. However,
support desired action using their experience, knowledge, and expertise
to influence others along the continuum can be very
An example of addressing the same health concern,
effective for occupational therapy practitioners.
physical activity for people with disabilities, from the
Encouraging advocacy; providing information to
five different levels is provided in Table 5-4.
clients, employers, and policy makers; and joining
Popular health promotion planning models that
community organizations and coalitions are exam-
offer ecological frameworks for planning programs
ples of how one might extend his or her “reach” and
include PRECEDE-PROCEED (Green & Kreuter,
leverage action at other levels. Doing so can also gen-
2005), social marketing (Storey, Saffitz, & Rimón,
erate new partners and possibly new funding for pro-
2008), and MATCH (Simons-Morton et al., 1995).
grams that meet mutual goals (Brownson, 1998).
They address all societal levels and can be used to
Although not addressed in this chapter, another
integrate diverse theories.
benefit of involvement at multiple levels is to expand
Some common intervention methods used at the
occupational therapy’s role in community, environ-
different societal levels are described in Table 5-5.
mental, policy, and social arenas.
Most occupational therapists and occupational
therapy assistants are involved in smaller subpopu- Evaluation Plan
lation interventions (levels 1 and 2), as opposed to
Evaluation strategies are designed during the plan-
working at changing systems, community norms,
ning process before implementing interventions.
or policies (levels 3 to 5). Even at the interpersonal
The evaluation plan should be created with input
or group level, understanding and maintaining an
from the key stakeholders, including potential par-
ecological perspective of the issue is useful. It be-
ticipants or clients. Several steps for developing an
comes a “mind-set” for viewing an issue of concern.
evaluation plan are as follows:
At the very least, seeing clients as part of larger sys-
tems can provide guidance for improving transi- 1. Determine who will coordinate data collec-
tions between and among programs and services tion and who will analyze it.
and for identifying gaps. Having an ecological per- 2. List the strategies, methods, or materials of
spective also should encourage collaboration with interest for evaluation (i.e., the evaluation
agencies and systems that focus more clearly on questions) and the anticipated results based
other levels of intervention. on program standards and objectives.
Table 5-4 Ecological Health Promotion Model and Occupational Therapy

Level of Intervention Potential Occupational Therapy Role
Intrapersonal/individual Adapt physical activities/exercises for people with functional limitations to
encourage fitness and promote health.
Interpersonal Offer adapted exercise classes for specific populations; provide education
to family members and friends.
Organizational Work with existing gyms, YMCA/YWCAs, and exercise facilities to make their
facilities accessible to people of all abilities; train staff.
Community Work with appropriate health agencies and health professions to develop mes-
sages about the importance of physical activity for everyone; use appropriate
channels to raise awareness; join others in advocating for accessible community
facilities and transportation; offer professional consultation on adaptations and
accommodations.
Government/policy level Advocate for funding to support making public parks, trails, and facilities
accessible to people with disabilities.
2580_Ch05_061-079 16/07/13 2:46 PM Page 75
Table 5-5 Societal Levels and Methods Used

Societal Level Method Description
Individual/group level Lecture-discussion Combination of prepared remarks by leader/
(educating, training, facilitator and guided discussion or
and counseling) question-answer session
Audiovisual aids Compact discs, booklets, posters, flipcharts,
models, display boards, YouTube slides,
videotapes, computers, and interactive
multimedia programs
Peer group discussion Use of small groups for discussion of topic
common to group
Simulation and games Games, role-playing, dramatizations, case studies,
storytelling, and songs
Skill development Explanation, demonstration, and practice of a
psychomotor competency
Mass media Information provided through television, radio,
texting, instant messaging, newspapers, magazines,
billboards, direct mail (Dignan & Carr, 1992; AMC
Cancer Research Center, 1994; Simons-Morton,
Greene, & Gottlieb, 1995; Office of Cancer
Communications, 1992)
Interpersonal level Enhancing/ Interpersonal relationships that provide emotional,
(educating, training, developing social ties instrumental, or informational assistance (Heaney
and facilitating) & Israel, 2008)
Use of natural helpers Members of social networks that other members
go to for advice, support, and other assistance
(Eng & Young, 1992)
Organizational level Organizational Implementation of planned change within organi-
(consulting, networking, development zations (Goodman, Steckler, & Kegler, 1997)
training, and advocating)
Community level Media advocacy The strategic use of mass media to increase public
(marketing, organizing, support for a social or policy initiative (Wallack,
developing, and advocating) Dorfman, Jernigan, & Themba, 1993)
Community coalitions An alliance of organizations or individuals
working together to achieve a common purpose
(Butterfoss, Goodman, & Wandersman, 1993)
Community organization A set of processes and procedures “by which
community groups are helped to identify problems
or goals, mobilize resources, and develop and
implement strategies to” solve a common problem
or pursue a common goal (Minkler, Wallerstein, &
Wilson, 2008, pp. 287–288)
Community A social action process through which “individuals,
empowerment communities, and organizations gain mastery over
their lives in the context of changing their social and
political environment to improve equity and quality
of life” (Minkler, Wallerstein, & Wilson, 2008, p. 295)
Governmental and policy Policy development/ Changes in, or development of, local, state, or federal
level (advocacy, lobbying, advocacy policies, programs, practices, regulations, and laws on
and political action) behalf of a particular interest group or population
2580_Ch05_061-079 16/07/13 2:46 PM Page 76
3. Construct “dummy” tables or charts to help Programs can be evaluated at one or more of
visualize how the information collected three levels:
might be organized and summarized to
1. Process,
show results.
2. Impact, and
4. Make a list of all the information needed.
3. Outcome.
5. Develop a time line or work schedule for
the remaining steps (6 to 11). Each level asks different questions, addresses
6. Identify the data collection techniques that different aspects of the program, and considers dif-
are appropriate and feasible for the infor- ferent indicators, as shown in Table 5-6. Note that,
mation needed (e.g., assessments, surveys, in this taxonomy, impact refers to the intermediate
medical records, reports, questionnaires, effects and outcome to the long-term effects of a
observations, tests, interviews, etc.). program or process (Green & Kreuter, 2005). Oth-
7. Identify sources of existing data that may ers have delineated two levels of program evaluation:
be used, existing tools or instruments for formative or process evaluation, which focuses on
data collection, and instruments that need program development, and summative evaluation,
to be developed. which focuses on program results.
8. Develop and test needed instruments. Evaluation designs range from simple to com-
9. Establish a data collection plan, including plex. The decision about the level and depth of eval-
what will be collected, when, and by uation to undertake is based on a number of
whom (this should be incorporated into factors, including the program’s objectives, time,
the overall program time line). money, and expertise available, and management
10. Establish a data analysis plan, including or funding agency priorities. Process evaluation,
time lines and responsible parties. which should be done on every program, tends to
11. Develop a plan for disseminating the be the least complex. As one moves along the con-
results, such as presentations, program tinuum to measure the impact and outcome of a
reports, and papers. (Green & Kreuter, program, evaluation becomes more complex and
1991; Dignan & Carr, 1992). costly in terms of time, money, and expertise
Table 5-6 Characteristics of and Distinctions Among the Levels of Program Evaluation
Level of What Is Being Time Frame Outcome of
Evaluation Evaluated for Evaluation Evaluation
Process Program Short-term—during Feedback on program implementa-
processes and and immediately tion (planned versus actual),
procedures following audience participation and
intervention response, quality and appropriate-
ness of materials, resources
expended, staff response, etc.
Impact Program Intermediate—end Feedback on changes in knowledge,
objecttives of program and attitude, behavior, and/or perform-
periodically ance of participants; changes in
thereafter environment; policies enacted, etc.
Outcome Program goals Long term—varies, Feedback on changes in health
depending on issue; status—morbidity, mortality, disability,
may be years and quality of life
Data from: Dignan, M. B., and Carr, P. A. (1992). Program planning for health education and health
promotion (2nd ed.). Philadelphia: Lea and Febiger. Green, L. W., and Kreuter, M. W. (1991). Health
promotion and planning: An educational and environmental approach (2nd ed.). Mountain View, CA:
Mayfield. Simons-Morton, B. G., Greene, W. H., and Gottlieb, N. H. (1995). Introduction to health
education and health promotion. Prospect Heights, IL: Waveland.
2580_Ch05_061-079 16/07/13 2:46 PM Page 77
required. Program evaluation strategies and designs • comparability of measures over time and
are described in more detail in Chapter 7. within populations
• an explicit data trail that clearly identifies
how data was obtained and analyzed
Planning With Evidence • consultation with relevant experts and
authorities to understand and accurately
Community-based programs should be developed, interpret the data (Murray & Evans, 2003).
implemented, and evaluated using appropriate theo-
According to Ardal et al. (2006), “an evidence
retical frameworks and program planning models
base that has proven validity, quantified reliability,
applying principles of scientific reasoning (Brownson,
comparability, consultation with experts and an
Baker, Leet, & Gillespie, 2003; Glanz & Rimer,
explicit data audit trail should lead to a plan that is
2005). Program planning begins with the best
valid, coherent and applicable” (p. 14). A plan is
evidence available. Evidence can be defined as data
valid when the information and evidence gathered
that informs decision making. Evidence is rarely con-
address relevant planning questions. A coherent plan
stant; it is always emergent. The best available
is explains the differences in data and conclusions
evidence of yesterday may be totally irrelevant today.
in a way that can be understood. A plan is applicable
Evidence may be quantitative, or numeric, and qual-
if it identifies how change can be measured, provides
itative in the form of narrative. Evidence-based plan-
information that informs decision makers, and
ning for health is the “application of the best
captures relevant situational realities.
available information derived from clinical, epidemi-
Framing questions clearly is key to locating and
ological, administrative, demographic and other
using the right evidence. Finding and evaluating
relevant sources and consultations to clearly describe
evidence can be time-intensive and requires some
current and desired outcomes for an identified pop-
research expertise. Systematic reviews are often
ulation or organization” (Ardal, Butler, Edwards, &
the most useful as they identify, assess, and synthe-
Lawrie, 2006, p. 1). Epidemiological and demo-
size research evidence from a number of individual
graphic data is information about a population usu-
research studies. A variety of sources of systematic
ally derived from a census or survey. Administrative
reviews of research exist, some of which are listed
data is information about services provided and
in Box 5-2. Utilizing a range of information types
the activities of the health care system. Consultation
and sources will create a comprehensive picture of
with experts can be a source of evidence. Expert opin-
the phenomenon of interest that results in a solid
ion should be sought when formulating questions,
evidence base from which to make decisions and
identifying sources of information and evidence, and
plan for the future.
interpreting the findings (Ardal et al., 2006).
There is no single type of evidence that is most
useful for planning health interventions. The type
of information needed varies depending on the stage Conclusion
of the planning process. Decisions about program
To further establish the role of occupational therapy
goals, objectives, and strategies should be based on
practitioners in community health, health promo-
established best practice, and interventions devel-
tion, and injury/disease prevention, more studies are
oped should have demonstrated effectiveness
needed to identify the occupational factors that af-
through research. Effectiveness means that the in-
fect health and well-being and to document the ef-
tervention chosen has better results than the alter-
fectiveness of occupation-based community health
natives, including no intervention.
and health promotion interventions. By being
The World Health Organization has developed
skilled in the steps of program development, from
five criteria for evaluating the quality of evidence.
preplanning to publication, occupational therapy
These are:
practitioners can strengthen their position in the
• proven validity of measurement instruments provision of health education and health promotion
• quantified reliability of measurement programs and increase their marketability in the
instruments evolving health care arena.
2580_Ch05_061-079 16/07/13 2:46 PM Page 78
Box 5-2 Sources of Systematic Literature Reviews and Other Evidence
• Best Practice Initiative (www.osophs.dhhs.gov/ophs/BestPractice)

• Campbell Collaboration Library (www.campbellcollaboration.org/library)
• Centers for Disease Control and Prevention (CDC) Recommends: The Prevention Guidelines System
(www.phppo.cdc.gov/cdcRecommends/AdvSearchV.asp)
• Centers for Medicare and Medicaid Services (CMS) Healthy Aging Initiative- Evidence Reports
(www.cms.hhs.gov/healthyaging/evidreports.asp)
• Clinical Evidence (www.clinicalevidence.bmj.com)
• Cochrane Collaboration (www.cochrane.org)
• ERIC Digests (www.eric.ed.gov)
• Evidence-Based Mental Health (www.ebmh.bmj.com)
• Joanna Briggs Institute Clinical Online Network of Evidence for Care and Therapeutics/JBI COnNECT
(www.jbiconnect.org)
• National Guidelines Clearinghouse (www.guideline.gov)
• National Rehabilitation Information Center (www.naric.com)
• OT Seeker (www.otseeker.com)
• Substance Abuse and Mental Health Services Administration (www.samhsa.gov)
• The Community Guide (www.thecommunityguide.org/library)
• What Works Clearinghouse (www.whatworks.ed.gov)
Learning Activities Program for the Occupational Therapist. Retrieved from

http://aota.org/Educate/Accredit/StandardsReview/guide/
1. You have been contracted to provide occupa- Masters.aspx?FT=.msword
tional therapy services to children in a rural Ardal, S., Butler, J., Edwards, R., & Lawrie, L. (2006). Evi-
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The day care manager has secured funding to tics of community-based health promotion programs. Jour-
develop a parenting class and has hired you nal of Public Health Management and Practice, 4(2), 1–9.
to develop and implement the program. Baum, C. (2006). Presidential address, 2006 Centennial
challenges, millennium opportunities. American Journal
What steps would you take to assess need? of Occupational Therapy, 60(6), 609–616.
Who would you involve? What questions Breckon, D. J., Harvey, J. R., & Lancaster, R. B. (1994).
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3. How would you use occupational therapy Brownson, R. C., Baker, E. A., Leet, T. L., & Gillespie, K. N.
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interventions at each of the five societal levels. (1993). Community coalitions for prevention and health
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Chapter 6
Program Design
and Implementation
Joy D. Doll, OTD, OTR/L
Never doubt that a small group of thoughtful committed people can change the world.
Indeed, it is the only thing that ever has.
—Margaret Meade
Learning Objectives
• Identify and discuss similarities and differences between intervention planning for individuals and the development
of community-based programs.
• Describe the best practices to use in the development of a mission statement.
• Describe the characteristics of an effective team and the stages of team development.
• Identify and discuss issues related to program sustainability.
Key Terms
Advisory board Objective
Board of directors Partnership
Direct costs Sliding scale
Goal SMART
Grant Sustainability
Indirect costs Team
Mission statement Vision statement
Introduction program development requires an occupational

therapy practitioner to use a systems approach
Occupational therapists develop individualized instead of the traditional individual patient model
intervention plans for their clients every day. Using (Fazio, 2008).
clinical reasoning, the practitioner is able to deter- A general overview of program development and the
mine which activities will enable clients to reach needs assessment process was provided in Chapter 5.
their goals. In community practice settings, the Details regarding developing a mission statement
occupational therapy practitioner utilizes these same and an implementation plan with goals and objectives
skills and applies them in the context of a commu- are shared in this chapter. Strategies for recruiting
nity. Designing and implementing a program participants, developing teams, and establishing part-
requires a similar thought process using reasoning nerships are reviewed. In addition, recommendations
skills to develop goals and objectives to implement for budgeting, program management, and program
a program. Many of the skills from practice with sustainability are presented. The strategies described
individuals can transfer to community practice. Yet, in this chapter utilize a systems approach based
80
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Chapter 6 | Program Design and Implementation 81
on the Occupational Therapy Practice Framework nonprofit organizations, the practitioner

(American Occupational Therapy Association may want to explore existing mission state-
[AOTA], 2008) and clinical reasoning models. ments of other non-profits as a starting
point. The United Way can be a useful
resource for identifying local nonprofit
Mission Statement organizations.
2. A mission statement is not a résumé repeated.
At this point in the process of developing and
Its purpose is not to provide accolades to
implementing a program, the occupational thera-
past successes or identify the reasons why
pist should have a clear understanding of the com-
the program was started. Instead, the mis-
munity and the type of program that should be
sion statement should focus on the values
developed. The practitioner should review needs
and the premise of the program.
assessment data to ensure that the program has a
3. Avoid emptiness. A mission statement devoid
clear focus. Often program planners will compose
of values lacks substance. The mission state-
a vision statement prior to the development of a
ment should be thoughtful and meaningful.
mission statement. A vision statement outlines the
It should elicit feelings of passion and offers
“ideal state or ultimate level of achievement to
an opportunity to articulate that passion for
which an organization aspires” (Strickland, 2011,
the program to others and those being served.
p. 103). A mission statement is “an organization’s
4. Keep it short. Mission statements should be a
core, underlying purpose, or basis for its existence,
brief snapshot that captures the essence of
focus and actions” (Strickland, 2011, p. 103).
the program or organization. Ideal mission
Companies and organizations utilize mission state-
statements are captured in a few easily
ments to guide employees in an overall plan and
recalled sentences.
to make consumers aware of the purpose of the
5. Be discipline-specific. Professional identities
company. A mission statement goes beyond simply
guide values and are certainly relevant to the
educating workers and consumers; it acts as the
mission statement. The only caution here is
driving force or motivation behind decisions,
to avoid jargon that might confuse people
actions, and program development. Mission state-
not familiar with occupational therapy
ments also imply future direction, indicating what
terminology.
the program hopes to accomplish over time (Ohio
6. Write clearly and concisely. The occupational
Literacy Resource Center, 2007). When an orga-
therapy practitioner should consider the lit-
nization is working in the community, the mission
eracy level of the audience when drafting the
statement should be collective and inclusive of
mission statement. Careful editing is impor-
those the program will serve. Including commu-
tant, as grammatical and syntax errors in the
nity members in developing the mission statement
mission statement can detract from the pro-
is one strategy to insure buy-in to a program both
gram and its purpose.
at its inception and in the future.
7. Ask others. One of the best strategies to
The challenge to developing a mission statement
developing a good mission statement is to
is to describe a program and its values, purpose, and
seek advice and feedback. This advice can
future direction in a few short sentences. In creating
come from peers or community members.
a mission statement, the occupational therapy prac-
Seeking feedback ensures that others under-
titioner can follow these best practices.
stand the intent of the program, which is
1. Do some research. The occupational therapy the ultimate goal of the mission statement.
practitioner and any team members assisting The occupational therapy practitioner can
in developing the mission statement should ask others the following questions to help
begin with finding current mission state- them evaluate the mission statement:
ments of organizations that the practitioner (a) Does the mission statement reveal the
admires or believes are easy to understand. values of the program?
Mission statements can easily be found on (b) What future direction does this mission
Web sites or in company materials. For statement indicate for this program?
2580_Ch06_080-095 16/07/13 2:47 PM Page 82
(c) Does the mission statement inspire? succinct document. According to Brownson, an
Why or why not? implementation plan “spells out the details of the
Answers to these questions can provide program and specifies who is responsible for each
feedback on the clarity and relevance of procedure and activity” (2001, p. 115). In the
a mission statement. implementation plan, the details of who, what,
8. Do not settle. Continue to revise the mission when, where, and how need to be finalized for the
statement until all parties are satisfied and program (Brownson, 2001; Chambless, 2003). The
passionate about it (Voltz-Doll, 2008). When implementation plan usually contains a time line
designing a program, it is important to be and persons responsible to address these goals to
thoughtful about a mission statement as it is reach the program outcomes. An implementation
often one of the first aspects program partici- plan allows the practitioner to map out the entire
pants may view. Furthermore, since the mis- program in an effective and pragmatic manner.
sion statement is included in reports and After completion, the implementation plan can be
grant proposals, it needs to be representative distributed to employees or even used for writing
of the program. Taking the time to ensure future grant proposals. Effective implementation
the mission statement clearly reflects the pro- plans help to ensure program success and sustain-
gram can aid the program’s sustainability. ability. Table 6-1 outlines a sample program imple-
mentation plan.
Following the aforementioned best practices will
Program implementation also requires thoughtful
aid the occupational therapy practitioner in devel-
planning in order to maintain focus and ensure
oping a relevant and meaningful mission statement
that activities are completed in a timely manner
for the program. After the mission statement has
(Timmreck, 2003). Many organizations now use
been established, the next step in program design is
strategic planning for program implementation.
to develop an implementation plan that includes the
Strategic planning is a common method, and facili-
program goals, objectives, and activities.
tators with expertise in strategic planning can be
hired to assist with the process. Ideally, implemen-
tation planning should be completed in a group
Implementation Plan environment to promote communication among
team members, especially if a program is new and in
Traditionally, when designing and implementing a development. Implementation planning provides an
program, the occupational therapy practitioner con- opportunity to clarify who will do what and when it
siders what will make the program work and also be will be done. Creating a document that outlines pro-
sustainable. This thought process aids in the devel- gram activities ensures that all team members stay on
opment of a structured and relevant implementation track, communication flows smoothly, and the pro-
plan. An implementation plan includes the goals, gram goals and objectives are completed in an effi-
objectives, activities, and desired outcomes of the cient manner. Implementation planning also allows
program. The plan should also identify: the program team to plan and anticipate challenges
in a proactive manner, which can impact program
• who will be served by the program
success and sustainability (Timmreck, 2003).
• how the individuals being served will be
recruited
Program qualifications should also be included that Program Goals and Objectives
describe how and why an individual qualifies for the In program development, a goal is defined as “a state-
program and how an individual enters the program ment of a quantifiable desired future state or condi-
once qualification is determined. tion” (Timmreck, 2003, p. 32). Goals are written to
Development of an implementation plan is im- be long-term and future-oriented, indicating a desired
portant to identify specifically how program goals outcome (Brownson, 2001). Goals capture intended
and objectives will be realized. The plan provides a outcomes of the program, while objectives are more
holistic approach for identifying the program’s pur- specific, identifying how goals will be met. Objectives
pose, program design, and implementation in one are measurable, short-term, and usually contain a time
2580_Ch06_080-095 16/07/13 2:47 PM Page 83
Table 6-1 Sample Implementation Plan

Measurement
Activities to
Intervention Determine Short-Term Long-Term
Objectives Activities Outcomes Outcomes Outcomes
Describe scopes • Article on what (a) Written exam (a) Knowledge of Increased confidence
of practice by constitutes scopes (b) Care plan scope of in referral to another
the end March of practice practice/ professional
• Internet research pharmacist/
on licensing physician/
parameters for nurse with
nurses / 95% accuracy
pharmacist/ (b) Utilization of
physician team resource
• Simulated patient on care plan
scenario where per “scopes
providers must rubric”
refer to another
professional
• Interdisciplinary
care plan
Develop a • Develop a (a) Count the Modules incorpo- Modules used in all
marketable marketing plan number of rated into the schools at university
educational courses using curricula of
module the material medicine, nursing,
focusing (b) Count the pharmacy
on number of
interprofessional learners using
ad hoc team the material
function by the
end of May
Develop and • Develop the Conduct reliability Obtain a reliability Publish the
validate instrument study on instru- factor of X instrument
measurement • Pilot the instrument (e.g., item
tools related to ment with suffi- analysis, factor
individual cient numbers loading)
professional to generate
performance power to do
measurement
study
Data from: Goulet, C. G., Begley, K., Gould, K., & Doll, J. D. (2008). Interdisciplinary Team Skills Development
for Health Professional Students. Association for Prevention and Teaching. Awarded October 2008.
line for completion (Brownson, 2001; Timmreck, outcomes. Too many goals and objectives can make a
2003). Goals and objectives are different but comple- program appear incoherent and disconnected, and
mentary. Goals and objectives should indicate the poses challenges to successful completion. Drafting
program’s priorities, the program’s intended out- goals and objectives that are difficult to achieve makes
comes, the communities’ priorities, and the evaluation a program appear disjointed and infeasible, which
plan. A program can have multiple outcomes but impacts program sustainability and the ability to
should have a defined focus and prioritize the garner support for the program, especially financially.
2580_Ch06_080-095 16/07/13 2:47 PM Page 84
Occupational therapists are familiar with goal and Another essential component of program plan-
objective writing related to intervention planning, but ning beyond the goals and objectives is to identify
writing goals and objectives for a program requires a programmatic roles. In the planning stage, the
different perspective. Writing goals and objectives for details of who will complete the program roles and
a community program requires occupational therapy responsibilities may not need to be identified, but
practitioners to think broadly and envision an overall thought should be given to potential roles and
outcome. In medical model patient care, the focus of responsibilities required to make the program a
goals is to enhance the well-being of an individual. In success. Drafting job descriptions for both employ-
program planning for community practice, however, ees and volunteers provides program structure and
the focus is population-based, identifying how an ensures successful implementation. Time lines
intervention impacts a group of individuals (Edberg, should also be discussed and developed.
2007). In community settings, occupational thera- Including all of these aspects in the implemen-
pists need an expanded thought process that incor- tation plan will ensure a stable and sustainable
porates a population-based approach. Although this program design. Such a plan guides implementa-
aspect of goal writing can be challenging, the process tion and ensures that the program remains aligned
of goal writing is similar to that in other practice with its mission and purpose. The implementa-
areas, just applied more broadly. tion plan can be tied clearly to the evaluation plan
The mnemonic SMART can aid in writing and used to aid in garnering funds, such as grants.
appropriate program objectives. SMART stands for: The plan should be dynamic and flexible enough
to change but sufficiently stable to act as a road
S = Specific,
map for program implementation.
M = Measurement,
A = Attainable,
R = Relevant, and Participant Recruitment
T = Timely.
A key aspect of successful implementation is the
Program objectives should be specific to the pro- recruitment of program participants. Recruitment
gram, identifying a measurable outcome. It is impor- and retention of program participants must be con-
tant that objectives are attainable and feasible sidered in the planning process and is crucial in pro-
considering time lines, resources, and staffing. Goals gram design. Inattention to this step can negatively
and objectives should also be developed with the tar- impact the use and success of the program, and
geted population to be served in mind and with ultimately not meet the community’s needs. Estab-
a focus on the community needs gathered in the lishing referrals requires the development of protocols
assessment. Written goals and objectives should align and roles for each person involved in the program
with community needs and wants to ensure success (Braveman, 2001). The development of policies and
in meeting these goals and objectives. This concept procedures for staff was already discussed; however,
follows the occupational therapy principle of client- a policy and procedure should also be developed
centered practice applied to a program model for recruitment of program participants. The recruit-
(Brownson, 2001; Law, 1998). Goals and objectives ment and referral policy and procedure outline how
that focus on community needs facilitate community community members will access and benefit from
buy-in and programmatic success. The SMART the services. If there are requirements or stipulations
approach is useful not only when drafting objectives for admission to the program, these need to be
but also when evaluating the match between objec- identified. The target population should have been
tives and program activities (Weis & Gantt, 2004). identified in the program development stage. Here,
After drafting the goals and objectives, specific the practitioner is planning how to recruit partici-
activities should be designed that address the goals pants, including qualifiers for program participation
and objectives. The program activities are specifically and marketing to potential clients.
what will be done and the day-to-day activities of a In some cases, this step may require developing
program. Similar to therapeutic activities used to a marketing plan to identify methods for recruit-
reach client goals, program activities are meant to ment. The marketing plan may be referred to as a
achieve the desired program outcomes. community awareness campaign depending on the
2580_Ch06_080-095 16/07/13 2:47 PM Page 85
program and target audience. Whatever the title, For example, faith communities may be willing to
the marketing of services needs to be considered in donate space for health programming that benefits
the program design. When marketing, the occupa- their constituents and the greater community
tional therapy practitioner should consider all nec- (Swinney, Anson-Wonkka, Maki, & Corneau,
essary venues and utilize community resources such 2001). Local nonprofit agencies may also be willing
as partners, advisory boards, coalitions and com- to share space or provide space at a reduced cost
munity members, and participants. In the market- in exchange for lower fees for participants or just
ing plan development process, the occupational as goodwill to the community. Organizations that
therapy practitioner should take into account the donate space can identify this as an in-kind dona-
services being provided, who will benefit from these tion, which may be of benefit to the organization.
services, and who needs to know about the services If lobbying an organization for space at a free or
(Braveman, 2001). For example, a nonprofit that reduced cost, the occupational therapy practitioner
offers a health equipment recycling program pro- should consider the benefits to the organization and
vides used health equipment to individuals in need. be able to articulate them clearly. If necessary, a
The main targets for marketing of this program are memorandum of understanding or a formal contract
social workers, physical therapy practitioners, and may need to be drafted to establish an agreement
occupational therapy practitioners. These individ- about space and its use.
uals refer many clients who cannot receive health When considering space for implementing a pro-
equipment through insurance and have been a suc- gram, the program manager has to consider the
cessful target audience for the organization (Doll, needs of program participants. The program man-
2009). Marketing or community awareness should ager should consider liability issues, accessibility for
be a thoughtful process because without customers, participants, and the regulations and use of the space
the program will not be a success. depending on program needs. Related to liability,
insurance to cover the facility is important and
should be included in the program budget. For pro-
Location and Space Issues gram success, accessibility to the location and space
In addition to marketing and recruitment of pro- are important. When considering accessibility, the
gram participants, location and space for program occupational therapy practitioner needs to consider
implementation are also issues to be addressed in the program participants (Gitlow & Flecky, 2005).
program development (Braveman, 2001). For some, For example, if program participants are not able to
these will not be issues because the program is part drive, then considering a location close to public
of a larger organization that will donate or loan transportation is important. Beyond access to public
space for the program implementation. This is the transportation, the occupational therapy practi-
case for a program implemented in a hospital prac- tioner needs to consider accessibility to the space
tice setting where meeting rooms may be available including ramps, elevators, accessible entrances,
for a community outreach program. Often these parking availability, and lighting. Locations such as
spaces will be free of charge if a case can be made to faith communities may not be as accessible as other
administrators that the program benefits the insti- public facilities, so it is important to consider these
tution. Program managers may need to make a for- factors when choosing a location for the program.
mal request for such space and should follow the Last, maintaining the space is important to consider
policies of the institution with which they partner. in program planning. For example, if the space
When designing a program, space and location needs regular, professional cleaning, then this will
are critical factors. If a paid space is necessary, it will need to be considered in the budget during program
be important for the occupational therapy practi- planning. Each location and space will come with
tioner to consider this when budgeting and deter- regulations, and it is important to consider these in
mining program costs. The program manager will planning and in budgeting. Furthermore, the
need to work with a realtor to find an appropriate amount of time the space will be used is important
space and location for the program. Collaborating to consider. In initial stages or with program
with other institutions in the community may also growth, a change of space and location may be
be of benefit, allowing for shared costs of space. needed. It is important to consider the impact of
2580_Ch06_080-095 16/07/13 2:47 PM Page 86
such a change on both participants and program occupational therapy practitioner may be the pro-
implementation. gram manager and the program evaluator.
Where to implement a program also will depend In a larger program, staff may be hired for specific
on the needs of the program and should be given roles in program management. It is important to
thoughtful consideration during the planning analyze what staff members are needed for the
process. Once a program has been implemented, program to be successful. If the program has a
challenges with space and location may arise that large budget, then a bookkeeper will be critical
need to be considered. One method for strategizing to help maintain records. Administrative and sup-
is to build an assessment of the space and location port staff may also be of benefit to help with
into the program evaluation plan to continually appointments or with basic administrative tasks.
assess the benefits and challenges of the place and If traditional occupational therapy services are
location for the program. offered and billing is necessary, then a staff mem-
ber trained in billing and coding may be necessary.
If the program experiences growth, then more
Supplies and Equipment staff may be needed.
Each program will have a need for unique supplies Along with identifying and hiring staff, it will
and equipment. During program planning, brain- be important to set up an infrastructure for evalu-
storming a list of supplies and equipment is criti- ating staff in order to ensure that personnel are suc-
cal to ensure the program has what is required for cessful in their ability to engage in their roles to
successful implementation (Brownson, 2001; make the program run smoothly. Staff members
Fazio, 2008). Most programs require similar basic should be clear on expectations and their role in
needs, such as computers and office supplies. any paid or volunteer position. Performance review
However, programs will require specific supplies is important to ensure staff members are function-
and equipment based on program demands. For ing in the way appropriate to the program (Family
example, in a grant-funded program using sensory Planning Management Development, 1998).
rooms for suicide prevention for Native American One way to clearly define staff roles is to
youth, funds were used to purchase equipment to develop job descriptions. Job descriptions have
develop the sensory rooms along with basic office multiple purposes; they can be used for hiring,
supplies. employee orientation, employee supervision and
Garnering supplies and equipment may be simi- performance review, and salary considerations. A
lar to garnering funds. Supplies may be donated, or job description traditionally includes the job title,
equipment may already be purchased by an organi- supervisor, summary of the job duties, and the
zation that will allow its use by a program. Other- qualifications needed for the job. When develop-
wise, in the program development phase, the needed ing job descriptions, the occupational therapy
supplies and equipment will have to be identified practitioner should start with the mission state-
and included in the budget. ment, which helps identify what values and goals
are desired in employees. A potential job should
be analyzed to identify the qualifications needed
Staffing and Personnel of a potential hire (Family Planning Management
The greatest resource of any program is the staff Development, 1998). Many samples of job de-
who make the program a success (Timmreck, scriptions exist on the Internet and can serve as a
2003). When developing a program, it is impor- template for developing appropriate job descrip-
tant to consider what staffing and personnel are tions for a program.
needed for successful program implementation. If paid staffing is not an option, volunteers may
It is important to recognize that what is ideal for be another choice in helping to implement a pro-
a program may not be feasible, and staff may gram. The use of volunteers in program implemen-
be responsible for multiple roles. An occupational tation is a popular model to leverage resources
therapy practitioner may play many roles in a and build social capital for a program’s success
community setting. For a small program, the (Finlayson, Baker, Rodman, & Herzberg, 2002).
2580_Ch06_080-095 16/07/13 2:47 PM Page 87
In academic-community partnerships, service-learning sources, such as a grant or donations, may be more

has been demonstrated as one approach that uses appropriate.
student volunteers to help with program implemen-
tation (Gitlow & Flecky, 2010). Programs can also
tap into other volunteer programs like SeniorCorp Funding Sources
or AmeriCorp to garner volunteers to aid in pro- When considering how to fund a community pro-
gram implementation (Simon, 2002; Simon & gram, it is important to consider multiple factors,
Wang, 2002). including the following:
• What is the funding needed for?
Compliance With Practice • Whom does the program plan to serve?
• What funding amount is needed to sustain
Regulations
the program?
As an occupational therapy practitioner, it is impor-
tant to consider practice regulations. If using occu- Multiple funding sources exist, including dona-
pational therapy skills to design and implement tions, sponsorships, grants, and fees-for-service.
the program, it is critical that the practitioner follow Funding can come from multiple sources
practice guidelines, including the differentiation depending on the program. In some cases, an insti-
of roles between the occupational therapist and tution may offer a program and cover the costs in
occupational therapy assistant. Programs must fall accordance with its mission to serve the community.
within the occupational therapy scope of practice For a small program, such as a yoga program offered
(AOTA, 2010b) and always follow the Occupational by an outpatient facility, the costs may be minimal
Therapy Code of Ethics and Ethics Standards 2010 and an institution may be willing to cover the
(AOTA, 2010a). If an occupational therapy practi- expense of marketing if the occupational therapy
tioner has questions about whether the programs practitioner is willing to donate his or her time.
falls within occupational therapy regulations, the Grants are another source of funding for pro-
state licensure board should be contacted in order gram support. A grant is essentially a sum of funds
to ensure the program is in compliance. In the case donated to an organization to cover the costs of
that the program is engaged in billing and coding a program (Doll, 2010). The recipient of funds is
for services, reimbursement regulations should be accountable to the funding agency and has to fol-
followed at all times. low the guidelines set forth by it, which often in-
clude specific accountability and reporting of
program challenges and successes. Grants are typi-
cally available only to non-profit agencies that are
Financing Options categorized with a tax identification of 501(c)(3).
Grant funds are available from a variety of sources,
Start-Up Costs including local and federal government agencies
When beginning a program, it is important to and foundations. Grants are also available in vari-
consider how initial funds will be acquired (Braveman, ous amounts, from very small amounts (e.g., $500)
2001; Timmreck, 2003). Depending on the pro- to millions of dollars, depending on the funding
gram, start-up costs will vary. Prior to exploring agency. Program development grants are often a
start-up costs, a well-defined budget should be source to start a program and are not regarded as a
developed and finalized. When considering start- sustainable source of funding to support ongoing
up costs, it is important to consider what is needed program implementation.
to initiate the program and whether these costs Programs may also benefit from donations.
will be initial or ongoing. If the program plans on Donors receive tax benefits when donating to a tax-
making a profit, then a business loan is an appro- exempt organization, so this fact should be empha-
priate option to consider. On the other hand, if sized when seeking donations. When soliciting
the program plans on simply making enough donations, it is important to be very clear about the
funds to cover program costs, then other funding purpose of the funds and to target individuals or
2580_Ch06_080-095 16/07/13 2:47 PM Page 88
organizations that have a specific interest in the pro- therapy practitioner may consider charging the same
gram or participants of the program. Fund-raising or similar fees. But if the service differs from the
may be another method for seeking donations for a local practice, then fees should be competitive with
program. It is important to remember that fund- similar programming. Another approach is to con-
raising and seeking donations can be time-consuming, sult with an accountant who can provide guidance
so this must be considered when program planning. on appropriate fees to charge. It is important not
Sponsorships are another possibility for garnering to have fees beyond the ability of program partici-
funds for a program. Typically, corporations are pants to pay, or that are not competitive with similar
more willing to sponsor events than sponsor a pro- programming.
gram. When seeking sponsorships, it is important to Fees for service should be clearly outlined for pro-
clearly designate what sponsor monies will cover and gram participants. In program planning, the timing
how they will benefit the program. Benefits to spon- and payment requirements should be established. If
sors should be considered. For example, if a sponsor adjustments in fees for service are needed, this must
provides a certain amount of funds, then the sponsor be clearly communicated to program participants
may receive free advertising on the program’s Web with adequate time for participants to determine
site. Sponsorships are another consideration as source whether they want to continue to receive program
for funding a program or program event. services. A rationale for fee increases is often impor-
tant to ensure that program participants understand
the need for the change.
Establishing Fees for Service
Fees for service are another method to support a
program during implementation and should be Budgeting
properly planned and included in the budget The budget is another important component of pro-
(Grossman & Bortone, 1986). In a fee-structured gram design and implementation. When creating a
program, participants are required to pay a fee for budget, the occupational therapy practitioner should
services. Fees need to be realistic based on what the consider what resources are needed for program
community can afford and what services are being implementation. Financial planning and budgeting
offered. The program team will need to complete a should be an annual practice for the program, and
careful analysis of costs and develop a fair and reli- budgets should be constantly monitored to ensure the
able fee structure (Shediac-Rizkallah & Bone, program’s viability. The operating budget outlines the
1998). Another consideration is how to address the program’s financial plans for revenue, including
differing abilities of program participants to pay for monies and resources that come into the program as
services. In this case, a sliding scale fee may be an well as operating expenses to be paid out of the pro-
appropriate method for addressing the socioeco- gram’s budget (Weis & Gantt, 2004).
nomic needs across program participants. A sliding When developing a budget, a thorough analysis
scale fee identifies a program payment based on a of costs and income should be calculated. After
participant’s income. When implementing a sliding determining the costs and income, the next step is
scale fee, records of participants’ incomes must be to consider the balance between the two to ensure
maintained, which requires additional record keep- that the program at least attains a zero balance or
ing and bookkeeping for the program as well as has reserves in place to pay additional expenses
processes to ensure confidentiality. (Weis & Gantt, 2004). Budgets are planned for the
Another option is to define a flat fee for program upcoming year as well as a proposed plan of the
participants that covers program costs. To explore income and expenses of the program . If a program
appropriate fees for a program, research should is new, the expenses and income should be recorded
be conducted on what similar programs charge for for completing the annual budgets in subsequent
similar services rendered. This information can be years. Program budgets should be in constant flux,
ascertained by contacting similar programs or adjusting to the expenses and income.
exploring program fees on program Web sites. If the Budgets usually consist of two major compo-
program offers a service similar to that offered by a nents: direct costs and indirect costs (Gitlin &
local occupational therapy practice, the occupational Lyons, 2004). Direct costs are those items in the
2580_Ch06_080-095 16/07/13 2:47 PM Page 89
budget that will be funded by the program’s performing in order to become effective (Blue
income. Common direct program costs include et al., 2008). In the forming stage, team members
salary, benefits, equipment, consultants, travel, etc. begin by getting to know one another and estab-
Indirect costs are those costs required to implement lishing goals for the team. Team members begin to
the program, including overhead and administrative explore what tasks they will undertake as part of the
costs (Weis & Gantt, 2004). Indirect costs are typ- team. In the storming stage, team members begin
ically held to a certain percentage of the budget to to voice their opinions about the team and its pro-
ensure the program can run. Examples of indirect posed tasks. Dysfunction can occur at this stage as
costs include but are not limited to “rental fees, pay- team members negotiate goals and team member
ment of utilities, equipment depreciation, providing roles. However, this negotiation process is normal for
security, and general maintenance of workspace” a successful and effective team.
(Ingersoll & Eberhard, 1999, p. 133). During the norming stage, team members
Budgets can be simple or complex, based on the come to an agreement about the expectations for
program. A novice in program design and imple- the team and its members. Trust begins to de-
mentation might want to seek external assistance velop, and team roles become clearly defined.
with budgeting. Programs often pay auditors to aid In the performing stage, the team is able to com-
them in determining fiscal viability on an annual plete goals successfully and effectively. The team
basis. Financial advisors are another resource for is able to work together without conflict towards
help in developing and managing a program budget. the team’s goals (Blue et al., 2008; Cole, 2005).
The stages of team development are described
in Table 6-2.
Team Development Key activities of a team include communica-
tion, decision making, delegation, and problem
Due to its complicated nature, community practice solving (White & West, 2008). These activities should
cannot be done in isolation. Community programs be collectively accomplished in the collaborative
require a team approach, making it necessary to cre-
ate a strong team (Fazio, 2008). Developing a team
to implement the program is an important aspect of
program design and facilitates successful implemen- Table 6-2 The Life Cycle of Team
tation. Being strategic with team development Development (Blue et al., 2008)
ensures that the program’s implementation is not Stage Process
hindered by miscommunication or mistrust among
team members. In this situation, the occupational Forming • Team members get to know one
therapy practitioner may lead the team or become another
• Establish goals and tasks for team
a member of a developing or existing team.
A team consists of “two or more individuals with Storming • Team members begin to voice
a high degree of interdependence geared toward the opinions
achievement of a goal or the completion of a task” • Dysfunction can occur with
arguments about goals or team
(White & West, 2008, p. 3). Teams make decisions,
member roles
solve problems, develop a focus, and accomplish
outcomes. In community practice, the team will in- Norming • Agreement of the team expectations
clude not only the occupational therapy practitioner • Trust develops
• Team roles become clearly
and other experts but also community partners and
understood
community members. Using a team approach pro-
vides different perspectives on program design and Performing • Shared leadership among team
implementation, enhances program success and sus- members
• Tasks are completed effectively and
tainability, and expands expertise and resources
efficiently
(Ruhs, 2000).
Teams require time to develop, going through Doll, J. D. (2010). Grant writing and program development:
a life cycle of forming, storming, norming, and Making the connection. Boston, MA: Jones and Bartlett.
2580_Ch06_080-095 16/07/13 2:47 PM Page 90
model of a team in order to successfully design ongoing commitment and making team members
and implement a community program. Yet, work- feel rewarded for their participation.
ing in a team is challenging. According to Patrick Teams need ongoing development and care,
Lencioni, author of the Five Dysfunctions of a especially if members of the team change (Holtzclaw,
Team, teams become dysfunctional when there is Kenner, & Walden, 2009). Group dynamics always
an absence of trust, fear of conflict, lack of com- come with challenges, but overcoming these chal-
mitment, and inattention to results (2002). These lenges is possible. The processes of the team need
factors can destroy a team, which ultimately de- to be clearly defined, including communication,
stroys a program or the ability to address a com- decision making processes, and problem solving.
munity need. The team should be aware of these One suggestion is to develop a dynamic team
challenges and develop plans to remedy them as commitment where team members identify each
they arise. of the processes for the team to be successful. In
A program team will look different for each pro- this commitment, all members of the team agree
gram, but having a collaborative and cooperative how the team and its members should function,
team can lead to success and ensure that the pro- ensuring buy-in and dispelling common team
gram operates successfully. When building a team, challenges. As a team changes and develops, the
the occupational therapy practitioner needs to team must revisit its purpose and mission fre-
identify who must be involved and when these in- quently to ensure success and effective outcomes
dividuals must be involved (Brooks, 2006). In (Blue et al., 2008).
some cases, bringing people in too late can be
detrimental to the team and ultimately to program
implementation. Establishing Partnerships
Next, the team members should collectively de-
fine their purpose and goals for the program (Blue In community practice, it is rare that a program
et al., 2008). In this process, the team members will occurs without connections to other similar or com-
communicate and begin to build trust with one an- plementary programs. Besides building a team of
other. Team members should take time to identify individuals to implement the program, program
what each brings to the group. This activity design and implementation should include building
will help in building trust early and in delegation community partnerships. Community partnerships
of activities later. Group process is an important are an effective method for developing successful
component of a team’s development (Cole, 2005). community programming. Partnerships are entities
Occupational therapy practitioners can use their “formed between two or more sectors to achieve
expertise in group processes to aid in team devel- a common goal that could not otherwise be accom-
opment and sustainability. plished separately” (Meade & Calvo, 2001, p. 1578).
In a team or group setting, power is shared. Partnerships also help with marketing and recruiting
When working in a community program, this is an participants that may be connected with other
especially important aspect to emphasize. In the case programs.
where community members may be working with Collaboration is the foundation for partner-
educated health care professionals, community ships, and successful collaboration is fundamental
members may feel inadequate, leading to a lack of to a partnership’s success (Ansari, Phillips, &
active participation. The team leader can identify the Hammick, 2001; Fazio, 2008). Occupational ther-
strengths and contributions of each member in ini- apy practitioners already understand the concept
tial team-building activities and publicly recognize of partnership as discussed in literature related
members for what each brings to the effort (Israel, to client-centered practice (Law, 1998). In these
Eng, Schulz, & Parker, 2005). Teams should cele- discussions, the practitioner is in partnership with
brate together. The focus of a team should be not the client to ensure the client’s therapeutic goals
only to address needs but also to celebrate when a are addressed (Law, 1998; Sumsion, 1999). Com-
challenge has been successfully tackled collectively. munity partnerships maximize resources by utiliz-
Taking the time to celebrate is crucial to ensuring ing the strengths of a mobilized group of people.
2580_Ch06_080-095 16/07/13 2:47 PM Page 91
In many cases, one program alone cannot address many aspects of developing a community partner-
a need, but in collaboration, community needs ship. Partnerships should be thoughtfully developed
can be addressed more efficiently. Furthermore, and maintained, especially if a community is under-
partnerships created to address health-related issues served. And, once a partnership is developed, it
can “aim to create a seamless system of relevant needs to be maintained.
healthcare services for the community” (Meade &
Calvo, 2001, p. 1578).
Partnerships form between groups or organiza- Program Management
tions. Occupational therapy practitioners can
be involved in multiple ways in community part- Programs are important to the communities they
nerships through academic-community partner- serve. In order to sustain programs and ensure they
ships, community coalition membership, advisory meet community needs, community members
board membership, non-profit board membership, should be actively involved in the program. When
or simply as members of the community. Commu- designing and implementing a program, the practi-
nity partnerships, in themselves, can be compli- tioner should consider how community members
cated to develop and maintain (Becker, Israel, will be involved in monitoring the program. Advi-
& Allen, 2005). As with the development of any sory boards are a model for including the commu-
team, a significant investment is required to nity in program implementation and maintenance.
develop trust and relationships and face the chal- An advisory board is a collection of community
lenges necessary to collaborate effectively (Becker members who provide feedback to a program
et al., 2005). Research has shown that developing (MacQueen et al., 2001). These individuals may be
and maintaining partnerships takes time, commit- community stakeholders and/or community members.
ment, and open communication to develop The advisory board is a resource to the program team
the mutual trust required for true exchange in and connects the team with community members.
a partnership (Burhansstipanov, Dignan, Wound, Prior to convening an advisory board, time should
Tenney, & Vigil, 2000; Kagawa-Singer, 1997; be taken to establish the role of the advisory board,
LaMarca, Wiese, Pete, & Carbone, 1996; Poole & the goals of the advisory board, and a description of
Van Hook, 1997). The occupational therapy prac- the role of members on the advisory board. Advisory
titioner included in collaboration will need to boards usually consist of experts who know the com-
commit the time and problem solving abilities munity and the organization, so these individuals can
needed to be an effective community partner. make recommendations and guide the organization
Partnerships can be very formal or very informal, or program. An advisory board demonstrates quality
depending on the partners involved, the community assurance and that the organization is listening to the
need, and the program. If partnerships are formal, voice of the community. When inviting individuals
then the partners may develop a strategic plan iden- to participate in an advisory board, the leader of the
tifying goals and objectives for the partners based advisory board needs to ensure that participants are
on the program’s mission (Becker et al., 2005). For- individuals who will provide constructive and critical
mal agendas and meeting minutes should be main- feedback, and also have the time to devote to advi-
tained to track partners’ efforts. In some cases, this sory board activities. Advisory boards typically do
documentation may be part of a program’s evalua- not meet often and do not require a significant
tion plan and may provide valuable information for amount of time, which is a benefit when recruiting
a grant report. Granting agencies that require part- members. Advisory boards are not the same as a
nerships will want documentation of the success of board of directors used in a non-profit model and do
the partners in reaching their goals. not necessarily require the same level of formality
Developing community partnerships requires (Weis & Gantt, 2004). In some cases, a program
commitment. Occupational therapy practitioners may have a board of directors and an advisory board,
can play a critical role in community practice using depending on the program needs.
their expertise in occupation (Fazio, 2008). How- A board of directors is a group of individuals
ever, it is important to remember that there are who guide the organization in its mission, finances,
2580_Ch06_080-095 16/07/13 2:47 PM Page 92
and programming. Non-profit agencies follow a lead to further mistrust and difficulty in forging
model of including a board of directors to aid future partnerships.
them in planning and ensuring financial viability When addressing significant health issues in com-
for the organization. Each board of directors has munities, sustainability can appear nearly impossible
traditional officer roles, including president, vice due to barriers and lack of resources. Yet, sustain-
president, treasurer, and secretary. Members of a ability is possible if programs are well designed and
board of directors are volunteers who have expert- complement the community’s needs and capacities
ise and can aid the organization. The members of (Akerlund, 2000). Successful approaches to sustain-
a board are fiscally responsible for the agency they ability include ongoing evaluation, ongoing service
support both in monetary donations and in expert development, program modification to meet com-
guidance. Depending on his or her role in relation munity needs and desires, effective program market-
to the board, the manager should know how ing, and use of capacity building approaches
to work with the board and communicate with (Gaines, Wold, Bean, Brannon, & Leary, 2004).
board members as necessary. An executive director Community programs also need to be flexible to
of a non-profit organization will work directly be successful. Community programs should respond
with the board, keeping them informed on the not only to community needs but also to social, eco-
organization’s functioning and development. nomic, and environmental conditions that impact
both the community and the program (Brennan,
Baker, & Metzler, 2008). Community programs are
Program Sustainability developed to address community needs, and sustain-
ability is more likely when services are modified as
A program’s sustainability is crucial and should be community needs and desires change.
part of the program design and implementation. When addressing program sustainability, the fol-
Community programs are not meant to be static and lowing factors should be considered: effectiveness of
are ever evolving (Shediac-Rizkallah & Bone, 1998). the program, the relationship with the community,
Sustainability is more than simply having the fund- anticipated duration of the program, funding, and
ing to continue a program and includes other factors staff expertise. Program effectiveness is determined
that influence the program’s ongoing success. Pro- through an evaluation plan. Evaluation results will
gram sustainability in communities means going be- reveal if the program is really worth continuing,
yond program implementation to connect with the responds to community needs, or requires changes
community and build capacity to engrain the pro- to be effective. In the case that the program is inef-
gram into the community (Edberg, 2007). Sus- fective or the need is short-term, then sustainability
tainable community programs are “endurable, might not be relevant (Glaser, 1981).
livable, adaptable, and supportable” (Akerlund, The length of the program is an important fac-
2000, p. 354). tor to consider. With most health-related commu-
Programs terminate for many reasons, including nity issues, a short-term solution will not be viable
poor or inadequate planning for program sustain- (Edberg, 2007; Timmreck, 2003). If the plan is to
ability, sustainability has not been a program prior- sustain the program for the long term, then goals
ity, the community lacks buy-in or support for the and objectives need to be put into place that pro-
program, or fiscal barriers exist, such as lack of fund- mote and suggest sustainability. If sustainability
ing or poor economic times. Major problems exist has not been considered in initial program devel-
when a program lacks sustainability. In some under- opment, the program team may need to go back
served and diverse communities, mistrust of outside to the drawing board of basic program develop-
individuals and sometimes mistrust of health care ment and redevelop components of the program
in general are part of the community’s dynamics. for the long term.
Developing a program that suddenly ends when The expertise of program staff is a very impor-
grant funding ends sends a message to the commu- tant factor in sustainability, especially because sus-
nity that the program was not really created for their tainability infers that programs change according
benefit (Jensen & Royeen, 2001). These actions can to the community. Having staff that are flexible
2580_Ch06_080-095 16/07/13 2:47 PM Page 93
and able to offer expertise in multiple areas related future oriented, focusing on what needs to be done
to community issues is important in maintaining to maintain the organization’s viability. The plan
a successful program. Involving stakeholders from should include goals, objectives, and action steps,
the community or hiring community members including who will do what and a date for accom-
to implement the program enhances this aspect plishment. All the aspects of this plan should be
(Edberg, 2007). If funding the salaries of staff is focused and geared towards sustainability rather
difficult, then the program may choose to move than program implementation.
towards a volunteer model instead of funding Sustainability planning should include identify-
positions. This strategy will depend on the pro- ing the challenges to sustainability. One question
gram, the access to volunteers, and the community to pose is: What could cause the program or organ-
needs (Akerlund, 2000). ization to not be able to sustain itself? Addressing
Obviously, funding plays a role in the ability this question is difficult but essential to the core of
of a program to sustain itself. Multiple strategies can any sustainability plan. Identifying the challenges to
be considered when exploring financial sustainabil- sustainability allows the program team to develop
ity of a program. If a program is grant funded, approaches to effectively address them (Akerlund,
it must remain sustainable either by garnering out- 2000; Conrad, 2008). Planning for sustainability
side funds or by implementing a fee for services. If is an essential process for a program’s survival. One
seeking funds from external sources, the program approach is to develop a committee or task group
team will need to have a plan in place to either focused specifically on sustainability (Akerlund,
search for future grant funds or engage in fund-raising 2000). In some cases, these individuals may be
efforts. A cost-benefit analysis should be done to be volunteers or members of the program team. Sus-
able to demonstrate to funders and donors the im- tainability planning should involve a group of com-
pact of the program and its relevance to be sustained munity stakeholders and those who have a vision
(Akerlund, 2000). The strategies for fund-raising are for the future. This group should include individuals
many and will differ based on the program’s struc- who have used the services and directly benefitted
ture and needs. The program team should also be from them. Including input from community mem-
aware of in-kind services, those that are provided bers ensures that the plan that is developed meets
free of cost to the program. Seeking in-kind services the needs and desires of the community, and aids
can aid in balancing a program budget (Akerlund, in establishing sustainability. Also, the plan needs
2000). Fund-raising may seek not only funds but to be practical and feasible to ensure success. This
also services or supplies needed by the program. means that it does not include raising community
Fund-raising is often most successful when program fees by an exorbitant amount nor propose strategies
staff have developed relationships with potential that will ultimately lead to challenges rather than
donors; sometimes this process is referred to as success. The sustainability committee also needs to
“friendraising” (Gottlieb, 2006). continually search for and garner resources that will
support the program.
Developing a Sustainability Plan
One of the best ways to ensure the long-term Conclusion
maintenance of the program is to develop a sus-
tainability plan. The sustainability plan encom- The occupational therapy practitioner needs to be
passes an overall strategy for program maintenance thoughtful in the program design to ensure that once
that includes specific goals for sustainability along a program is implemented, it is viable and sustainable.
with an action plan to address these goals (U.S. Program design requires the development of the pro-
Department of Justice, 2005). A sustainability plan gram’s mission and implementation plan. Team
is meant to be an action plan outlining specifically building, sustainability planning, and budgeting are
what needs to be done and who needs to do it in important components of program design to ensure
order to maintain the program. The sustainability successful implementation. Program design requires
plan is similar to the implementation plan but is the occupational therapy practitioner to thoughtfully
2580_Ch06_080-095 16/07/13 2:47 PM Page 94
consider how the program will work, who will be (2008). Team Skills Handbook. Charleston, SC: Medical
involved, who will benefit from services, and how the University of South Carolina.
Braveman, B. (2001). Development of a community-based
program will be funded. In this process, the occupa- return to work program for people living with AIDS.
tional therapy practitioner can take a programmatic Occupational Therapy in Health Care, 13(No. 3-4), 113–131.
idea and design a program that meets community Brennan, L. K., Baker E. A., & Metzler M. (2008). Promoting
needs to impact occupation and quality of life. Health Equity: A Resource to Help Communities Address
Social Determinants of Health. Atlanta: U.S. Department
of Health and Human Services, Centers for Disease
Control and Prevention.
Learning Activities Brooks, D. M. (2006). Grant writing made easy. Presentation
1. Draft a mission statement for a potential pro- made at the E-Tech Conference: Columbus, OH.
Brownson, C. A. (2001). Program development: planning,
gram. Gather some mission statements from implementation, and evaluation strategies. In M. Scaffa,
corporations or local organization via the Ed. Occupational Therapy in Community-Based Practice
Internet. Compare and contrast your drafted Settings (pp. 95–118). Philadelphia: F.A. Davis.
mission statement with those of other Burhansstipanov, L., Dignan, M. B., Bad Wound, D.,
organizations. Tenney, M., & Vigil, G. (2000). Native American
recruitment into breast cancer screening: The NAWWA
2. Brainstorm the staff you need for your project. Cancer Education, 15, 28–52.
program idea. How many staff members do Chambless, D. L. (2003). Hints for writing a NIMH grant.
you need? What would you pay them? What The Behavior Therapist, 26, 258–261.
qualifications do they need to implement the Cole, M. B. (2005). Group dynamics in occupational therapy:
program? The theoretical basis and practice application of group
intervention, Third Edition. Thorofare, NJ: SLACK.
3. Contact local programs similar to your pro- Conrad, P. (2008). To boldly go: A partnership enterprise to
gram idea and set up an interview with an produce applied health and nursing services researchers in
employee. Find out more about the program, Canada. Health Care Policy 3, 13–30.
including staffing, budgeting, and supplies Doll, J. D. (2010). Program development and grant writing in
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Chapter 7
Program Evaluation
David Ensminger, PhD, Marjorie E. Scaffa, PhD, OTR/L, FAOTA,
and S. Maggie Reitz, PhD, OTR/L, FAOTA
What gets measured gets done. Measure the wrong things, and the wrong things get done.
—Michael Patton (2007, p. 110)
Learning Objectives
• Define program evaluation.
• Identify the purposes of program evaluation.
• Describe several approaches to program evaluation.
• Discuss the process of program evaluation.
• Describe the differences between experimental, quasi-experimental, and non-experimental evaluation designs.
• Discuss the appropriate use of qualitative methods in program evaluation.
• Identify the uses of evaluation results.
• Discuss the importance of disseminating the results of program development and evaluation.
• Identify the ethical considerations in designing and conducting evaluation research.
Key Terms
Appreciative inquiry approach Objectives approach
Conceptual use Outcome evaluation
Contingency perspective Participatory approach
Efficiency evaluation Process evaluation
Experimental designs Process use
Formative evaluation Program efficiency evaluation
4D Model Program evaluation
Impact evaluation Qualitative
Indicators Quantitative
Instrumental use Quasi-experimental designs
Logic models Stakeholders
Managerial approach Summative evaluation
Needs assessment Symbolic use
Non-experimental designs Utilization-focused approach
Introduction the use of this information for decision making

and action (Johnson & Christensen, 2008). Fink
Evaluation research, more commonly referred to (1993) defines program evaluation as “a diligent
as program evaluation, is used to make a judgment investigation of a program’s characteristics and
of merit, worth, or value of a program. Evaluation merits. Its purpose is to provide information on
research optimizes the collection of relevant data the effectiveness of projects to optimize the outcomes,
for various stakeholder groups and then facilitates efficiency, and quality of health care. Evaluations can
96
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Chapter 7 | Program Evaluation 97
analyze a program’s structure, activities, and organi- Although both lead to valuable information that
zation and examine its political and social environ- can assist stakeholders in making decisions and
ment. They can also appraise the achievement of taking actions regarding a program, it is often the
a project’s goals and objectives and the extent of its nature of the decision or action being made that
impact and costs” (p. 2). helps form the purpose of an evaluation. Formative
Because evaluators seek to provide useful infor- evaluations are conducted when decisions or ac-
mation to various stakeholder groups, the evaluator, tions to be taken from evaluation results center
unlike a “researcher,” does not control all aspects on program improvement. Thus, formative evalu-
of the evaluation. This is most evident in determinations provide credible and relevant information
ing the questions for the evaluation. Evaluators rely concerning a program’s theoretical framework,
on stakeholders to help develop the essential ques- design, activities, and operation. This information
tions that will be answered in the evaluation. Stake- assists stakeholders in making changes that will lead
holders are “individuals, groups or organizations to improvements in the program’s activities, prac-
that can affect or are affected by an evaluation tices, processes, or operations.
process and/or its findings” (Bryson, Patton, & Summative evaluations are conducted when de-
Bowman, 2011, p. 1). The degree of stakeholder cisions or actions to be taken from an evaluation
involvement is often dependent on the approach center on continuing or discontinuing a program,
and can range from helping generate questions to increasing program size, or determining the effect
full involvement in the collection, analysis, and re- of a program on a particular social problem or need.
porting of results. Evaluators also differ from other Thus, summative evaluations provide credible,
researchers in that they consider the context to be valid information concerning the program’s out-
a critical component of the research. As a result, comes, impact, and effectiveness. The information
there are limitations to generalizing results from an from summative evaluations provides evidence that
evaluation to other contexts. In addition, evaluators changes experienced by the clients of a program
make value statements related to the merit or worth result from the program activities and not from
of the program based on the data. other factors.
The determination of a program’s merit or
worth is founded in the perspective that programs
should have some level of accountability to stake- Focus of Program
holders and the community at large. Although Evaluations
public perception of the need for evaluations
generally focuses on accountability in terms of Evaluations tend to be conducted around five
program effects and efficiency, evaluations also main foci (Rossi, Lipsey, & Freeman, 2004),
can be conducted to support the development which include:
and improvement of a program, or to further or • needs assessment
deepen stakeholders’ understanding of the pro- • program theory
gram (Chelimsky, 1997). Although the notion • program implementation
of accountability suggests a decisive type of judg- • program impact
ment, as will be explained in this chapter, the • program efficiency.
reporting of merit, worth, and value has different
meanings depending on the purpose and focus Even though these five focus areas are distinct,
of the evaluation as well as the approach used to it is helpful to understand the relationships among
conduct the evaluation. them. Social programs are developed to address
specific needs or problems within a community or
society. In order for a program to be designed,
Purpose of Program Evaluation there must be a clear, agreed-upon understanding
When designing or planning evaluations, evaluators and definition of the problem the program is to
work with key stakeholders to determine the main address. Needs assessments are conducted for this
purpose of the evaluation, which often falls into one purpose. Once the problem is defined, programs
of two broad categories: summative or formative. must develop theories (often referred to as logic
2580_Ch07_096-113 16/07/13 2:48 PM Page 98
models) that explain the cause-and-effect links by the problem. The information from needs assess-
between the problems, program activities, and ments provides the foundational information about
outcomes. the problem and population that helps determine the
Program theory evaluations help stakeholders types of services needed in a program.
develop a clear and agreed-upon model of how the As stated previously, the nature of this informa-
program is intended to operate in order to address tion is formative, because this evaluation most often
an identified social problem. To achieve their in- provides information that leads to the design and de-
tended outcomes, programs need to be imple- velopment of programs or improvement of existing
mented as they are described within a program programs to better address the defined need. Basic
theory. Implementation evaluations focus on eval- questions that drive this type of evaluation include:
uating the fidelity of program implementation in
• How often is this problem/need reported or
terms of design and logic models. Programs that
observed in the community?
are implemented correctly should produce out-
• How widespread is the problem within the
comes that address the social need or problem.
community?
Outcome evaluations focus on the long-term
• What are the characteristics of the individuals
effects of a program or process, establishing cause-
who have this problem/need?
and-effect relationships between the program and
• How do different groups perceive the nature
the outcomes or changes in the social problem
and the cause of the problem?
or need. Impact evaluations assess the immediate
• What services would help reduce or eliminate
effects of a program or process on the target pop-
the problem?
ulation and typically measure the achievement
of program objectives (Green & Kreuter, 2005). Through a needs assessment, the evaluator provides
Efficiency evaluations are used to examine the information that helps stakeholders better understand
costs and benefits of programs in terms of quality the nature of the social problem and use the data to
of their operations and the outcomes they pro- design and implement programs or program activities
duce. Efficiency evaluations are important because to meet the identified need. The needs assessment
programs are often accountable to external stake- process is discussed in more depth in Chapter 5 of
holder groups such as boards of directors, local this text.
communities, and governments that provide the
program with resources and funding. Program Theory Evaluation
All five of these focus areas are important to ad-
Program theory evaluation focuses on working with
dress, and each lends itself to either summative or
stakeholders to construct a clear description of how a
formative purposes. Needs assessments, program
program is intended to work. Program theory evalu-
theory, and implementation generally have a more
ations result in information that describes the causal
formative structure, whereas outcome, impact, and
links between the activities and events of the program
efficiency evaluations tend to have a more summa-
and the outcomes these activities are intended to
tive nature. Each focus will be examined in more
produce. Additionally, program theory evaluations
detail in the following sections.
describe the rationale behind how the program is in-
tended to operate. Program theory evaluations often
Needs Assessment result in visual diagrams or logic models that repre-
sent the casual links between the problem, the pro-
The main objective of needs assessment is to provide
gram activities, and the program outcomes. See
stakeholders with information that leads to a deeper
Figure 7.1 for an example of a logic model. Questions
understanding and working definition of the social
that drive program theory evaluations include:
problem or need. In addition, this type of evaluation
should assess the extent of the problem in terms • How well does the logic model describe the
of incidence (how often it is observed or occurs in causal links between activities and outcomes?
society) and prevalence (the distribution of the prob- • How well does the logic model fit with the
lem within society) as well as describe the target pop- current theories/practices used to address the
ulation and secondary populations that are affected problem?
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Program Action-Logic Model
Outputs Outcomes-Impact
Inputs
Activities Participation Short term Medium term Long term
What we What Who we What the What the What the

invest we do reach short-term medium-term ultimate
results are results are impact is
Staff • Conduct Participants
Priorities workshops, Learning Action Conditions
Situation Volunteers meetings Clients
Consider • Deliver Awareness Behavior Social
Needs and • Mission Time services Agencies
assets • Vision • Develop Knowledge Practice Economic
• Values Money products, Decision-
Symptoms • Mandates curriculum, makers Attitudes Decision- Civic
versus • Resources Research resources making
problems • Local dynamics base • Train Customers Skills Environmental
• Contributors • Provide Policies
Stakeholder • Competitors Materials counseling Opinions
engagement • Assess Social action
Intended Equipment • Facilitate Aspirations
outcomes • Partner
Technology • Work with Motivations
media
Partners
Assumptions External Factors
Evaluation
Focus – Collect Data – Analyze and Interpret – Report
Fig. 7•1 Example of a Logic Model. (Retrieved from University of Wisconsin-Extension-Cooperative

Extension, Program Development and Evaluation Unit Web site: http://www.uwex.edu/ces/pdande/
evaluation/evallogicmodel.html Reprinted with permission.)
• Does the service utilization display the cor- the operation of a program, or how the program
rect order of activities to produce the desired models are enacted on a daily basis. Implementation
outcomes? evaluations examine components of the program,
• Does the organizational process plan provide such as the activities, events, functions, communi-
adequate, accessible resources and qualified cation, and resources, with special focus on docu-
personnel to fulfill the utilization plan? menting and describing the actual practices of a
program.
The aim of program theory evaluation is to pro-
One purpose of implementation evaluation is to
vide information that allows stakeholders to better
determine the level of program fidelity in relation
understand the theoretical foundations of a program
to the program logic model. Program fidelity pro-
and the causal links between program activities and
vides an opportunity for formative accountability by
program outcomes. In addition, the logic model
providing stakeholders with information about the
should demonstrate the connections between
degree to which the intended program (logic model)
needed resources and program operation.
matches the actual program. These evaluations can
provide useful formative recommendations to en-
Program Implementation Evaluation sure the target population is being reached, program
Whereas program theory evaluations focus on what activities are being offered as designed, and program
a program is intended to do, implementation (or outcomes are being monitored.
process) evaluations provide information on the ac- Program monitoring involves the identification
tual operation of the program (Stuffelbeam, 2000). of key outcomes, and the systematic practice of
Implementation evaluations provide information on collecting data to inform the stakeholders of the
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program’s effectiveness in reaching these outcomes. with similar objectives may be targeted to the same
Even though program monitoring can provide population at the same time, which could influence
useful knowledge of the program’s successes at the outcome. In addition, the normal development
achieving outcomes, it should not be mistaken for and maturation of participants, particularly chil-
impact evaluation. Questions that drive implemen- dren, could contribute to the outcome. Likewise,
tation evaluations include: some program participants may have already been
predisposed to the outcomes being measured
• How well does the program reach its intended
and would have realized those positive outcomes
target populations?
without being exposed to the program interven-
• How well does the actual program match the
tions. The questions that drive impact evaluations
impact theory and service utilization plan?
include:
• What are the barriers that prevent the program
from operating as intended? • What effect does the program have on the
• What factors facilitate the implementation of social problem?
the program? • To what extent can program outcomes be
• How well do the organizational processes directly linked to program activities?
support the program?
In summary, a well-conducted impact evalua-
• To what extent is the program reaching
tion provides the foundation for sound policy
intended outcomes?
making. It describes whether or not the program
This focus relies on the evaluator providing had an impact as well as how much of an impact
information that allows stakeholders to identify and on whom.
areas where program operation does not fit with
the program design, to identify areas where pro-
gram activities can be improved, and to identify Program Efficiency Evaluation
and establish means for ongoing data collection Where impact evaluations focus on determining
related to program activities and outcomes. the cause-and-effect relationship between the pro-
gram and its outcomes, program efficiency eval-
uation focuses on the merit or worth of a program
Program Impact Evaluation from the standpoint of its financial benefits and
Like program monitoring, program impact evalu- costs. In this type of evaluation, evaluators must
ations focus primarily on the goals, objectives, and develop a method for explaining the benefits and
immediate effects related to a program. However, costs of a program in monetary terms. Program
in impact evaluations, evaluators try to employ the efficiency evaluations often take two main forms:
most rigorous methods for examining the cause- benefits analysis and cost-benefits analysis. In
and-effect relationship between the program and benefits analysis, evaluators look for ways of rep-
the achievement of the program goals and objec- resenting program outcomes in terms of monetary
tives. Thus, impact evaluations attempt to measure benefits (e.g., reduction in cost of future services
program effects and have a summative purpose. needed by clients, increase in income of clients,
Evaluators are seeking to provide valid evidence reduction in program costs compared to other
concerning the extent to which the program actu- programs, increase in human and social capital).
ally causes the measured or observed outcomes. In When conducting benefits analysis, the evaluator
order to demonstrate this, a comparison group that must be able to show links between the outcomes
did not receive the program is needed to determine of the program and the identified benefits. The
what would have happened if the intervention had merit or worth of the program is determined by
not been implemented. the benefits the program provides.
Outcomes can be affected by a number of other In cost-benefits analysis, the evaluator compares
variables aside from the program intervention. For the benefits of the program determined in a benefits
example, changes in economic or social conditions analysis to the actual costs of the program. When
can influence health outcomes. Other programs conducting cost analysis, evaluators must examine
2580_Ch07_096-113 16/07/13 2:48 PM Page 101
all the costs associated with running the program, the objectives approach, managerial approach, par-
not simply the costs associated with direct services ticipatory approach, utilization-focused approach,
to the client (e.g., material resources, operation and appreciative inquiry (AI) approach.
expenses, salary and benefits of employees, loss of All evaluation approaches are concerned with
work days for clients in program). Questions that the values and merit, or worth, of programs.
drive efficiency evaluations include: However, they can differ in what elements of
evaluation are emphasized (e.g., which stake-
• What are the monetary values of the program
holders have more input, what information or
outcomes?
data provides greater evidence, or what methods
• How do the benefits of the program compare
for collecting information are more important)
to the cost of running the program?
and how program value is determined. These ap-
• Which program is more cost-effective to run?
proaches emphasize different aspects of the eval-
This focus requires the evaluator to provide in- uation process or the program; it is important to
formation that informs the stakeholders about the note that each approach has its unique set of
observed benefits of a program in relation to meas- strengths and weaknesses. Evaluators should have
ured costs. an understanding of each approach so they can
effectively modify or combine approaches in
order to meet the needs of stakeholders.
Approaches to Program
Evaluation Objectives Approach
The field of program evaluation has been influenced Mistakenly viewed as the main goal of all evalua-
by diverse epistemologies, beliefs, methodological tions, the objectives approach emphasizes the de-
views, values, and perspectives (Fitzpatrick, Sanders, termination of the achievement of stated goals and
& Worthen, 2004). These influences have shaped objectives in the program design. Specific evalua-
the approaches used by evaluators today. These vary- tion models that emphasize this approach include
ing approaches provide foundational perspectives the Tylerian approach, Discrepancy Evaluation,
of how evaluations can be conducted for different and Metfessel and Michael’s Evaluation Paradigm
purposes. The authors of this chapter do not favor (Fitzpatrick et al., 2004).
one approach but instead encourage evaluators to The main activities in this approach are deter-
employ a contingency perspective (Shadish, Cook, mining the goals and objectives of the program,
& Levinton, 1991) when determining the methods including the development of specific operational
and activities to be carried out in an evaluation. definitions (i.e., specific behavioral or observational
The contingency perspective advocates the use definitions) of the objectives. Whereas stakeholders
of different approaches to evaluation based on may be involved in determining the objectives and
important information such as the nature of the providing operational definitions, typically in this
program being evaluated, the context of the evalua- approach the objectives are determined based on the
tion, the informational needs and intended use of mission and goals of the program, and in some cases
the evaluating results by stakeholders, programmatic specific objectives may already exist as part of the
resources, and the specific evaluation questions. In program documentation.
order to apply a contingency perspective, evaluators Once the objectives are determined, a method for
must have an understanding of the broader evalua- measuring the objectives is agreed upon. The evalu-
tion approaches used in the field. ator then collects the data from these measurements
Although many specific models of evaluation exist and compares the data collected to the specific
(e.g., Discrepancy Evaluation, CIPP [Context, goals and objectives. If a specific criterion of success
Input, Process, and Product], Utilization Focused), has been established for an objective (e.g., 75% of
these models fit into one of the broader approaches program participants will report using bicycle
to evaluation. Several of these approaches will be dis- helmets upon program completion), then data col-
cussed in the second half of this chapter, including lected is compared to the predetermined criterion.
2580_Ch07_096-113 16/07/13 2:48 PM Page 102
Discrepancies between the observed data and the the context, planning, structure, resources, imple-
stated objectives are interpreted to provide either mentation, and organizational factors that impact a
formative or summative information to stakehold- program. Specific evaluation models associated with
ers. For the objectivist approach, program value is this approach include the CIPP, UCLA Model
directly related to the achievement of stated objec- (Fitzpatrick et al., 2004), and Evaluability Assess-
tives, and quantitative methods are frequently used ment (Wholey, 2004).
to measure program outcomes. Stufflebeam’s (2000) CIPP model provides a
Strengths associated with this approach include: comprehensive example of this approach and em-
ploys four different types of evaluation to provide
• it is easy to understand and carry out,
managers with information related to specific deci-
• objectives are a clear and easy way to define a
sions. The CIPP acronym represents the major con-
program’s success, and
structs in this model: context, input, process, and
• information concerning achievement of pro-
product evaluation. Context evaluations assist with
gram objectives is relevant to most stakeholder
decisions regarding program planning, while input
groups.
evaluations are used for decisions concerning pro-
Although this approach has many advantages, it gram structure. Process evaluation, also referred
also has limitations. Weaknesses associated with this to as formative evaluation, assesses, analyzes, and
approach include: documents the development and implementation
of a program or strategy to determine if the pro-
• program merit or worth is limited to the
gram activities were conducted as planned. Process
program objectives,
evaluations are used for decisions surrounding pro-
• no value is set for the objectives themselves,
gram implementation, and product evaluations in-
• outcomes or program values not related to
form managers’ decisions about program outcomes
objectives are often overlooked,
and objectives. The purpose of these evaluations is
• information concerning program planning
to provide quick, ongoing, and useful information
and implementation is ignored, and
to managers for the purpose of ongoing program
• in many cases stakeholder involvement may
improvement.
be minimal (Fitzpatrick et al., 2004).
In the managerial approach, program value is
Although this approach is simple and provides determined by the managers or program directors
valuable information about a program, it often and is reflected in the decisions they make based
provides limited information that stakeholders can on evaluation results. The decisions made by man-
use to improve programs. Even though objectives agers can take either a formative tone and focus
might be a part of an evaluation plan, few evalua- on program improvement, or a summative nature
tors rely solely on this approach when conducting and result in program expansion or program elim-
an evaluation. ination. Both qualitative and quantitative research
methods may be utilized, depending on the nature
of the evaluation questions. Qualitative approaches
Managerial Approach use language or narrative as raw data in order to
Similar to the objectives approach, the managerial study people’s thoughts, experiences, and perspec-
approach does include examining program objectives. Quantitative approaches use numbers as
tives; however, it looks beyond programmatic raw data in order to test hypotheses and establish
outcomes and views the informational needs of cause-effect relationships (Barker, Pistrang, &
managers as a critical aspect of evaluation. This ap- Elliott, 2002). The managerial approach to eval-
proach emphasizes providing useful information to uation is closely related to the field of human
managers or program directors in order to improve performance technology and performance im-
their decision making. Evaluations must provide in- provement in business and industry. Many of
formation about how the program operates, not the specialized models of performance improve-
simply if objectives are being reached. In order to ment and quality assurance used in business and
assist managers, the managerial approach evaluates industry (e.g., Six Sigma, Lean, and Total Quality
2580_Ch07_096-113 16/07/13 2:48 PM Page 103
Management [TQM]) share core aspects with the likelihood that evaluation information will be used.
managerial approach to evaluation. Participatory evaluators seek to determine the critical
The strengths of the managerial approach include: information needs of the various stakeholder groups
and then plan evaluations that will provide the
• collecting useful information to make in-
needed information to these stakeholders in order to
formed decisions for the purpose of program
promote program improvement. Whereas the man-
changes,
agerial approach applies a top-down perspective, the
• focusing of evaluation activities on specific
participatory approach uses a bottom-up perspective
program aspects (e.g., planning, structure,
of program change. One important outcome of par-
implementation), and
ticipatory evaluations is increased dialogue among
• emphasizing timely ongoing feedback
the various stakeholder groups that results in broader
through the life cycle of the program.
perspectives of the program, deeper understanding
The emphasis on a single stakeholder group’s of the program, and promotion of social justice
needs (i.e., managers) makes this approach undem- through the inclusion of marginalized populations
ocratic. Other potential limitations include the in the evaluation process. Program merit and worth
possibility that important information may not be is often a result of the evaluator’s interpretation and
gathered if the manager does not see its impor- presentation of multiple perspectives, and perceived
tance, or the manager may fail to make decisions value of the program from the various stakeholder
even when presented with relevant information groups. This approach favors qualitative methods
(Fitzpatrick et al., 2004). Additional weaknesses and reports that provide detailed descriptions of the
include the fact that it can be costly to carry out program and the various stakeholders’ accounts of
an evaluation on all aspects of a program, and that the program.
important decisions may be made in advance, The strengths of this approach include:
which may ignore the organic nature of programs.
• involving a variety of stakeholder groups,
• recognizing that programs serve people and
Participatory Approach are run by people,
• bringing to light multiple accounts of the
The participatory approach emphasizes the for-
program,
mative purpose of evaluation. Similar to the mana-
• placing importance on the democratic
gerial approaches in that both types emphasize the
processes and the need for stakeholder
need to provide information for program improve-
dialogue,
ment, the participatory approaches consider the
• considering the complexity of programs, and
information needs of all stakeholder groups rather
• recognizing that one of the contextual elements
than emphasize the information needs of managers.
of evaluations is that different stakeholder
The involvement of all stakeholders is viewed as
groups will have different evaluation questions
essential to the evaluation process in order to gain
and need different information.
multiple perspectives of the program. Of all the
approaches, the participatory approach places Weaknesses associated with this approach in-
the most value on democratic principles, viewing clude the:
the knowledge of those who carry out program ac-
• subjective nature of these evaluations,
tivities (i.e., front end users), clients, and program
• emphasis on qualitative methods causing
supervisors as critical when gathering information
concerns of evaluator bias, and
about a program and determining the merit or
• extensive cost and time associated with quali-
worth of the program.
tative data collection and analysis (Fitzpatrick
Specific examples of this approach include
et al., 2004).
Utilization Focused, Responsive, and Empower-
ment evaluations (Fitzpatrick et al., 2004). Along Participatory evaluations require evaluators who
with multiple perspectives, the inclusion of multiple are skilled at qualitative research practices. Skilled
stakeholders in the evaluation process increases the qualitative researchers are trained in carrying out
2580_Ch07_096-113 16/07/13 2:48 PM Page 104
evaluation studies that will stand up to methodolog- Box 7-1 Steps in the Utilization-Focused
ical criticism, questions concerning validity of the Evaluation Process
evaluation results, and evaluator bias.
• Program/Organizational Readiness Assessment:
Determine if the key players in the organization
Utilization-Focused Approach understand and are interested in U-FE.
• Evaluator Readiness and Capability Assessment:
The utilization-focused approach is not a specific
Determine if the evaluator has the skills to conduct
evaluation methodology but rather a process U-FE and is committed to the underlying philosophy.
for including the users in the design of the evalua- • Identification of Primary Intended Users: Find and
tion process and focusing on their intended pur- recruit persons who are credible, knowledgeable,
poses and uses of the evaluation results. The basic teachable, and interested in using the results of the
premise of utilization-focused evaluation (U-FE) evaluation and assess the characteristics of these
is that the results of evaluative processes should be primary intended users.
judged by their utility, usability, and use or actual • Situational Analysis: Identify, understand, and
application of the findings (Patton, 2008). An adapt to situational factors (barriers and supports)
important step in designing utilization-focused that may affect the use of evaluation results.
evaluations is to identify the intended users of the • Identification of Primary Intended Uses: Make de-
cisions about the purposes of the evaluation, what
assessment results and how best to meet the needs
types of data are needed, and how the evaluation
of these users. The goal of U-FE is to generate results will be used.
valid, useful, consistent, and credible information • Focusing the Evaluation: Actively involve users in
that provides data to guide action. U-FE shifts at- identifying evaluation priorities and questions.
tention from the program to be evaluated to the • Evaluation Design: Involve users in decisions
users and stakeholders who will utilize the program about evaluation methods, assessment instru-
evaluation data. U-FE is highly situation- and ments, and responsibilities for data collection.
context-specific, and choices made in developing • Simulation of Use: Create and implement a simu-
evaluation strategies are based on utility. A U-FE lation using fabricated findings to determine the
is grounded in the perspectives, values, and inter- usability of the evaluation results.
ests of program participants and stakeholders and • Data Collection: Involve intended users and other
stakeholders in the data collection process and
can serve a variety of purposes (e.g., formative, sum-
provide interim results as appropriate.
mative, cost-effectiveness) and focus on processes, • Data Analysis: Organize the data to make them un-
impacts, and/or outcomes. U-FE research often uses derstandable and relevant for the users, and facilitate
mixed methods, employing both quantitative and data interpretation among users to increase their
qualitative data collection strategies. According understanding of the implications of the results.
to Patton (2002), “intended users of evaluation • Facilitation of Use: Work with the primary users to
are more likely to use evaluations if they understand identify what they have learned in the evaluation
and feel ownership of the evaluation process and process and to implement the findings in mean-
findings” (para. 4); in this way U-FE is a very par- ingful ways.
ticipatory process. The primary tasks of U-FE are • Meta-evaluation: Determine if the evaluation met
outlined in Box 7-1. the needs of the users and the extent to which the
results were utilized.
In addition to improving the usability of evalu-
ation results, U-FE also appears to impact pro- Data from: Patton, M. (2008) Utilization-focused evaluation
grams and organizations that have participated in (4th ed). Thousand Oaks, CA: Sage.
its process. Participation in the evaluation process
can result in individual and collective changes in
(Patton, 2004). Patton (2007) identifies six types
attitudes, thinking, acting, and organizational cul-
of process use:
ture as a result of learning. These changes, referred
to as process use, may in fact be more long lasting • Infusing evaluative thinking into organizational
than the mere utilization of the evaluation results culture
2580_Ch07_096-113 16/07/13 2:48 PM Page 105
• Enhancing shared understandings within the dream phase, participants imagine themselves and
program their organization functioning at its best and envision
• Supporting and reinforcing the program what might be, developing a broad and holistic vision
intervention of a desirable future. In the design phase, the dream
• Instrumentation effects or vision is operationalized into what should be and
• Increasing participant engagement, self- co-constructed through the development of goals,
determination, and sense of ownership strategies, processes, collaborations, and systems. The
• Program and organizational development destiny phase involves implementing the strategies,
(p. 110). monitoring progress, sustaining the change, and
engaging in new AI dialogues. The 4D process is on-
going, iterative, cyclical, and highly participatory in
Appreciative Inquiry Approach nature (Coghlan, Preskill, & Catsambas, 2003).
An appreciative inquiry (AI) approach to evalua- AI has the potential to contribute to evaluation
tion focuses on organizational and program assets as practice in many ways. Coghlan et al. (2003) pro-
opposed to the identification of problems and vide a list of situations in which AI might be most
deficits. The evaluation process attempts to discover useful. These include:
what is working particularly well and then envision
• “Where there is a fear of or skepticism about
what the future might be like if these positive attrib-
evaluation”
utes were to manifest themselves more frequently.
• “When change needs to be accelerated”
AI is grounded in social constructivism, which re-
• “When dialogue is critical to moving the
flects a belief that there is no single, objective reality,
organization forward”
but that many realities exist based on individuals’
• “When relationships among individuals and
perceptions and shared understandings.
groups have deteriorated and there is a sense
Cooperrider and Whitney (2000) described five
of hopelessness” and
principles for the practice of AI. These include:
• “Where there is a desire to build a community
• The constructivist principle: acceptance that of practice” (p. 19).
multiple realities exist
• The simultaneity principle: inquiry and change
are simultaneous and therefore inquiry is The Process of Planning
intervention and Conducting Evaluations
• The poetic principle: an organization or pro-
gram is continuously authoring its own story Planning an evaluation is best done prior to pro-
and can take the plot line in any direction at gram implementation. The creation of an evaluation
any time plan involves:
• The anticipatory principle: the image an or- • identifying stakeholders
ganization or program has about its future • developing evaluation questions
guides its current actions • determining data needs, and
• The positive principle: by focusing on positive • choosing evaluation methods and instruments.
experiences, participants become more moti-
vated, inspired, and engaged.
Identifying Stakeholders
The most common method for conducting AI
Stakeholders may include:
is referred to as the 4D Model (Discovery, Dream,
Design, and Destiny). The discovery phase of the (a) persons having authority over the program,
process involves participants sharing stories about such as funders and advisory boards,
their peak experiences and appreciating what is cur- (b) persons having responsibility or oversight
rently good about the program or organization. Out for the operations of the program, such as
of these stories, key themes are identified. In the program managers and administrators,
2580_Ch07_096-113 16/07/13 2:48 PM Page 106
(c)persons who benefit from the program, organize evaluation activities. A basic logic model
including program participants and their was previously illustrated in Figure 7.1.
families, Rossi et al. (2004) identify three types of logic
(d) persons who may be disadvantaged by the models: impact theory, service utilization, and or-
program in some way, and ganizational processes. Impact theory logic models
(e) members of the general public who may visually display the change processes produced
have a direct or indirect interest in the by the program. Construction of impact models
outcomes of evaluation. includes the identification of program goals,
objectives, inputs, and outputs, as well as the
Involving stakeholders in the evaluation process
primary, secondary, and tertiary outcomes of the
“is presumed to enhance the design and implemen-
program. Once identified, the evaluator works
tation of evaluations and the use of evaluation re-
with the stakeholders to construct a model that
sults in decision-making” (Bryson et al., 2011, p. 1).
represents the process of how program activities
Failure to incorporate the interests and needs of
work to produce the intended change. Emphasis
stakeholders in the evaluation process frequently
is placed on illustrating the causal links between
leads to useless findings and other poor outcomes.
activities and outcomes. Activities typically do not
However, in order to make stakeholder participa-
provide direct links to outcomes; instead, activities
tion practical, decisions must be made about which
often address some condition associated with the
stakeholders will be the primary users of the evalu-
problem or need (Rossi et al., 2004). Also, models
ation findings. Identifying the stakeholders who
can form virtuous cycles (Rogers, 2000) with some
should be involved in the evaluation requires knowl-
outcomes serving not only as effects but also as
edge about:
causes to future outcomes.
• who cares about the program, Service utilization logic models show the move-
• who has potential influence over the program, ment of clients through a program. These models
• who has resources to support the program, often take on the appearance of a flowchart that rep-
• who will use the evaluation findings, and resents the pathway of clients as they progress
• how they will use the findings. through the program. The models also show the
activities, events, outcomes, and decision points
Stakeholders should have a high level of interest
from the clients’ perspective.
in the outcome of the evaluation and substantial
Organizational processes logic models are con-
power to affect change. Not all stakeholders will par-
structed to display the links between organizational
ticipate equally, some may only desire information,
resources (e.g., financial, personnel, material) and
some may want to be consulted, others will be in-
the associated program activities, events, and out-
volved, and a few will collaborate as decision makers
comes. These models represent the resources needed
(Bryson et al., 2011).
to operate a program as it is described in the impact
theory and the service utilization logic models. In
Developing Evaluation Questions addition, organizational processes logic models also
The most difficult task in evaluation is often the de- provide an illustration of how auxiliary program
velopment of clear, useful, and researchable evalua- activities, such as fund-raising, political liaison,
tion questions. The information needs of program marketing, and personnel management, work to
developers and managers change with varying support the function of the program.
organizational and environmental conditions. Re-
sources may limit the scope of the evaluation, and
therefore evaluation questions must be chosen care- Determining Data Needs
fully and prioritized. Resource constraints may Evaluation questions influence the research design,
also impact evaluation design, data collection strate- types of impact, outcome data to be collected, and
gies, and scope of the inquiry. Logic models can be data collection methods. Short-term impact mea-
used to identify program components and out- sures often assess knowledge, attitudes, skills, and
comes, to generate evaluation questions, and to opinions. Intermediate-term impact measures target
2580_Ch07_096-113 16/07/13 2:48 PM Page 107
behavior change, and longer-term outcome measures methods should be practical, cost-effective, and
address changes in social, economic, and health con- ethical. Typically, evaluation designs fall into two
ditions. In some cases evaluation data will include categories: quantitative designs and qualitative
program attendance and changes in knowledge, designs. These approaches may be combined in
attitudes, values, behaviors, and health outcomes. It a mixed-methods approach either sequentially or
is critical to choose impact and outcome indicators concurrently. Combining the methods can mitigate
that will answer the evaluation questions. Indicators the weaknesses of each.
are observable and measurable milestones toward an
outcome target. According to the American Occu- Quantitative Designs
pational Therapy Association (2008, pp. 662–663), Quantitative approaches to program evaluation gen-
occupational therapy outcome indicators include: erally fall into the three broad categories listed here,
beginning with the least complex.
• Occupational performance
• Adaptation • Non-experimental designs (e.g., cross-sectional
• Health and wellness designs, cohort studies) involve participants ser-
• Participation ving as their own controls. Evaluation measures
• Prevention are gathered on participants before and after the
• Quality of life intervention program.
• Role competence • Quasi-experimental designs (e.g., nonequiv-
• Self-advocacy alent control group design, interrupted time-
• Occupational justice series design) compare two groups. The group
that is receiving the intervention is matched
In addition to determining what types of data are
to a population that is similar demographi-
needed for the evaluation, the timing of data collec-
cally but is not receiving the program. Data
tion is a consideration. Typically, baseline or pre-test
are collected from both groups at the same
data is collected prior to program implementation,
time points and compared.
post-test data is collected immediately after the in-
• Experimental designs (e.g., randomized
tervention has been completed, and follow-up data
controlled trial) randomly assign people to
is collected at intervals following the post-test in
two groups. One group receives an interven-
order to determine if the program effects are lasting.
tion and the other does not. Data are collected
Figure 7.2 provides an outline for developing the
from both groups at the same time points and
data collection aspect of the evaluation plan.
compared (Crosby, DiClemente, & Salazar,
2006; Shadish, Cook, & Campbell, 2002).
Choosing Evaluation Methods Impact evaluations typically consist of studies that
Evaluation methods should be appropriate for the involve either experimental or quasi-experimental de-
evaluation questions being asked. The proposed signs. These types of evaluations resemble traditional
Outcome Indicator(s) Source of Data Method of Data When Data will Person
(program Collection be Collected Responsible
participants, (survey, (baseline, post- for Collecting
records, census, interviews, intervention, Data
etc.) observation, follow-up with
etc.) dates)
1.
2.
3.
Fig. 7•2 Evaluation Data Collection Plan.

2580_Ch07_096-113 16/07/13 2:48 PM Page 108
quantitative research studies that test hypotheses and easily quantifiable. It is especially useful when the
attempt to control for confounding variables that evaluator wants to understand not only what
might arise as alternative explanations for the cause- worked but also why it worked. Qualitative meth-
and-effect relationships. Because evaluations occur ods are particularly suited to analysis and interpre-
in the context of the program, evaluators want tation of the contexts within which programs are
to minimize any disruption to the normal operation operating. Qualitative assessment can produce a
of the program when conducting impact evalua- deeper, fuller understanding of the program and its
tions. These types of evaluations can be difficult to effects. This is done by collecting firsthand, direct
design depending on the contextual constraints of observation of naturally occurring situations in nat-
the program. urally occurring settings. Qualitative methods in
Whereas impact evaluations seek to have the most evaluation use an inductive approach to data gath-
rigorous design (i.e., randomized, pretest-posttest ering and interpretation. It is a holistic, naturalistic
control group design), in many instances the ability orientation, searching for themes in the evaluation
to randomly assign clients to control or experimen- data and attempting to understand the lived experi-
tal groups is not possible. Often evaluators are faced ence of program participants. A qualitative approach
with selecting the quasi-experimental design that to evaluation can illuminate what happened, to
will fit best with the program. Most often this whom, and with what outcomes. There are many
involves the use of a nonequivalent group pretest- benefits to qualitative evaluation, such as providing
posttest design. When employing these designs, information about context and meaning.
evaluators must minimize the threats to internal There are many ways to collect qualitative data,
validity that arise from selection bias inherent in including interviews, focus groups, observation, and
this design (Johnson & Christensen, 2008). Most review of documents. If the evaluation seeks to un-
often evaluators will employ matching techniques derstand what the program participants experienced,
or proximity scores as a means of equating the what they believe, or how they feel, then interviews
two groups (Shadish et al., 2002). The main goal are a good data collection strategy. Interviews can be
of these types of research designs is to measure conducted individually face-to-face, over the tele-
treatment effects (Shadish et al., 2002). While phone, online, or with multiple people in a focus
evaluators seek the most stringent designs when group. Semi-structured interviews using open-ended
conducting the impact evaluations, contextual questions tend to produce the most useful informa-
limitations often result in the use of weaker quan- tion. If the evaluation seeks to identify what people
titative designs such as single group pretest-posttest do during given time frames, observation is a good
designs, single group posttest-only designs, and data collection strategy to use.
time-series designs. These designs do not control Observations should be carried out in a variety
for many of the threats to internal validity (Johnson of contexts, across multiple time periods. Recording
& Christensen, 2008), and, as a result, evaluators observation data in field notes is recommended. If
must address the limitations of these designs when the evaluation seeks to understand the mission, his-
reporting program impact. These weaker designs tory, and activities of an organization or agency, then
are better suited for program monitoring because document reviews can be a useful data collection
they tend to measure either outcome levels (the approach. Documents to review may include mis-
measurement of an outcome at a particular time) sion statements, policies and procedures, brochures,
or outcome change (the difference between out- Web site content, and meeting minutes (FRIENDS
comes measured at two different times). National Resource Center for Community-Based
Child Abuse Prevention, 2009).
Qualitative Designs
The purpose of qualitative evaluation is “to capture
the perspectives of program participants, staff and Utilizing Evaluation Results
others associated with the program” (Patton, 2002,
p. 151). A qualitative evaluation approach provides Use refers to how “real people in the real world apply
an in-depth perspective on phenomena that are not evaluation findings and experience the evaluation
2580_Ch07_096-113 16/07/13 2:48 PM Page 109
process” (Patton, 2002, para. 1). There are several One particularly effective method for presenting
types of use, including instrumental, conceptual, evaluation results for community-based programs
process, and symbolic. Instrumental use refers to is the “success story.” A good success story
using evaluation results to inform action. This is the captures the attention of the audience, provides
most common type of use referred to in the evalua- a compelling story, describes specific outcomes,
tion literature. Conceptual use refers to the impact and is based on reliable and valid data. A success
of evaluation processes on decision makers’ thought story consists of four parts: the situation, the re-
processes about a current or future program. Process sponse, the results, and the evidence. The situation
use occurs when cognitive and behavioral changes refers to the problem, concern, or issue that needed
result as a function of participating in the evaluation to be addressed. Describe the situation and its im-
process, and symbolic use is the use of evaluation pact locally. The response refers to the program
data for political gain (Johnson, 1998). characteristics, who participated and benefited,
Rossi et al. (2004) outline several guidelines for and the services provided. The results section of
maximizing the utilization of evaluation results, the success story describes the outcomes, what
including: changed and for whom, and what was learned.
Finally, the evidence component refers to how the
• Evaluation results should be timely and readily
program and its outcomes were evaluated and how
available.
the results are known to be accurate and credible
• Evaluation results should be understandable
(University of Wisconsin-Extension, Cooperative
to stakeholders and decision makers.
Extension, 2009).
• Dissemination plans should be explicit and
part of the evaluation design.
• Utilization of results should be assessed.
Ethical Issues in
Communicating Evaluation Results Community-Based
Evaluation results can and should be disseminated Program Evaluation
in a variety of ways, depending on the information
Appropriately used evaluation approaches in
needs of the audience. Reporting evaluation results
community-based practice can enhance efficacious
serves several purposes, including:
community-centered needs assessments, program
• Providing a basis for further program develop- development, program implementation, and pro-
ment and quality improvement gram evaluation. However, inadequate, misused,
• Generating support for continuing or expand- or incorrectly targeted evaluations can result
ing programs in community alienation, wasted expenditure
• Enhancing public relations, and of limited resources, and missed opportunities
• Demonstrating good stewardship of funds. for enhancing quality of life (Reitz, Pizzi, &
Scaffa, 2010). Poorly developed or implemented
There are typically a number of different audiences
program evaluations would be in conflict with
for evaluation findings. These may include: stakehold-
one or more of the profession’s core values and
ers, program staff, program participants, funders,
attitudes, which include “altruism, equality, free-
collaborating agencies, professional organizations,
dom, justice, dignity, truth, and prudence”
elected officials, and business groups, among others.
(AOTA, 2010, p. S17). In addition, the principles
The presentation of evaluation results should include
from the AOTA Occupational Therapy Code
the focus of the evaluation, the processes used, and the
of Ethics and Ethics Standards (2010) apply to
strengths and limitations of the evaluation. Dissemi-
all aspects of the program evaluation process,
nation involves communicating the procedures and
including:
lessons learned from an evaluation in a timely and
unbiased way. Communication may take the form of • Selecting the appropriate evaluation ap-
verbal presentations, written reports, or visuals in the proach and outcome measures (Principle 1
form of graphics or photographs. Beneficence)
2580_Ch07_096-113 16/07/13 2:48 PM Page 110
• Obtaining IRB approval from all applicable • Reporting accurate results to participants and
institutions (Principle 1 Beneficence, stakeholders in a timely manner (Principle 1
Principle 3 Autonomy/Confidentiality, Beneficence, Principle 6 Veracity), and
and Principle 5 Procedural Justice) • Securing evaluation materials and resulting
• Avoiding conflicts of interest (Principle 1 data (Principle 3 Autonomy/Confidentiality).
Beneficence, Principle 7 Fidelity)
• Acquiring and using current assessments/ In addition to official documents of the American
outcome measures and upholding copyright Occupational Therapy Association (AOTA), groups
laws (Principle 1 Beneficence) such as the Joint Committee on Standards for Edu-
• Ensuring compliance with established cational Evaluation can offer guidance regarding the
program evaluation protocol and appropriate use of evaluation (Yarbrough, Shulha,
anonymity/confidentiality as appropriate Hopson, & Caruthers, 2011). In Table 7-1, portions
(Principle 1 Beneficence, Principle 3 of the program evaluation standards developed
Autonomy/Confidentiality) by this group are compared to the AOTA Occupa-
• Training program staff and evaluators to en- tional Therapy Code of Ethics and Ethics Standards
sure competency (Principle 2 Nonmaleficence) (2010) and the NBCOT Candidate/Certificant Code
Table 7-1 Program Evaluation Standards

Occupational Therapy Code of NBCOT Code
Program Evaluation Standards Ethics and Ethics Standards (2010) of Conduct (2010)
Utility Standards
U1-Evaluator Credibility Beneficence (1D, 1E,1G) Accuracy & Veracity (3)
Procedural Justice (5E, 5F, 5G) Procedural Justice (4)
Veracity (6A) Nonmaleficence (6)
U2-Attention to Stakeholders Beneficence (1B) Nonmaleficence (6)
Social Justice
U3-Negotiated Purposes Beneficence (1B, 1C) Accuracy & Veracity (3)
U4-Explicit Values Beneficence (1B) Nonmaleficence (6)
Autonomy/Confidentiality (3A)
U5-Relevant Information Beneficence (1B, 1C) Nonmaleficence (6)
U6-Meaningful Processes & Products Beneficence (1B) Nonmaleficence (6)
U7-Timely & Appropriate Beneficence (1A, 1B, 1C) Accuracy & Veracity (3)
Communicating & Reporting Veracity Nonmaleficence (6)
U8-Concern for Consequences & Beneficence (1D) Nonmaleficence (6)
Influence Nonmaleficence (2A)
Feasibility Standards
F1-Project Management Beneficence (1F, 1N) Accuracy & Veracity (3)
F2-Practical Procedures Beneficence (1B, 1C) Accuracy & Veracity (3)
Procedural Justice (5N)
Fidelity (7A)
F3-Contextual Viability Social Justice (4D, 4F) Accuracy & Veracity (3)
Nonmaleficence (6)
F4-Resource Use Procedural Justice (5K) Procedural Justice (4)
Fidelity (7H)
2580_Ch07_096-113 16/07/13 2:48 PM Page 111
Table 7-1 Program Evaluation Standards—cont’d

Occupational Therapy Code of NBCOT Code
Program Evaluation Standards Ethics and Ethics Standards (2010) of Conduct (2010)
Propriety Standards
P1-Responsive & Inclusive Orientation Autonomy/Confidentiality (3A) Nonmaleficence (6)
Social Justice (4C, 4F)
P2-Formal Agreements Autonomy/Confidentiality (3J) Accuracy & Veracity (3)
Social Justice (4F) Procedural Justice (4)
Procedural Justice (5I)
P3-Human Rights & Respect Nonmaleficence (2A, 2C, 2I, 2J) Procedural Justice (4)
Autonomy/Confidentiality (3B, 3G, 3H) Nonmaleficence (6)
Social Justice (4D)
Fidelity (7A)
P4-Clarity & Fairness Autonomy/Confidentiality (3B) Accuracy & Veracity (3)
Social Justice (4D)
Veracity (6A)
P5-Transparency & Disclosure Autonomy/Confidentiality (3G, 3H) Accuracy & Veracity (3)
Veracity (6A) Procedural Justice
P6-Conflicts of Interest Beneficence Accuracy & Veracity (3)
Fidelity (7E, 7F)
P7-Fiscal Responsibility Procedural Justice (5K) Accuracy & Veracity (3)
Accuracy Standards
A1-Justified Conclusions & Decisions Procedural Justice (5P) Accuracy & Veracity (3)
Veracity
A2-Valid Information Veracity Accuracy & Veracity (3)
A3-Reliable Information Procedural Justice (5P) Accuracy & Veracity (3)
Veracity
A4-Explicit Program & Context Procedural Justice (5P) Accuracy & Veracity (3)
Descriptions Veracity
A5-Information Management Veracity (6A) Accuracy & Veracity (3)
A6-Sound Designs & Analyses Beneficence (1D, 1F, 1G) Accuracy & Veracity (3)
A7-Explicit Evaluation Reasoning Beneficence (1G) Nonmaleficence (6)
Veracity
A8-Communication & Reporting Social Justice (4D) Accuracy & Veracity (3)
Veracity (6)
Evaluation Accountability Standards
E1-Evaluation Documentation Beneficence (1F) Accuracy & Veracity (3)
Veracity (6A, 6C, 6D)
E2-Internal Metaevaluation Beneficence (1F, 1N) Accuracy & Veracity (3)
E3-External Metaevaluation Beneficence (1N)
Procedural Justice (5B)
Data from: The standards in column 1 are from “The Program Evaluation Standards: A Guide for Evaluators
and Evaluation Users, 3rd ed.,” by D. B. Yarbrough, L. M. Shulha, R. K. Hopson, & F. A. Caruthers, 2011,
Washington, DC: Sage. Copyright 2011 by Joint Committee on Standards for Educational Evaluation.
The principles in column 2 are from “Occupational Therapy Code of Ethics and Ethics Standards,” by the
Ethics Commission of the American Occupational Therapy Association, 2010, American Journal of Occu-
pational Therapy, 64(6), 151–160. Copyright 2010 by the American Occupational Therapy Association.
The principles in column 3 are from the Certification Renewal Handbook 2010 (p. 22), by the National
Board for Certification in Occupational Therapy, 2010, Gaithersburg, MD: Author. Copyright 2010 by
National Board for Certification in Occupational Therapy.
2580_Ch07_096-113 16/07/13 2:48 PM Page 112
of Conduct (2010). As can be seen from this table, make statements concerning the merit, worth, and
evaluation is complex and open to a variety of possi- value of a program. Evaluations tend to be completed
ble ethical concerns. The terminology used in the for one of two main purposes: formative (i.e., evalu-
AOTA Occupational Therapy Code of Ethics and ations to inform decisions or activities related to
Ethics Standards is used to describe the content of program improvement) or summative (i.e., evalua-
the NBCOT principles so that parallels can be seen tions to inform decisions or activities related to the
between these two documents. expansion, termination, or funding of programs).
In community-based practice, the client can be Evaluations often have one of five main areas of
an individual, a portion of a community, or an en- focus: needs assessment, program theory, program
tire community. The same standards that apply implementation, program impact, or program effi-
when evaluating individuals carry over to working ciency. Each focus area provides unique and valuable
with communities. When the client is an entire information regarding the program, although all five
community or portion of a community, such as in are related to program improvement or accountabi-
program development, implementation, and eval- lity. Although these approaches provide good foun-
uation, an additional layer of complexity becomes dational knowledge for planning, all evaluations
evident due to the involvement of people from a should be program-specific and based on important
variety of professional backgrounds and other nu- information, such as: the nature of the program being
merous stakeholders. All stakeholders may not have evaluated, the context of the evaluation, the informa-
the same motives or ethical framework. The AOTA tional needs and intended use of the evaluation results
Occupational Therapy Code of Ethics and Ethics Stan- by stakeholders, programmatic resources, and the
dards (2010) can be used to help support ethical specific evaluation questions.
participation in important projects aimed at
addressing societal needs. Performing due diligence
to ensure all actions taken support community Learning Activities
rights and autonomy is an ethical necessity. 1. Identify and list at least five school or commu-
Whereas it may be relatively simple to match an nity health programs in which you or a family
assessment to an individual, locating an assessment member has participated over the years. Which
or developing an outcome measure that is well of these programs had a program evaluation
suited for a broad array of individuals within a component? Was this program evaluation
program or community can be complicated. For formative or summative in nature?
example, individuals in the community may have 2. How would you improve upon the program
significantly differing reading levels, languages and evaluation process for one of the programs you
language skills, visual acuity, and activity tolerance. have identified? Or, if you do not remember
Any of these differences can make it challenging any of the programs having an evaluation
to select an appropriate measure to be part of an component, describe at least one potential
evaluation approach for use with all program par- summative evaluation strategy.
ticipants or community members. It is essential to 3. Design a formative program evaluation plan
avoid selecting approaches that exclude portions of for a course that you are currently taking.
the community based on a desire to reduce time, 4. You have conducted a backpack awareness
effort, or expense. Program evaluation teams must campaign at a middle school for the past two
be open to using multiple methods in order to pro- semesters. This year you wish to conduct an
vide all program participants or community mem- evaluation in order to gather data to support a
bers with the opportunity for inclusion in program request to the county school board for fund-
development and program evaluation. ing, including a salary for yourself, to imple-
ment a countywide program. You are
concerned about your conflict of interest in
Conclusion gathering the data. How can you ensure that
the data is collected and that you are in com-
Program evaluation uses systematic processes for pliance with the AOTA Occupational Therapy
collecting, analyzing, and interpreting data in order Code of Ethics and Ethics Standards (2010)?
to provide information to program stakeholders and
2580_Ch07_096-113 16/07/13 2:48 PM Page 113
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Chapter 8
Entrepreneurship and Innovation

in Occupational Therapy
Marjorie E. Scaffa, PhD, OTR/L, FAOTA, Michael A. Pizzi, PhD, OTR/L, FAOTA,
and Wendy M. Holmes, PhD, OTR/L
It is time to build a system around your heart. Build a system around your passion . . .go
and build what you know you must build.
—Kiyosaki (1999, p. 129)
Learning Objectives
• Identify the characteristics of entrepreneurs.
• Describe the various aspects of the entrepreneurial process.
• Identify the similarities and differences between intrapreneurship, social entrepreneurship, and business
entrepreneurship.
• Compare and contrast for-profit and non-profit businesses.
• List the steps in developing a small health care business.
• Describe the components of a typical grant proposal.
Key Terms
Business plan Intrapreneur
Contract Marketing
Diffusion Social entrepreneur
Entrepreneur Strategic planning
Environmental scan SWOT analysis
Grant
Introduction roles of occupational therapy practitioners mirror

those of entrepreneurs.
As occupational therapy services expand to diverse The word “entrepreneur” derives from the French
populations and settings, therapists are required entreprendre, to “undertake” (Kuratko & Hodgetts,
to develop new and innovative models of service 1995, p. 4). Commonly, an entrepreneur is de-
delivery. These models may take the form of a new scribed as a person who starts or owns his own
occupational therapy business, private practice, or businesses (Allen, 1999; Bhide, 2000), or as “some-
program developed to meet the needs of a partic- one who undertakes to make things happen” (Kirby,
ular client group or community. A business op- 2004, p. 511) whether within a business or non-
portunity must be recognized and nurtured; profit organization.
establishing a business requires a steadfast vision Being an entrepreneur has been a recognized role
and perseverance. The skills, characteristics, and within the profession for many years. Historically,
114
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Chapter 8 | Entrepreneurship and Innovation in Occupational Therapy 115
the American Occupational Therapy Association The Entrepreneurial Mind-Set

(AOTA) defined an entrepreneur as an occupa-
Bygrave (1997) discussed the contribution of
tional therapy practitioner who is self-employed on
personal attributes to the development of an entre-
a part- or full-time basis (AOTA, 1993). More cur-
preneur. He suggested certain personality charac-
rently, the 2010 Occupational Therapy Compensation
teristics, such as decisiveness, determination, and
and Workforce Study (AOTA, 2010) provides infor-
a desire for control, are commonly associated with
mation about occupational therapy practitioners
entrepreneurs. However, while certain traits such
who identify themselves as self-employed or con-
as vision, perseverance, and energy are deemed as
tractors. Approximately 27.4% of the respondents
important for success, Cunningham and Lischeron
were self-employed on a part- or full-time basis
(1991) report, “there is little evidence to suggest
(AOTA, 2010). Over time, the percentage of indi-
that certain traits are associated with successful
viduals who were self-employed part-time increased
entrepreneurs” (p. 48).
at a greater rate than the percentage of those who
Despite the differing opinions, the suggestion that
were self-employed full-time. The study results in-
certain personality traits or characteristics are typical
dicate that self-employment levels for occupational
of entrepreneurs and markedly different from non-
therapists (28.1%) and occupational therapy assis-
entrepreneurs is a premise basic to the psychological
tants (23.1%) are at the highest rates since 1993.
(Cunningham & Lischeron, 1991; Kirby, 2004) or
Most of the respondents who classified themselves
the trait schools of thought about entrepreneurs
as self-employed were independent contractors,
(Kuratko & Hodgetts, 1995). Particularly, the per-
agency contractors, or owners/co-owners of a private
sonal values of honesty and responsibility, a risk-taking
practice (AOTA, 2010).
propensity, creativity, locus of control, the desire for
Foto (1998) described an occupational therapy
autonomy, and the need for achievement, among
entrepreneur as one who is “actively involved in
others, are all variously considered to be fundamental
organizing, launching, and operating not only
to successful entrepreneurship (Cunningham &
new models of practice, but also profit-making
Lischeron, 1991; McClelland, 1961). More specifi-
businesses” (p. 765). Others in the profession
cally, Schmit, Kihm, and Robie (2000) developed a
described entrepreneurs as practitioners who pos-
personality assessment that measures five major
sess the ability to identify and respond to new
personality characteristics thought to be integral to
opportunities that are innovative (Loukas, 2000).
entrepreneurs: openness, extroversion, agreeableness,
No matter the definition, Pazell and Jaffe (2003)
conscientiousness, and neuroticism.
stated, “Industry leaders admit that occupational
In brief, observations of entrepreneurs point to
therapy practitioners who are functioning as
the identification of multiple characteristics com-
entrepreneurs are a poorly researched and ill-
mon to their mind-set and motivation. However
represented group” (p. 223).
controversial this approach is, it is now thought that
Research on entrepreneurship, intrapreneurship,
these characteristics can be inherent to the individ-
and social entrepreneurship, and application to
ual or acquired through study and practice.
occupational therapy, will be described in this
chapter. In addition, basic steps in starting for-profit
and non-profit businesses, marketing, strategic plan- The Entrepreneurial Process
ning, and grant writing will be discussed. A second perspective broadly addresses the activities
and events of entrepreneurship. The entrepreneurial
process has been well documented and is typically ra-
Research on Entrepreneurs tional, controlled, and systematic. From the economic
perspective, an entrepreneur notices or identifies a new
As an evolving field of study, one that Low describes opportunity, gathers all relevant information pertinent
as “in its adolescence” (2001, p. 17), the literature to developing the opportunity, systematically evaluates
presents and discusses entrepreneurship from a the alternatives, and finally chooses the option that
variety of perspectives, several of which will be dis- maximizes economic viability and success (Corner-
cussed here. Doyle & Ho, 2010).
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In the 1980s, Gartner (1985, 1989) and others Lim (2002) studied how specific cognitive factors
proposed a change in orientation in research away affect the assessment of a possible entrepreneurial
from the entrepreneur and his or her intentions opportunity. The authors surveyed the founders of
(Carland, Hoy, Boulton, & Carland, 1984; medium-sized companies to gather information
Carland, Hoy, & Carland, 1988) to a focus on the about how the individuals perceived the risk of an
complexity of the organization or venture creation. opportunity in relationship to the cognitive con-
In support of this shift, Gartner stated, “if we are to structs of overconfidence, belief in the law of small
understand the phenomenon of entrepreneurship in numbers, planning fallacy, and illusion of control.
order to encourage its growth, then we need to un- The study results indicated that the entrepreneurs’
derstand the process by which new organizations are evaluation of an opportunity and its associated risks
created” (1989, p. 62). A case in point is Bygrave’s was influenced primarily by the individual’s cogni-
(1989) entrepreneurial events model. This model tive beliefs in small numbers and the illusion of con-
considers personal, environmental, social, and orga- trol. Consequently, the study participants acted after
nizational elements influencing the entrepreneurial considering just a few similar cases or examples or
process, beginning with the generation of the inno- relied on minimal valid information to draw con-
vative idea to the implementation and growth of the clusions for action. As well, the participants demon-
entrepreneurial venture. Further, the model’s author strated a propensity to believe their skills and
acknowledges a triggering event, such as a change in abilities could control most situations and out-
employment or personal circumstances, as a signifi- comes, thereby underestimating the risk associated
cant ingredient to the innovative idea or opportu- with the opportunity.
nity becoming a reality. More recently, a second model for the entrepre-
Understanding the relationship between the re- neurial process has been recognized, that of effectu-
quired skills and successful behaviors of entrepre- ation. A key premise to this viewpoint is that
neurs to new development and successful innovation entrepreneurs begin with “a set of means” (Corner-
is integral to the entrepreneurial process. The entre- Doyle & Ho, 2010, p. 4), their skills, knowledge,
preneur requires skills to identify the need for a new and resources, and consider how those means might
product or unmet service and to recognize the situ- address a particular issue or need. As such, this view
ation as an available opportunity for development. of the process is conducive to addressing both social
Once the entrepreneur chooses to respond to the op- and economic opportunities. Opportunities and
portunity, a plan to address the identified gap is cre- outcomes can then be shaped, adapted, and influ-
ated. Often, entrepreneurs approach this phase with enced by the passion and vision of the entrepreneur
enthusiasm or a strong sense of purpose (Farrell, rather than waiting to be identified or recognized.
2001; Smilor & Sexton, 1996). Along the way, the Beyond opportunity recognition and the entrepre-
entrepreneur needs to communicate his or her vision neur’s orientation to the promising prospect, external
to gain the necessary resources and support for resources available to facilitate the development of
launching and growing the new enterprise from a new organizations or ventures are also crucial. Specht
start-up endeavor to a stable business (Bhide, 2000). (1993) categorized these resources into social, eco-
Consequently, the ability to tolerate uncertainty, to nomic, political, infrastructure development, and
recognize the unexpected as potential opportunities, market emergence factors, all of which influence the
to communicate effectively, and to navigate change potential success of the entrepreneurial event.
are thought to be critical to the entrepreneurial
process (Bhide, 2000; Drucker, 1985; Smilor
& Sexton, 1996). Intrapreneurship
Opportunity recognition is an important element A third perspective of entrepreneurship further
of the entrepreneurial process. Successful entrepre- explores the entrepreneurial process within or-
neurs or entrepreneurial organizations not only rec- ganizations, commonly termed intrapreneurship
ognize opportunities but also capably take advantage (Cunningham & Lischeron, 1991; Pinchot, 1985).
of them to reach their goals. To better understand Intrapreneurship focuses on the innovation, creati-
how entrepreneurs make decisions, Keh, Foo, and vity, and resulting behaviors within organizations
2580_Ch08_114-132 16/07/13 2:49 PM Page 117
rather than on the individual entrepreneur. Pazell may advocate for social changes that will make a pos-
and Jaffe (2003) defined an intrapreneur as an in- itive difference to the community or the organization’s
dividual “who harnesses the resources within an or- clients (Prabhu, 1999). Commonly, social entrepre-
ganization to develop, improve, promote, extend, neurship may also involve for-profit ventures within
or enhance a new or existing program” (p. 223). social service or not-for-profit organizations to assist
Intrapreneurship is not found in all organizations in achieving the organization’s mission and sustaining
or corporations. Cunningham and Lischeron its service base.
(1991) reported that some organizations are more Researchers purport that social entrepreneurs
successful in creating an environment that allows share common characteristics and behaviors with
its members to act in an entrepreneurial fashion, business entrepreneurs. Nga and Shamuganathan
while others lose employees to their own ventures. (2010) studied the characteristics that influence the
“The success of the intrapraneurial model seems to intentions of social entrepreneurs in relationship to
depend on the abilities of the organizational level the five major traits of entrepreneurs proposed by
participants to exploit entrepreneurial opportuni- Schmit, Kihm, and Robie (2000). They found that
ties” and whether managers “see the need to exploit agreeableness, openness, and conscientiousness had
these opportunities” (p. 54). More specifically, a positive influence on all aspects of the social en-
Kuratko and Hodgetts (1995) advised that inno- trepreneurship endeavor, further suggesting the
vation within organizations requires the develop- spirit of social entrepreneurship may be promoted
ment of explicit goals, systems for feedback and among “future would-be” entrepreneurs.
reinforcement, an organizational emphasis on Barendsen and Gardner (2004) studied a group
personal responsibility, and a process for linking of social entrepreneurs in an effort to identify if and
rewards to results (p. 121). how they are different from business entrepreneurs
and service professionals. The authors found the
social entrepreneurs’ personal histories and belief
Social Entrepreneurship systems about their obligation, and ability to create
The vast majority of entrepreneurship research positive change in society, were atypical. However,
focuses on the entrepreneur and the profit-making the greatest ongoing challenge faced by the entre-
venture or business. This wealth of information preneurs was carrying out their vision of the needed
applies to those individuals providing innovative changes while meeting the financial obligations and
services under the auspices of for-profit companies realities of keeping their organizations solvent. This
or businesses. However, many professionals provide challenge appeared to be more demanding than for
services for community-based, not-for-profit, vol- either the business entrepreneurs or service profes-
untary, or service organizations. The entrepreneurial sionals participating in the study.
process in these settings generated a new direction Spear (2006) conducted an exploratory study of
of research focusing on the social entrepreneur and six small to medium-sized enterprises to further the
the social entrepreneurial process. research on social entrepreneurship. Among the six
The mission of social entrepreneurs differs from firms, entrepreneurship was collectively practiced
that of business entrepreneurs and influences the en- and distributed among employee teams along with
trepreneurial process as a result (Mort, Weerawardena, external stakeholders such as customers rather than
& Carnegia, 2002). “Social entrepreneurship leads to by one champion individual. The motivation for
the establishment of new social organizations or not- business decisions was varied but included ideolog-
for-profits and the continued innovation in existing ical aspects, and decisions were negotiated and
ones” (p. 79). Much as the mission of an entrepreneur “mediated through professionals, advisers, or sup-
with a for-profit focus is to provide a superior product, port organizations” (p. 408). The author’s findings
service, or value to its customers, the mission of a offer a broader, collective view about social entre-
social entrepreneur may be to provide superior value preneurship, suggesting multiple models of social
or services to his or her clients or to find “effective entrepreneurship are common. In summary, social
ways to harness commercial forces for social good” entrepreneurship appears to be a viable role within
(Dees, 2000, p. 67). Similarly, a social entrepreneur small and large organizations or businesses.
2580_Ch08_114-132 16/07/13 2:49 PM Page 118
Corner-Doyle and Ho (2010) studied the entre- Consequently, the entrepreneurial process is inextri-
preneurial process of social entrepreneurs, in partic- cably linked to the process of innovation. Van de
ular the stage of opportunity recognition. Four Ven, Polley, Garud, and Venkataraman (1999) de-
patterns emerged among the social entrepreneurs scribe this progression as a journey that “from initi-
studied. First, the pattern of opportunity develop- ation to implementation or termination can vary
ment was multifaceted, complex, and did not follow greatly in number, duration, and complexity. What-
the typical linear steps of commercial entrepreneur ever its scope, the journey is an exploration into the
endeavors. Second, the opportunity benefited from unknown process by which novelty emerges” (p. 3).
the collective efforts of multiple individuals with The study of how individuals learn about, accept,
skills, talent, and a passion for a social issue. Third, and implement new, innovative ideas or practices in-
the experience each of the individuals brought to the herently includes the examination of the process by
endeavor affected the success and outcome. Finally, which changes are diffused.
the fourth pattern described a moment of “spark” Rogers (2003) defined diffusion as “the process
(p. 655) or inspiration that related to but was separate by which an innovation is communicated through
from the recognition of an opportunity. These find- certain channels over time among the members of a
ings suggest the social entrepreneurship process may social system” (p. 35). Diffusion research examines
be more collective, fluid, and spontaneous in nature. the multiple facets of this process, such as the rate
Research leading to a better understanding of and consequences of adoption by others and the
the relationship between the entrepreneur and the factors that affect the adoption in a variety of social
entrepreneurial process will ultimately influence and cultural settings. The four main elements of the
entrepreneur training and educational programs. diffusion process Rogers identified include:
Drucker (1985) described innovation as “the spe-
1. the innovation
cific tool of entrepreneurs, the means by which they
2. the communication channels
exploit change as an opportunity for a different busi-
3. time
ness or a different service. It is capable of being pre-
4. social system.
sented as a discipline, capable of being learned,
capable of being practiced” (p. 19). Hundreds of The characteristics of the innovative idea, product,
how-to books, courses, and academic programs are or service itself influence how individuals perceive it
available to develop the knowledge and skills for en- when considering its adoption. Customarily, indi-
trepreneurism. However, Kirby (2004) argued that viduals weigh the perceived complexity, usability,
all too often, programs “educate ‘about’ entrepre- and advantages of an innovation before trial. How-
neurship and enterprise rather than ‘for’ entrepre- ever, a common development during the trial and
neurship” (p. 514). He emphasized that course adoption period is the re-invention or modification
content and learning activities need to capitalize on of the innovation to better suit the individual’s pur-
the learner’s entrepreneurial attributes and creative poses, frequently contributing to the sustainability
ways of thinking and behaving, in addition to teach- of the innovation (Rogers, 2003, p. 183). The com-
ing the principles and practices of entrepreneurship. munication process and channels by which persons
Applying the entrepreneurial process, one or more learn about an innovation vary widely and frequently
individuals sharing a common ideology can be a include the mass media and the Internet. However,
powerful force for positive change within an orga- research demonstrates the power of interpersonal
nization or community. communication between individuals with similar in-
terests and values as equally important to successful
diffusion.
Entrepreneurship Next, the element of time considers the speed by
and Innovation which the decision to adopt occurs, along with the
characteristics of the persons who adopt the inno-
Among the multiple skills required of an entrepre- vation. Rogers (2003) classified these individuals
neur, the ability to effectively create, transform, and as innovators, early adopters, early majority, late
promote a new venture or service is critical to success. majority, and laggards (p. 22), depending on when
2580_Ch08_114-132 16/07/13 2:49 PM Page 119
each group embraces the innovation. Rogers (2003) of occupational therapy as preparatory skill and
suggested that innovativeness is the cornerstone of knowledge. A qualitative analysis was conducted of
the diffusion process and associated certain charac- the interview content, and four general themes
teristics with each of the adopter categories. “The emerged:
salient value of the innovator is venturesomeness,
1. identification of trends,
due to a desire for the rash, the daring, and the
2. characteristics of effective entrepreneurs,
risky” (p. 283). In contrast, the early adopters are
3. the importance of research, skill building,
more conservative than innovators and yet serve as
and planning, and
leaders and role models by embracing the innova-
4. the benefits and barriers involved in starting
tion. “In one sense, early adopters put their stamp
a new business.
of approval on a new idea by adopting it” (p. 283).
Occupational therapy entrepreneurs meet the
definitions of innovators and early adopters as pro- Identification of Trends
posed by Rogers (2003) or of change agents. As
While the entrepreneurs approached their busi-
change agents, occupational therapists frequently
nesses from different angles, networking within
promote innovative social changes for the benefit
and outside of occupational therapy was important
of their clients or service systems. Zaltman and
to identify trends. Reading literature related to
Duncan (1977) suggested, “One of the basic func-
each of their business ideas also was a means of
tions performed by a change agent is to establish a
identifying trends. Each recognized that by follow-
link between a perceived need of a client system and
ing trends and developing new knowledge in their
a possible means of satisfying that need” (p. 187).
area of interest, they could best meet community
Early adopters also function as change agents and,
needs and expand their businesses to include a
in so doing, demonstrate effective communication
wide array of customers. One entrepreneur stated,
of the vision and the ability to motivate and influ-
“I have always been a person who followed the
ence others; both entrepreneurs and leaders share
trends to obtain ideas for how the world works,
similar attributes.
what people were following and how that trans-
lated for the profession of occupational therapy.
Occupational Therapy That, combined with my personal history (living
in a family with chronic disability), provided cre-
Entrepreneurship ative ideas for developing new and innovative proj-
ects” (M. Pizzi, personal communication).
The delivery of entrepreneurial occupational therapy
services often requires the ability to identify an op-
portunity and address an unmet need through new Characteristics of Effective
practice methods (Fazio, 2001; Jacobs, 2002). Entrepreneurs
Alternatively, occupational therapy practitioners
The characteristics of entrepreneurs derived from
may already possess knowledge and skills that upon
the interviews varied widely; however, there were
self-reflection are suitable to addressing a particular
five qualities of an entrepreneur that all interviewees
cause or social need within their communities. They
stated in different forms. These include:
may turn their talents and resources to developing
an innovative service that best addresses an identi- 1. Be visionary and future oriented.
fied social need (Corner-Doyle & Ho, 2010). One of the entrepreneurs stated: “I stayed
Four occupational therapy entrepreneurs were attuned to shifting markets and trends by
asked seven basic questions about their businesses. reading and networking with a diverse array
The practices of each of the entrepreneurs were very of individuals from different professions. I re-
different from one another and included wellness alized that there was an opportunity to use my
coaching, ergonomics, a mental health practice, and skills and expertise in ergonomics to develop
a community health non-profit organization. All a consulting practice in this area” (K. Jacobs,
of the practices were innovative and used principles personal communication).
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2. Maintain optimism. One entrepreneur stated, “Problems will occur

The entrepreneurs agreed that to make a if you are not being willing to adapt to changing
business succeed, one must have a “can-do” at- situations; it is important to continue to work
titude and spirit. Pushing through barriers and on your practice and to always launch new
obstacles is part of entrepreneurship, and having products and ideas” (L. Learnard, personal
the right person-business-attitude fit is vital to communication).
establishing a business that works for you. One
entrepreneur stated that it is “the ability and
confidence to say yes I can do that then figure Importance of Research, Skill
out how to do it well [furthers your business]” Building, and Planning
(L. Learnard, personal communication). An- This theme centered on developing a business plan
other entrepreneur takes her can-do attitude and doing the research necessary for a successful
from Goethe, “Whatever you can do, or dream, business. Unlike traditional occupational therapy
you can begin it,” and the Nike slogan, “Just do practice, starting a business requires other skills that
it” (K. Jacobs, personal communication). often are not in the skill set of practitioners. Taking
3. Be a risk-taker. the time to develop this skill set will enable one to
All of the entrepreneurs are risk-takers, but enhance the likelihood of developing exactly what it
calculated risk-takers. They weren’t afraid to is one envisions. Business plans were created by two
begin something for which they had great pas- of the entrepreneurs, while a third developed a strate-
sion because of some obstacles or perceived bar- gic plan and another developed community relation-
riers. One of the entrepreneurs stated it ships to disseminate information about the business
concisely by saying, “If it feels right to YOU, to have consumers purchase the products being
and is part of the vision for who YOU are in the offered. Three of the four entrepreneurs engage in
world, both personally and professionally, then fee-for-service payment, meaning that an agreement
go for it!” (M. Pizzi, personal communication). is reached for a fee for the service/product, some-
4. Take advantage of opportunities. times a written contract is developed, and payment
Being open to seeing opportunities is the cor- is in the form of cash after the service/product is de-
nerstone to a successful business. Communicat- livered. Several community resources were identified
ing effectively, networking, and approaching that could assist with research, skill-building, and
people and situations with your ideas can ex- planning. These include the Small Business Admin-
pand your business. The entrepreneurs view the istration (SBA), the Chamber of Commerce, busi-
possibilities in every situation and with every ness and management courses offered by local
person they meet as potential business. One en- colleges, and support groups for new entrepreneurs.
trepreneur stated that in order to take advantage
of opportunities, an entrepreneur needs to “step
outside of the traditional occupational therapy Benefits and Barriers to Starting
practice arenas and take advantage of opportu- a New Business
nities that span across professional boundaries”
In addition, the entrepreneurs described the benefits
(M. Scaffa, personal communication).
and obstacles involved in starting one’s own business.
5. Be persistent.
These are described in Table 8-1.
Barriers and obstacles can occur daily with a
new business. Persistence in strategically placing
your ideas in the marketplace, networking, and
communicating, while at the same time under- Starting a New Business:
standing that everything takes time, can help
your business grow. Not allowing negativity to
The Basics
alter your vision and being persistent about hav- There are many advantages to starting one’s own
ing others recognize the value of your product business, but not all occupational therapists have en-
are important factors in business expansion. trepreneurial characteristics and most have little, if
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Table 8-1 Benefits and Obstacles in Starting a Business

Benefits Obstacles
Autonomy; taking control of your business future Limited resources (primarily financial)
The challenge (to create something meaningful Limited time (to dedicate to the business; feeling
that contributes to individuals and society) pulled in many directions)
Focus on creating value that contributes to Lack of vision for the business and its growth
improving quality of life (sometimes feeling overwhelmed and subse-
quently unwilling to move forward)
Feeling good about what you do and the process Trying to be all things to all people and being
of doing it unable to delegate
Financial rewards (with yourself in control of making Unwilling to adapt to changes in trends, business
that happen) needs, and personnel needs
any, training in business. Therefore, it is critical to source of revenue. For-profit businesses generate in-
identify and utilize experts knowledgeable in busi- come through the sales of products or services. Non-
ness, accounting, and law. If the business will be profit businesses also can sell products and services,
marketed as occupational therapy, the services pro- but they also are allowed to solicit donations and
vided should conform to the legal scope of practice apply for grants from the government and private
in the licensure law of the state in which the business foundations (Fritschner, 2006).
will operate (Glennon, 2007). The legal structures also may be different. A
Types of businesses and legal structures are highly for-profit business can be a sole proprietorship,
variable. It is important to determine the best orga- partnership, limited liability company (LLC), or
nizational structure for the unique needs of one’s corporation. A non-profit can never be a sole pro-
business. Starting a business can be a daunting prietorship but can be set up as an LLC, corpora-
process. It is critical to understand all aspects of the tion, or trust, depending on state laws. For-profit
business in as much detail as possible. The aim of companies pay federal taxes, state and local in-
this chapter is not to provide the reader with a come taxes, sales taxes, property taxes, and em-
definitive strategy for starting a business, as there are ployment taxes on employees. Non-profits are
other excellent resources for this purpose. However, often referred to as tax-exempt because they do
some general principles to consider when embarking not pay federal taxes and may also be exempt from
on a business venture will be presented. some state taxes depending on the laws in each
state. However, non-profit companies must pay
employment taxes on employees.
For-Profit or Non-Profit? In for-profit businesses, profits are usually dis-
The first decision to be made in starting a business is tributed to the owners or shareholders in the form
to determine whether it will be a for-profit or non- of dividends. Non-profit businesses can “make a
profit organization. There are many differences be- profit,” meaning they can accumulate earnings in
tween these two types, and each has unique benefits excess of their expenses. However, these “profits”
and liabilities. First, the purposes are usually differ- must be put back into the non-profit organization
ent. The purpose of a for-profit company is to gen- and cannot be distributed as dividends. The excess
erate profits for the owner(s) and shareholders. The funds can be used to purchase equipment and sup-
purpose of a non-profit is typically charitable, reli- plies, provide staff training, or increase salaries and
gious, or educational. An individual or shareholders benefits, or be retained for future charitable use.
do not own a non-profit; it is owned by the public. If a for-profit company is dissolved, then the assets
The board of directors directs and operates the non- are distributed to the owners. If a non-profit is
profit but does not own it. Another difference is the dissolved, its assets must be distributed to other
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non-profit organizations or to the government state has its own policies and procedures regarding
(Fritschner, 2006). In either case, both non-profit incorporation, and these can usually be obtained
organizations and for-profit businesses are incor- from the Office of the Secretary of State.
porated entities.
Incorporation Process Starting a For-Profit

Articles of incorporation provide the legal description Business
of the business or non-profit organization. Establish- Richmond and Powers (2004) outline 15 steps for
ing a legal entity protects the board of directors, staff, starting a health care business (Box 8-2). These
and volunteers from liabilities such as lawsuits or steps apply to all types of businesses to some degree
debts. When the business or non-profit organization and provide a useful framework for planning. There
is formalized in this way, it is assigned an EIN, or em- are four basic types of legal structures used in for-
ployer identification number, which allows the estab- profit businesses. These are a sole proprietorship, a
lishment of a bank account and the ability of the partnership, an LLC, and a corporation. The sim-
entity to own property. In addition, it allows a non- plest for-profit business to develop is a sole propri-
profit organization to solicit funds in the form of do- etorship. This is a business with one owner and no
nations and apply for grants that are often restricted employees. A sole proprietorship is a useful structure
to entities with a 501(c)(3) designation of tax-exempt for a small private practice, a consulting business, or
status. A format for articles of incorporation is pre- an independent contractor. The benefits of this type
sented in Box 8-1. of structure are that it is easy to form, the owner is
It is important to obtain a copy of requirements in total control, he or she receives all income, certain
for incorporation from the state in which the busi- business expenses can be deducted from income
ness or non-profit organization will be located. Each taxes, and there are few record-keeping require-
ments. However, the owner assumes all liability risks
and has all legal and operational responsibilities
Box 8-1 Format for Articles of (Richmond & Powers, 2004).
Incorporation
• Article I: Name of the business or non-profit Box 8-2 15 Steps for Starting a Business
organization
• Article II: Street address of the business or non-profit • Perform a self-assessment and identify business
organization and mailing address of registered agent opportunities
(usually the president) • Create a vision statement
• Article III: Name and address of each incorporator • Develop a mission statement
or founding board member • Describe your business concept
• Article IV: Purpose of the business or non-profit • Adopt a legal structure
organization and mission statement • Develop an organizational structure
• Article V: Membership of the non-profit organization • Research and register your business name
and mission statement • Write a business plan
• Article VI: Meetings of the non-profit organization • Develop a marketing plan
membership (if applicable) • Solicit advice from experts
• Article VII: Committees • Complete start-up tasks
• Article VIII: Board of Directors • Hire staff
• Article IX: Officers and Duties • Implement and manage business operations
• Article X: Amendments to the Articles • Manage financial operations
• Article XI: Dissolution of Assets • File quarterly and annual reports
• Article XII: Limitation on Activities (if applicable)
Data from Richmond, T. & Powers, D. (2004). Business funda-
Data from: Fritschner, A. (2006). An easy, smart guide to starting mentals for the rehabilitation professional. Thorofare, NJ:
a nonprofit. New York: Barnes & Noble Books. SLACK.
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Partnerships have two or more owners and may or products will be depends on how thoroughly the
may not have employees. Written partnership agree- prospective entrepreneur has researched and ana-
ments stating the roles, responsibilities, and liabilities lyzed the business plan” (p. 638). A business plan
of each partner are essential. This structure is useful is a road map or blueprint for a business and in-
for group practices, for joint ventures with separate cludes the goals of the business and a description of
businesses sharing space and overhead expenses, and how the business is going to organize its resources
when one prefers to take on a financial partner rather in order to achieve the desired outcomes (Richmond
than a loan. The benefits of a partnership are that & Powers, 2004). A business plan should be a work
it is relatively easy to set up, liability risks and in progress that is reviewed and modified on a
operational tasks are shared, and there are more op- frequent and routine basis to guide business deci-
portunities for growth. The disadvantages are that sions both large and small. To establish this plan,
decision making is shared and disagreements between Richmond and Powers devised five areas in which the
partners can harm the business. In addition, each entrepreneur needs to focus. The entrepreneur must:
partner is individually and jointly responsible for the
• Perform a market assessment.
actions of the other (Richmond & Powers, 2004).
• Develop a mission statement.
LLCs allow the owners the liability protection of a
• Develop a business concept.
corporation while retaining the operational flexibility
• Develop business goals.
of a sole proprietorship or partnership. Each state has
• Develop the plan.
specific LLC restrictions, and some states do not per-
mit occupational therapists and other health care Market assessment helps entrepreneurs examine the
providers to establish an LLC business structure. Some geographic region of their products, the clientele, and
of the advantages of an LLC are that it is easier to es- their needs. The Internet has provided occupational
tablish than a corporation, there is no personal liability therapy entrepreneurs with the world as their market;
for business debt, there is less recordkeeping and pa- however, it is wise to develop product lines slowly and
perwork required, and business losses can be used as a create your niche before expanding globally.
tax deduction on personal income taxes. Two major Mission statements are broad ideas of the purpose
factors in the success of a for-profit company are a of the business. “Once a mission statement has been
comprehensive business plan and effective marketing. developed, it should serve as a guiding principle for
Corporations are the most complicated business practice. It should meet today’s needs and tomor-
structures, but they also afford the most protection row’s prospects” (Jaffe & Epstein, 1992, p. 639).
against liability for the owners. Corporations have The development of mission statements is discussed
multiple owners or stockholders. The persons with in greater detail in Chapter 6.
the largest shares of stock have the most control over A business concept defines specifics of the busi-
business decisions. A corporation has a board of ness. For example, if you wish to offer wellness con-
directors and officers, has bylaws and articles of in- sultation services to underprivileged families, you
corporation, and is subject to extensive governmental would describe your specific location of services, the
regulation. There are several types of corporations, for types of services offered, how often services can be
example, the C corporation, the S corporation, and offered, and costs of services. These details are im-
the professional service corporation (PC). Each of portant for you to focus your practice and will later
these has different tax implications, so an accountant help with marketing those services.
and an attorney should be consulted to determine the Business goals are those you develop initially and
most advantageous structure for your business. can change as your business grows. As an entrepre-
neur, a typical business goal is to be financially sta-
ble. Meeting your costs can be a goal versus having
Developing a Business Plan to turn a profit in a specific amount of time. An-
According to entrepreneurs, a business plan can take other goal can be one of philanthropy, whereby the
various forms, depending on the type of business in business works towards giving to the community.
which one chooses to engage. According to Jaffe Philanthropic goals and financial goals do not have
and Epstein (1992), “how successful the business’s to be mutually exclusive.
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The plan is the organizational plan, or structure, comes from the constituencies the non-profit serves.
of the business. This includes the types of people one For example, the American Red Cross and the United
might employ (if any), bookkeeping practices, and Way receive monies from the public in order to pro-
strategies to financially manage the business. There vide services. Public non-profits can provide educa-
are many books and other resources for entrepre- tional, advocacy, community, cultural, and health
neurs in developing plans that fit their needs. Local services. Private foundations exist to distribute money
chambers of commerce and the SBA are also avail- to charities. Typically, private foundations derive
able to assist one with resources. their funding from a single, private source, frequently
Even though occupational therapy is a service- wealthy philanthropists, such as the Carnegie Foun-
oriented profession, developing a clear, focused plan dation. Membership-supported non-profits can re-
and marketing one’s services and products are crit- ceive funds from the general public, but what makes
ical to the success of the business. Marketing refers them unique is that their members help to financially
to the “communications activities the organization support them. Environmental groups, labor unions,
will undertake in order to attract service users” fraternities, and sororities fit into this category. Serv-
(Fritschner, 2006, p. 200). The goals of marketing ice non-profits provide services to the general public,
include creating consumer awareness of the product such as schools and hospitals, and receive their fund-
or service, building name recognition, and meeting ing from a variety of sources (Fritschner, 2006).
financial goals. MacStravic (1977) outlined five Starting a non-profit organization is much the
components of social marketing: same as starting a for-profit business. The tasks
for starting a non-profit organization are listed in
• Identification of constituencies
Box 8-3. The first stage is the idea phase. It is impor-
• Assessment of the marketing environment
tant to research the services or products one hopes
and its problems
to deliver. Is there a need that is not being met by
• Selection and evaluation of marketing
other community agencies? The second stage is to
objectives
gather people who share one’s vision and commit-
• Design of a marketing strategy
ment. These are people who will become the board
• Planning, implementation, control, and
of directors, officers, and volunteers. The third stage
evaluation of marketing efforts (as discussed
is determining the form or legal structure for the
in Gilkerson, 1997).
non-profit. Considerations at this stage include size
Developing a plan and possessing knowledge of of the organization, perceived liabilities, and tax-
how to implement that plan and market your serv- exempt status. Next is the development of a strategic
ices can turn a great idea into a successful practice. plan, followed by publicity and a fund-raising cam-
Karen Jacobs (1998), past president of the American paign. Finally, there must be a plan for growth and
Occupational Therapy Association, stated that the continued development of the organization.
“use of a marketing approach will allow practitioners Three major factors in the success of a non-profit
to approach the health care environment proactively organization are strategic planning, fund-raising,
and be ready to meet the changing needs and wants and grant writing.
of the marketplace. In all times of change, there is
great opportunity” (p. 620).
Strategic Planning
Strategic planning is a systematic process of setting
Starting a Non-Profit long-term organizational goals and priorities, identi-
Organization fying organizational activities, and predicting potential
outcomes. Strategic planning “is an ongoing, contin-
Non-profits are often referred to as agencies, founda- uous process, which must adapt to environmental
tions, associations, and organizations. There are four changes, both external and internal’ (Smith, Bucklin
types of non-profits: public non-profits, private foun- & Associates, 2000, p. 5). A strategic plan is a
dations, membership-supported non-profits, and realistic agenda for action that operationalizes the
service non-profits. Funding for public non-profits organization’s mission statement and focuses the
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Box 8-3 Tasks Involved in Setting Up a planners to understand the trends and issues that im-
Non-Profit Organization pact the organization and how the environment may
facilitate or hinder the accomplishment of the orga-
• Meet with volunteers and discuss what type of nization’s mission. An environmental scan identifies
services and products the organization will provide trends in a variety of spheres, including demo-
and who will be in charge of various operational graphic, economic, technological, political, profes-
functions. A board of directors must be established
sional, and educational. An internal scan of the
and officers elected. Create a mission statement
and choose a name for the organization.
organization’s financial and human resources, tech-
• Develop the organization’s articles of incorporation. nological capabilities, and culture is also an impor-
These describe the non-profit’s legal structure and tant source of information. Sometimes this approach
how it will be operated. is referred to as a SWOT analysis, where “S” refers
• File the articles of incorporation with the state in to strengths and assets, “W” to weaknesses and lim-
order to establish the organization as a legal entity. itations, “O” to opportunities, and “T” to threats.
Be prepared to pay a filing fee. Once the organization’s strengths, weaknesses, op-
• Apply to the Internal Revenue Service (IRS) for an portunities, and threats are identified, a strategic plan
Employer Identification Number (EIN). This can be can be developed to address these factors. An exam-
done online. This number identifies the non-profit ple of a SWOT analysis is provided in Box 8-4.
and affords the organization the legitimacy to
Trends that have a high probability of occurrence
establish a bank account in its name.
• File an application for non-profit tax-exempt status
and potentially may have a significant impact on the
with the IRS (referred to as 501(c)(3) status). This organization should be considered critical issues to
allows the organization to receive tax-deductible be addressed in the strategic plan (Smith, Bucklin
contributions and avoid paying federal income tax. & Associates, 2000). The second step in strategic
• Create a logo and acquire stationery that displays planning is setting broad organizational goals. These
your logo, mailing address, and other contact goals are generally derived from the mission state-
information. ment and represent the purpose of the organization.
• Set up a corporate bank account and acquire a mail- The third step in strategic planning is setting
ing permit from the post office for bulk mailings. strategic objectives, those “major accomplishments
• Create a Web page to enhance the credibility and the organization hopes to achieve in a defined time
visibility of the non-profit organization. Register
frame,” usually three to five years (Smith, Bucklin
your domain name as.org, which is the identifier
for a non-profit, rather than .com.
& Associates, 2000, p. 19). Strategic objectives sup-
port the mission and goals of the organization, pro-
vide direction, and afford a means for measuring
outcomes. These objectives should be realistic,
organization’s energies toward high-yield objectives meaningful, and measurable. Strategic objectives
and activities. A well-designed strategic plan will: identify what is to be accomplished. The next step
is to operationalize the strategic objectives; this
• establish priorities,
involves specifying how the objectives will be
• guide program activities,
achieved. An operational plan describes the tasks to
• allocate resources, and
be accomplished, who is responsible, what resources
• establish mechanisms to assess the organiza-
are required, when the objectives will be achieved,
tion’s accomplishments.
the anticipated results, and how these results will be
The steps in the strategic planning process include: measured. Finally, the strategic plan is imple-
mented, monitored, and adjusted as necessary.
• conducting an environmental scan and analysis,
• setting broad organizational goals,
• establishing strategic objectives, and Fund-Raising
• developing an operational plan.
There is a science and an art to fund-raising. The
An environmental scan and analysis is the first science is applying fund-raising models and using
step in strategic planning. It is important for the available data and research to target fund-raising
2580_Ch08_114-132 16/07/13 2:49 PM Page 126
Box 8-4 SWOT Analysis Example: A Senior Center Wishing to Expand and Provide Health
Promotion Services
Strengths/Assets Opportunities
• Stable, experienced staff • Recent hospital downsizing producing unused space
• Good reputation in the community • Increasing older adult population
• Adequate financial resources for current services • University collaboration for potential student training
• Well networked with other non-profit agencies • Lack of local services for older adults with dementia
• Member of the Chamber of Commerce or mental disorders
Weaknesses/Limitations Threats
• Inadequate space to expand • Current economic recession
• Lack of finances to build a new facility • Inadequate political support
• Limited parking • Competition from medically based health services
• Location not on public transit routes
efforts. The art consists of developing and nurturing corporate donations are tax deductible, often produce
interpersonal relationships with potential donors publicity, and generate goodwill for the corporation.
and funders. Funding for non-profit organizations Typically, corporations are not interested in funding
can come from a variety of sources, including indi- annual operating costs but will provide start-up funds
vidual donors, corporate donors, bank loans, for new projects or programs. In lieu of money, some
grants, contracts, online fund-raising, and other corporations will provide in-kind donations, often in
fund-raising events. The most viable non-profit the form of goods and services. Corporations repre-
organizations bring in dollars, goods, and services sent approximately 5% of the dollars, goods, and
from multiple sources. The vast majority of dona- services donated nationwide (Fritschner, 2006). For
tions, approximately 75%, comes from individuals; example, a homeless shelter needing a vehicle in order
therefore, it is imperative to cultivate a donor base to provide transportation to and from medical ap-
(Fritschner, 2006). pointments and job interviews may receive an in-kind
Developing a donor base occurs in phases. The donation of a van from a car dealership.
first phase, prospecting, is where a list of potential Another source of funding for start-up ventures
donors is developed. These potential donors are then is small business loans. Small business loans are
prioritized based on how much they might donate available to 501(c)(3) non-profit organizations that
and the probability of successfully soliciting a dona- have at least a 3-year operating history. Just like any
tion. Each potential donor is invited to observe and other business loan, repayment with interest on a
participate in the activities of the organization, and schedule is expected, and the interest rate is typically
then a request for a donation can be made. When a similar to that of a for-profit business.
donation is solicited, it is important that it is so- Online fund-raising usually takes the form of sell-
licited from the right person, for the right amount ing some product to the general public; however, on-
of money, at the right time, and for the right pur- line donation solicitation is also an option. To take
pose. This is called the Rule of Rights in fund- advantage of the Web as a source of funds, it is nec-
raising. In-person solicitation is always more effec- essary for the organization to be able to process credit
tive than fund-raising through the mail. Thanking card payments. Another option is to collaborate with
the donor, acknowledging the contribution publicly, brand name companies that donate a portion of their
and informing the donor about how the money was online sales proceeds to charitable organizations.
spent will improve the likelihood the donor will Many non-profits sponsor special fund-raising
choose to donate again (Fritschner, 2006). events. These may include dinners, concerts, theatri-
Corporations are often interested in donating cal productions, auctions, and sports outings, with
funds to non-profits that serve the local communities the type of event limited only by one’s imagination.
in which their employees live and work. In addition, In addition to garnering revenue from ticket sales,
2580_Ch08_114-132 16/07/13 2:49 PM Page 127
non-profits may also solicit sponsorships from cor- 2. Corporate foundations, sponsored by large
porations. Fund-raising events are time- and labor- companies
intensive, with costs often approximating 50% of 3. Community foundations, designed to serve
the revenue generated. However, they are useful in a particular geographic region
publicizing the work of the non-profit, increasing 4. Special-purpose foundations, focused on a
its visibility, and cultivating new donors (Smith, specific area of interest
Bucklin & Associates, 2000). 5. General-purpose foundations, typically
national in scope and supporting a variety
of activities with no geographic limitations
Grant Writing (Smith, Bucklin & Associates, 2000).
Foundations provide nearly 12% of the funds pro-
Information about foundation funding can be
vided to non-profits. Most foundations require a
obtained from the Foundation Center (www.
grant proposal from the organization that is com-
fdncenter.org) and the Council on Foundations
patible with the mission and purpose of the foun-
(www.cof.org).
dation. There are a number of different types of
In addition to foundation sources, funding can
grants, and these are listed in Box 8-5. It is impor-
be obtained from state and federal government
tant to identify the type of grant and the appropriate
agencies. The Catalog of Federal Domestic Assis-
foundation from which to solicit funds before writ-
tance is the primary source of information about
ing a grant proposal (Fritschner, 2006).
federal funding opportunities. Government agencies
There are five basic types of foundations:
may offer funds in the form of grants or contracts.
1. Independent family foundations, established Grants are funds awarded for a specific purpose
by persons of wealth based on the submission of an original creative pro-
posal. Contracts are also awarded for a specific pur-
pose, but in this case the government agency has
already outlined the scope of services to be provided
Box 8-5 Types of Grants
and non-profit organizations are invited to bid com-
• Start-up grants: also called “seed money”; grants petitively on the project (Scaffa, 2001). Funding for
that are used to partially fund new programs or occupation-based health promotion projects may be
projects in order to attract other donations available from the following federal agencies:
• Program grants: grants that are used for a specific
program within an organization
• Centers for Disease Control and Prevention
• Continuing support grants: grants that can be • Department of Education
renewed for a number of years • Department of Health and Human Services
• Consulting grants: grants that are used to hire • Department of Housing and Urban
consultants for a project Development
• Conference grants: grants that are used to send • Department of Labor
organization board members or staff to continuing • Department of Transportation
education workshops, or to plan and implement • National Institutes of Health
conferences or seminars for others • Public Health Service
• Research grants: grants that provide funding for • Veterans Administration.
basic or applied research, usually provided to or
through hospitals and universities Grant funding is often a non-profit organiza-
• Challenge or matching grants: grants that provide tion’s primary source of support. Grants are consid-
partial funding but require other donors to match ered “soft money,” meaning the funding is available
the funding in order to receive the grant for only a specified period of time, usually a year,
• Endowment: monetary gift, or grant, to be invested, occasionally for 3 years, and rarely for up to 5 years.
the income from which can be used to fund proj-
No single grant or contract provides a permanent
ects and support the non-profit organization
revenue stream, and therefore it is imperative that
Data from: Fritschner, A. (2006). An easy, smart guide to starting non-profit staff and volunteers develop, or contract
a nonprofit. New York: Barnes & Noble Books. for, grant writing capabilities.
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Grant Proposals Box 8-6 Sample Grant Goals and

Objectives
Grant proposals typically consist of the following:
• Introduction Goal:
• Statement of need Increase the ability of teachers, school counselors,
• Goals and objectives clergy, health-care professionals, emergency response
• Program activities personnel, and human resource and personnel direc-
• Program evaluation strategies tors of local businesses to effectively respond to the
• Budget and personnel mental health needs of persons affected by disaster.
• History of organization and prior funding Objectives:
• Summary or conclusion Workshop participants will demonstrate:
• Appendices of supporting materials • Increased knowledge of the symptoms of post-
(Fritschner, 2006). traumatic stress disorder (PTSD) and the critical
incident stress model
Although the introduction is the first thing the • Improved identification and referral of persons in
funder will read, it is typically one of the last com- need of mental health services
ponents of the grant proposal you write. To ensure • Effective use of appropriate interventions for per-
that the introduction is a complete synopsis of the sons experiencing critical incident stress or PTSD.
full grant proposal, it is typically written at the same Goal:
time as the conclusion. Enhance the mental health of individuals affected by
The most efficient strategy is to write a basic grant disaster.
proposal with all of the above components. Then
Objectives:
this information can be “cut and pasted” into any
grant proposal format for any funding source. The Support group participants will demonstrate:
• Reduced symptoms of critical incident stress and
first step is to identify and describe the need for the
PTSD
particular project or service that is being proposed. • Increased use of adaptive coping strategies in
The statement of needs provides data that is specific response to critical incident stress
to the problem and population being addressed and • Decreased use of maladaptive coping strategies in
the geographic area the project is designed to serve. response to critical incident stress.
Basically, it answers the question, “Why is this proj-
ect important and necessary?”
The second step is to identify the goals and objec-
tives of the program or project. These define what is equipment, and supplies that are necessary to imple-
to be achieved. A goal is a general statement regard- ment the activities. It answers the question, “What
ing expected outcomes, while an objective is a spe- activities will be done to achieve the objectives?”
cific statement that defines the goal in measurable Program evaluation, the fourth step, is an ex-
terms. Goals represent the final destination; objec- tremely important component of a grant proposal.
tives specify how the goals will be achieved. Exam- Funders want to know that their money is well
ples of goals and related objectives can be found in spent, how program effects will be measured, and
Box 8-6. The objectives should support the achieve- which program goals and objectives were achieved.
ment of the goals, and the goals should address the The program evaluation describes how and when
needs identified in the statement of needs. Basically, progress will be measured and what assessment tools
this section answers the question, “What is to be ac- will be used. Program evaluation assesses what was
complished by this project?” Describing program done, the activities, and the effects of those activities
activities is the third step in the grant writing process. or outcomes. It answers the question, “Did the pro-
These activities are designed to accomplish the spec- gram accomplish what it set out to achieve?”
ified program objectives. Typically, there are several The fifth step, describing the budget and person-
program activities for each objective. This section of nel, provides support for the amount of funding that
the proposal often includes a time line for comple- is being requested. It answers the question, “How
tion of the program activities and a list of staff, will the money be spent?” Funders want to see that
2580_Ch08_114-132 16/07/13 2:49 PM Page 129
you have accurately estimated the costs of imple- evaluation tools, and the IRS tax-exempt letter des-
menting the program. This requires the grant writer ignating the organization as a 501(c)(3) corporation
to collect cost information for salaries, rent, utilities, (Fritschner, 2006).
equipment, and supplies. Some people speculate
that if the costs are underestimated and the total
costs are lower, then the grant is more likely to be Conclusion
funded. However, this is typically not true. Funders
frequently know the costs of doing business, and Entrepreneurship, like occupational therapy, is both
proposals that claim to be able to implement pro- a science and an art (Kiyosaki, 1999). Occupational
grams at significantly below market costs are therapy practitioners who aspire to become business
deemed unrealistic and likely to fail. It is useful to owners should take courses and immerse themselves
have the assistance of an accountant in the prepara- in the science of business management and leader-
tion of a budget for a grant proposal. When describ- ship. The art of entrepreneurship is best learned
ing personnel by name, mention only those who will through mentoring. Surrounding oneself with in-
play a major role in the project, and list their rele- novative thinkers, leaders, and business owners is
vant credentials and qualifications. The rest of the one of the keys to success. Finding an entrepreneur-
project staff can be identified by categories, such as ial role model is extremely useful.
childcare workers, bus drivers, tutors, and others Entrepreneurship is developing rapidly in the
(Fritschner, 2006). profession of occupational therapy, yet the process
Finally, the last step is to write the introduction of entrepreneurialism is not well defined nor under-
and summary or conclusion for the grant applica- stood. This process and the need for continued re-
tion. These two sections are extremely important, as search were presented in this chapter along with the
they are the first and last impressions the proposal characteristics, steps, and strategies for developing
reader will have of the project or program. If the in- entrepreneurship. Occupational therapy practition-
troduction is not well written, clear, and interesting, ers are typically creative, adaptive, and relationship
the reader may choose not to continue or to peruse builders. These characteristics provide a solid foun-
only superficially. A poorly written introduction is dation for becoming entrepreneurs.
often a death sentence for a grant proposal. The in-
troduction and the conclusion contain basically the
Learning Activities
same information, and they provide a concise
overview of the project as a whole. Fritschner (2006) 1. Identify an entrepreneur in your business or
recommends that the introduction use action words health-care community. Arrange to interview
and the conclusion use more of an emotional ap- him or her to discover how and why this indi-
peal. The introduction and conclusion should in- vidual chose to become an entrepreneur, what
clude a brief statement of the problem, how the personal qualities this person brings to the en-
program will address the problem, the non-profit trepreneurial role, and the challenges and
organization’s qualifications, and the amount of rewards to being an entrepreneur.
money needed. Including the name of the founda- 2. Visit the Small Business Administration (SBA)
tion or funding source in both the introduction and Web site and review the business plan tem-
conclusion is highly recommended. This personal- plate (http://web.sba.gov/busplantemplate/
izes the grant proposal and engages the funding BizPlanStart.cfminformation). Using an idea
sources as co-participants. for a community-based, occupational therapy
In addition, certain documents may be requested service, write a mission and vision statement
for the appendices of supporting material. Support- for your business idea that would meet those
ing material may include: letters of support and en- elements of a business plan.
dorsement from key community stakeholders, 3. Go to the following site to take the Entrepre-
newspaper clippings regarding the problem to be ad- neur Risk Assessment Quiz from the Georgia
dressed by the program, resumes of key program State University Small Business Center
staff members, copies of assessments and program (www2.gsu.edu/~wwwsbp/entrepre.htm).
Continued
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Complete the quiz, note your score, and visit Foto, M. (1998). Competence and the occupational therapy
the Answer Sheet to interpret your score and entrepreneur. The American Journal of Occupational Therapy,
52(9), 765–769.
see if you possess the personal characteristics Fritschner, A. (2006). An easy, smart guide to starting a
necessary to succeed in business. nonprofit. New York: Barnes & Noble Books.
4. With a group of your classmates, identify an Gartner, W. B. (1985). A conceptual framework for describing
unmet need for occupational therapy services the phenomenon of new venture creation [Electronic
in your community. Visit either the Grants.gov version]. Academy of Management Review,10(4), 698–708.
Gartner, W. B. (1989). “Who is an entrepreneur?” Is the
or The Foundation Center Web site to see if wrong question [Electronic version]. Entrepreneurship:
you can identify a government agency or foun- Theory and Practice, 13(4), 47–68.
dation with funding criteria that match the Gilkerson, G. (1997). Occupational therapy leadership:
proposed new services. Note whether a request Marketing yourself, your profession and your organization.
for a proposal (RFP) or funding announcement Philadelphia: F.A. Davis.
Glennon, T. J. (2007). Putting on your business hat. OT
is available for your idea. Practice, 12(3), 23–25.
Jacobs, K. (2002, June 24). Navigating the road ahead. OT
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SECTION III
Children and Youth

Chapter 9
Early Intervention Programs

Donna A. Wooster, PhD, OTR/L, and Abigail Baxter, PhD
Article 27: Every child has the right to a standard of living adequate for [her/his]
physical, mental, spiritual, moral and social development.
—United Nations Children’s Fund, n.d.
Learning Objectives
• Identify the components of Early Intervention (EI) programs.
• Discuss the role of the occupational therapist in EI programs.
• Identify and describe appropriate areas for evaluation and assessment instruments for early intervention
occupational therapy services.
• Discuss the importance of family involvement in early intervention.
• Identify best practice in occupational therapy early intervention services.
Key Terms
Amplification Food neophobia
Early Intervention (EI) Individualized family service plan (IFSP)
Ecological evaluation Natural environments
Eligibility Service coordinator
Family-centered Solution-focused questions
133
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134 SECTION III | Children and Youth
Introduction In this chapter the authors discuss the need for,

and purpose of, EI and the legislatively mandated
Early Intervention (EI) is a federally supported components of EI programs. The role of the occu-
program implemented by states for children age pational therapist in EI services is described, including
birth to 3 years who have a disability. Federal fund- evaluation, intervention, and family involvement. In
ing is available to states that have developed EI ser- addition, a case study illustrates the major points of
vice systems. States that have taken federal dollars the chapter.
for EI are mandated to implement a “statewide,
comprehensive, coordinated, multidisciplinary,
interagency system of early intervention services for EI Programs
infants and toddlers with disabilities and their
families” (Individuals with Disabilities Education The number and percentage of children birth to
Improvement Act [IDEIA], 2004, p. 5). Even age 3 being served in EI has increased over the
though EI is not a federally mandated program, past 20 years. Estimates suggest that these trends
each state has developed an EI system based on will continue. In the past, parents were urged to
federal guidelines designed to address its specific place children with disabilities in institutions.
needs and resources. Occupational therapists Changes in society have contributed to the expec-
should seek information specific to the state(s) in tation that families will care for their child at
which they practice. home regardless of the child’s disability. Some
The primary purpose of EI services is to identify families need intense interventions and supports
children with disabilities or delayed development to competently handle this level of care. Research
who may be eligible for services and to provide nec- suggests that professionals can help families by
essary services to promote the family’s ability to care providing information, emotional support, and
for the child. The components of the programs are continuous services (Anderson & Telleen, 1992;
detailed in the IDEIA. Part A describes the general Hebbeler, Spiker, Bailey, Scarborough, Mallik, &
purpose and provisions of the act, including defini- Simconsson et al., 2007).
tions. Part B covers centers and services to meet Medically fragile children now have longer life
special needs of individuals with disabilities aged expectancies than they did in the past (Fitzsimmons,
3–21 years, and Part C defines infants and toddlers 1993; Gortmaker & Sappenfield, 1984). Although
with disabilities (birth through age 2). The compo- the total size of the population of children with
nents requiring a Free Appropriate Public Educa- disabilities and chronic illness probably will remain
tion (FAPE) are in parts A and B, which mandate stable, the longer life span will result in families with
the provision of education for all children with needs that will change over time as the child grows
disabilities between the ages of 3 and 21 years. (Wallace, Biehl, MacQueen, & Blackman, 1997).
Improvements in the legislation have occurred Societal trends, such as recessions and interna-
over time. A more inclusive environment for the tional crises and conflicts, also can impact the
infants and toddlers with disabilities was mandated. number of families in need. For example, job
Services were required to be provided in natural relocation and deployment of servicemen and
environments (i.e., places children would normally servicewomen are both factors that may result in
find themselves, depending on age and activity). having fewer family members living close by
These include home, day care provider’s home, who could be resources. Additionally, many
day care center, nursery school, and playgrounds. children with disabilities may live in poverty, dys-
Parents have input guiding the team in the choice functional families, and disadvantaged communi-
of location(s) of service delivery. Service provision ties (Thompson, 1992). Poverty is associated
also should be provided in these inclusive environ- with increased risk for disability and increased
ments. More recently, the IDEIA 2004 required hospitalizations for problems related to chronic
that EI services be evidence-based. In addition, the health conditions (Newacheck, 1989; Wissow,
IDEIA emphasized measureable results and pre- 1988), thus placing children with disabilities at
literacy and language skill development. greater accumulated risk.
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Chapter 9 | Early Intervention Programs 135
Components of Early Intervention or contexts increases the reliability of the evaluation

(Miller, 1994). If possible, occupational therapists
There are three components of EI programs. These
should conduct observations of the child at home
components include identification, eligibility deter-
and in the community, including day care or nursery
mination, and evaluation.
school and other natural environments. Factors
Identification that may be evaluated include response to different
Each state must establish a system to identify children environments, effects of peer role models on per-
who may be eligible for services and refer them to the formance, solitary versus group function, and social-
EI system. Children with suspected developmental emotional and communication skills with children
delays or a disability may be identified through a as well as adults other than the parents. Gathering
variety of sources, including occupational therapists, information across environments will help the occu-
parents, physicians, other health providers, and com- pational therapist to match the child’s abilities with
munity agencies. Professionals must seek verbal the requirements of the occupation and the features
approval from the parents to make a referral. A central of the environment to enhance performance.
phone number (usually an 800 number) is typically A variety of factors, such as the child’s age, gender,
available for referrals. ethnic background, native language, culture, and
information needs of the family and team, influences
Eligibility Determination the selection of assessment tools. Assessments must
One component of each statewide system is estab- be standardized test instruments that assess perfor-
lishment of the local lead agency. This appointed mance in five areas:
agency varies from state to state and may be part of 1. motor,
the state health department, education department, 2. cognitive,
or another department. The local lead agency sched- 3. social-emotional,
ules the evaluation with the parents to determine 4. communication, and
eligibility. Eligibility refers to whether or not the 5. adaptive development.
child qualifies, under the state’s criteria, to receive
EI services. States must serve children “who are Assessment instruments must not be culturally
experiencing developmental delays” in accordance biased. Many states indicate a specific instrument
with the state’s definition of developmental delay as the assessment tool of choice and allow other
and children with “a diagnosed physical or mental informed clinical opinions to be expressed in writing
condition that has a high probability of resulting in to support the findings. Parents should be included
developmental delay” (IDEIA, 2004, p. 100). Once in the evaluation process to provide information
written parental consent is obtained, the evaluation about the abilities of their child. Assessments of
process is initiated. The evaluation can be done by family needs also are conducted.
a variety of trained professionals. The evaluation The EI program is primarily an educational
scores will be used to determine eligibility for model with teachers as the primary evaluators and
services. A specific level of developmental delay providers. EI teams must have many other profes-
(such as 25%) in one or more areas, or two standard sionals, including occupational therapists, physical
deviations below the norm in any two areas, may therapists, speech language pathologists, audiolo-
constitute eligibility. In some states, professional gists, nurses, and others, available. One team mem-
opinions of high risk may qualify the child. ber, usually a teacher, may perform the primary
assessment. This person administers assessment tools
Evaluation and then, based on test findings across the five areas,
The IDEIA 2004 includes specific information about calls in other services such as speech or occupational
the evaluation process. Multidisciplinary evaluations therapy.
must be done within 45 days of referral and given in Another format is the arena-style evaluation.
the native language or type of communication that Multiple service providers gather to simultaneously
suits the family. Best practice research indicates that observe the evaluation being conducted by one or
the evaluation of a child in multiple environments two primary evaluators. Each team member records
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information and discusses the child’s abilities. The also includes the appointment of a service coordinator
team members discuss the observations and write a and a family meeting, the nature and extent of serv-
joint evaluation report. A child may be determined ices will be delineated. The IFSP is reviewed every
eligible for EI services based on the test scores. A 6 months (or more frequently if required) and must
report is written following the evaluation, and if the be evaluated once a year. Outcomes can be modified
child is eligible for services an individualized plan is or changed at any time if the parent desires.
developed based on the assessment information. The Occupational therapy may be a primary service
results and observations of the evaluation are used provider for the infant/toddler under the IFSP plan
to make referrals to appropriate service providers. (Decker, 1992). Occupational therapy may be the
For example, if the child scored low on adaptive and only service provider or may be part of a team of
fine-motor skills, then a referral is usually made for providers. Each plan is customized to the needs of
occupational therapy services. the child and the family. Any child with an identi-
fied need for occupational therapy must receive the
service. Occupational therapy is one of the “big five”
Individualized Family Service EI services, and more than a third of infants and
Plan (IFSP) toddlers receiving EI services receive occupational
Once eligibility has been established, a written plan, therapy services (Hebbeler et al., 2007).
called an individualized family service plan (IFSP), The service coordinator functions as a consultant
must be developed by the team. This process is sum- to the parents and service providers. The service
marized in Box 9-1 and includes the development of coordinator may be involved in training parents and
child and family goals. Only one IFSP is developed other family members and professionals, coordinating
despite the involvement of a number of agencies. appointments with medical personnel, participating
Family members are key participants in the develop- in the team IFSP process, and establishing links with
ment of the IFSP. All services required by the child service providers. In addition, the service coordinator
must be documented in the plan, including which assists the family in planning for the transition to
community agency will provide the service. The public school when the child is 3 years of age. The
service providers, the frequency of intervention, the service coordinator is responsible for implementing
family goals, and the resources that will be involved the IFSP. An occupational therapist also could serve
are specified in the plan. Expected measurable out- in the role of the service coordinator, which would
comes are clearly stated. This process will identify the decrease the number of professionals involved.
child’s needs, family resources, priorities, concerns, Parents have many rights associated with the
and supports. At the conclusion of the process, which IFSP process. The parents may review records at any
time and can consent to share medical information
with the IFSP team. A parent who is dissatisfied
with the service provision or finds the documented
Box 9-1 The Individualized Family Service IFSP services are not being provided has the right
Plan (IFSP) Process to due process. This is a legal proceeding that
involves a hearing conducted by an impartial medi-
The IFSP process gathers information on the
following. ator to resolve disputes. This clearly illustrates the
• Child’s current status. rights of the family in planning for the needs of their
• Family resources, priorities, and concerns. child who is receiving EI services.
• Major measureable outcomes expected.
• Specific services—frequency, duration, provider, and
dates to initiate. Team Members
• Description of natural environment in which serv-
Members of the EI team usually consist of the parents,
ices will be provided
• Need for other services, for example, medical. teachers, therapists, and other individuals, including
• Name of service coordinator. a variety of contracted service providers, working with
• Steps to support transition at age 3. the child. There are 14 early intervention services, as
shown in Box 9-2. The occupational therapist can be
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Box 9-2 Early Intervention Services occupational therapist personally to facilitate the
transition. This may be helpful to provide perti-
• Assistive technology devices and services nent information about techniques and procedures
• Early identification, screening, and assessment that have worked well, such as positive reinforcers,
services the amount and course of progress, and the inter-
• Family training, counseling, and home visits vention approach. If a meal-time protocol has been
• Health services needed to benefit from other early
developed, providing it to the preschool program
intervention services
• Medical diagnostic or evaluation services
staff will improve continuity.
• Occupational therapy Transitioning into the preschool-based setting
• Physical therapy is stressful to families. The model changes from a
• Psychological services family-friendly model to a special education school-
• Service coordination based model. EI teams should assist parents in devel-
• Social work oping assertiveness and advocacy skills to request
• Special instruction necessary services for their child. If the family is relo-
• Speech/language pathology and audiology cating, the occupational therapist might offer to make
• Transportation-related costs a videotape of the current feeding/toileting/dressing
• Vision services programs and routines. This facilitates carryover of
desired techniques. If possible, adaptive equipment
should be sent with the child and family. If that is not
one member of this team. The team’s primary goal is possible, team members can make a list of specific
to provide the needed services to the family as docu- equipment and purchasing information for the par-
mented in the IFSP. Each team is formed based ents and the new team.
on the needs of the family. Teams that have a clear,
focused statement of purpose, goals, and philosophies
function more effectively (Briggs, 1993). Occupational Therapy
Services in EI
Transition Planning Occupational therapists may assume many roles in
Transition planning must be part of any IFSP. In the EI process. They can be part of the evaluation
transition planning, families and service providers team, provide direct services, provide consultation
should discuss the possible options for the child to other team members in a transdisciplinary
after he or she can no longer be served by an EI model, or fulfill any combination of these roles
team. Possible options include the local school (Hanft, 1989). The occupational therapist working
system, a private preschool, a child care center, in early intervention needs to have good back-
Head Start, or other community services for young ground knowledge of assessment tools for children
children. The discussion of options should occur and common therapeutic interventions. Some best
early and referrals to other programs should be practice guidelines for occupational therapy in EI
made at least 6 months before the child’s third are listed in Box 9-3.
birthday. Approximately 60% of children served
in EI transition into preschool special education
services. If the family wants the child to be consid- Occupational Therapy Evaluation
ered for such a placement, the local education Evaluations must be nondiscriminatory; be performed
agency (LEA) will determine preschool programs by qualified and trained personnel; and include
that are available to the child. The IFSP team informed opinion, review of the child’s pertinent
works closely with the family to notify the future medical records, and the child’s overall developmental
placement staff of any special equipment that level. Depending on if any other evaluations have
will be required in the preschool environment. If been conducted by the EI team members, occupa-
possible, when given parental permission, the EI tional therapists must determine the scope of the
occupational therapist should contact the school occupational therapy evaluation process depending on
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Box 9-3 Best Practice Guidelines for Open-ended questions or requests are often
Occupational Therapy in Early better to facilitate retrieval of this information than
Intervention close-ended questions. Requests such as “Tell me
what a typical day is like for you and your child”
• Regard parents as partners in decision making. or “Describe for me the feeding process for your
• Use a clear, open, and collaborative communica- child” will elicit a much more detailed response.
tion style with all team members.
The use of narratives and life stories provides a view
• Share responsibilities for service implementation
with team members.
that encompasses the child within the family and
• Use knowledge to improve performance and community context.
functional outcomes. During the interview with the parent, the mes-
• Deliver cost-effective quality intervention. sage that families are competent and in control of
• View child’s abilities in context of natural their child’s life must be conveyed. One way to do
environments. this is to ask solution-focused questions (Andrews
• Incorporate carryover into natural daily routines. & Andrews, 1993). Solution-focused questions are
• Use amplification and solution-focused questions. worded such that they assume the family is already
working toward improving the situation, giving the
family credit for their efforts. For example, “I have
noticed how carefully you position your child’s head
the child’s needs, diagnosis, medical concerns, and and arms when you place him in the infant seat.
family priorities. Selected assessment instruments This is great. Do you do this in any other tasks or
should demonstrate high validity and reliability; positions as well?” Another example is “Turning off
include comprehensive health, social, behavioral, and the TV during feeding really seemed to help your
environmental components; and involve the family as daughter concentrate on feeding. Have you noticed
equal partners with the professionals (Hanson & other things you do that help her pay attention?”
Lynch, 1989). Important information, as well as trust building,
Children, especially those about 6–10 months of can be gained from this approach. This interview
age, may experience stranger anxiety and therefore provides a framework for understanding the child
need more warm-up or adjustment time with the as an occupational being in the context of his or her
occupational therapist before actual testing begins. family and his or her physical, social, economic, and
Allowing the parents to initially remain with the cultural world.
child is important. Also, during this time, the child
should be approached slowly with time allowed for Observation
gradual interaction and play. Performance will be Observation is a key element of the evaluation
negatively affected when a child is crying or afraid. process that guides interpretation and planning and
begins the minute the destination is reached. The
Parent Interview occupational therapist examines the community and
A parent interview is an essential element of the eval- home environments, the parent-child and child-
uation process of a young child. The purpose of the child interactions, and the family caregiving routines
interview is to obtain needed information, including: and play experiences. Observations usually are made
in a variety of areas, including the:
• parents’ perspective of their needs for caring
for this child, • quality of the movement of the infant,
• the child’s condition and interventions • interactions and communication between the
to date, infant/child and others,
• an understanding of family daily routines and • safety, accessibility, and opportunities pro-
structure, vided in the home environment,
• identification of resources available to the • daily routines and the amount and types of
family, and structure provided,
• the family’s story of hopes and wants for • caregivers’ responsiveness and stress, and
their child. • opportunities provided and resources available.
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The concept of amplification may be a useful strat- vary significantly as may the types of equipment,
egy for occupational therapists. Amplification is a toys, and presence of other children. The routines
process of “noticing, describing, and discussing an at home are often different than those allowed in a
interactive event between family member and child child care center. For example, a child care setting
that is likely to promote child change” (Andrews & may require the child be able to move from his chair
Andrews, 1993, p. 42). This means that the occupa- to sit in a circle on carpet squares, remove outer
tional therapist discusses his or her observations with clothing and place it on a hanger, request to go to
the family regarding any communication attempts the bathroom, play safely on the playground with
the child makes and the responses of the parents other children moving about, and obtain lunch or
that reinforce the child’s behavior. This encourages snacks from a lunch box. These are very different
the parents to notice and respond to nonverbal com- routines than in the home environment. Each envi-
munication attempts. For example, during lunch, the ronment will require different skills, thus task analy-
occupational therapist might comment, “I just saw sis is helpful for determining a child’s abilities and
your child visually attend to you and move his head needed modifications or adaptations.
toward the spoon. Try placing the spoon just in front
of his mouth again this time, and see if he moves that Play
way again.” This encourages the parent to attend to Play is assessed by occupational therapists because
nonverbal communication and reinforces the child’s it is the primary occupation of children. A variety
efforts. This may be the first recognition of interac- of assessments are available to assist the occupa-
tion, which can facilitate bonding between the child tional therapist in gaining specific information
and parent. about baseline play performance and skills. Most
Looking at the family’s normal daily routine also children are motivated to play and have play pref-
is important. Families will be better able to carry erences. Often a play history is conducted to find
over positioning and exercises if they are taught out the child’s typical play and preferences
how to fit them into their established daily routine (Takata, 1974). This is an interview designed
(Pretti-Frontczak & Bricker, 2001). Examples to determine both the quality and quantity of
include suggesting to the parent(s) to the child’s play experiences, interactions, environ-
• perform range of motion exercises during ments, and opportunities across time. There is
diaper changes, great diversity in the play environments, play
• incorporate an undressing routine just before opportunities, toys, peers, and promotion of play
bath time, skills. Not all children have equal play opportuni-
• implement sensory calming techniques after ties. Culture influences the adults’ view about what
dinner time to promote calming down for is appropriate play for children, what should be
sleep, and provided, and what is acceptable. Intervention
• plan rough-and-tumble play with one parent techniques are easily embedded into play routines
or family member while another is cooking to improve the skills, participation level, and satis-
dinner. faction of the child’s play experiences.
Ecological Evaluation Play Assessments

Ecological evaluation determines the skills needed The Transdisciplinary Play Based Assessment,
to be successful in various environments. The home Second Edition (TPBA2) is an observation-based,
environment will have its own opportunities and transdisciplinary assessment tool (Linder, 2008).
obstacles for the child to navigate. A child may have The team evaluates the child in normal play in a
freedom to move about and play in childproofed natural environment. Data is collected on normal
safe areas requiring little supervision while provided developmental sequences of skill acquisition in
with developmentally appropriate toys. In another the areas of cognition, social-emotional, communi-
home environment, the child may be restricted to a cation, and sensorimotor skills. Procedures for con-
very small play area such as a playpen for her or his ducting a transdisciplinary arena-type assessment
own safety. The opportunities for outdoor play may are included.
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The Revised Knox Preschool Play Scale is for An examination of infant states, infant behaviors,
children from birth to 6 years of age (Knox, 1997). and infant responses to the environmental demands
Four areas of play are examined: is important for the occupational therapist to con-
sider. The Infant-Toddler Symptom Checklist
1. space management,
(Degangi, 1995) and the Infant Toddler Sensory
2. material management,
Profile (Dunn, 2002) are useful tools to examine the
3. pretense/symbolic, and
infant’s responses to sensory stimulation, including
4. participation.
need for and avoidance of stimulation.
This requires play observation both indoors and A newly developed tool called the Newborn
outdoors in natural environments with peers over a Behavioral Observations (NBO) will be helpful to
minimum of two 30-minute observations. More therapists who work with newborn infants up to the
detailed descriptions of the evaluation process and age of 4 months (Nugent, Keefer, Minear, Johnson,
interpretation of play assessments can be found in & Blanchard, 2007). This assessment is an individ-
the work of Parham and Fazio (2008). ualized, infant-focused, family-centered assessment
The Test of Playfulness (ToP) has been designed for use in examining communication and interac-
specifically to evaluate components of play related tions between infant and parent. This assessment
to suspension of reality, source of motivation, and consists of 18 neurobehavioral observations that
perception of control. This tool can be used with describe the infant’s capacities and behavioral
children from 18 months–18 years old (Skard & adaptations. It is designed to help parents identify
Bundy, 2008). Free play is observed and then the the infant’s unique capabilities and vulnerabilities.
test is scored. The test is recommended to evaluate Occupational therapists can help parents learn to
the play skills of children with autism spectrum dis- understand and interpret the infant’s behaviors so
orders and those whose delay interferes with their parents can in turn respond in ways to meet their
spontaneity and playfulness (Skard & Bundy, child’s developmental needs.
2008). In conjunction with the ToP, the Test of Additionally, the Infant Neurological Interna-
Environmental Supports is often administered. tional Battery (INFANIB) is useful for infants
The Test of Environmental Supports (TOES) from birth to 18 months and includes examination
assesses the environmental support for a child’s items in the categories of spasticity, head and
motivation for play (Bronson & Bundy, 2001). This trunk, vestibular functions, legs, and French angles
assessment is helpful for reviewing the relationships (passive movement at a single joint) (Ellison,
between the child’s motivation, caregiver supports, 1994). It is based on observation and includes a
playmates, toys and objects, spaces, and the envi- rating scale. The scores reflect an infant’s neuro-
ronment (Skard & Bundy, 2008). Scores are only motor status and may be useful to the occupational
interpreted on a per item basis, and discussion with therapist by identifying specifics about distribution
caregivers can lead to ideas for needed environmen- of abnormal tone and poor quality of motor
tal modifications and other adaptations to promote responses (Ellison, 1994).
play in that particular environment.
Occupational Therapy Interventions
Sensory Processing and Neuromotor Kellegrew (2000) determined that the self-care
Status routines of children with disabilities were often
Sensory processing and neuromotor status are related to the value mothers placed on the routines,
important components for the occupational thera- the time afforded to conduct them, and the goals
pist to evaluate. Understanding the body language established. She also determined that on a daily
of premature babies is especially important for basis, mothers make small adjustments in the
therapists and parents to interpret the behaviors home routines that shape the opportunities for
appropriately and avoid under- and overstimulation. skill development offered to their children. Prac-
Hussey (1988) has developed a helpful manual tices regarding adaptive skills and social-emotional
to consult when working with premature infants. skills are very much dependent on the culture of
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the family. Views regarding child rearing vary resources available for a comprehensive evaluation
greatly, including the involvement of other chil- (Wooster, Brady, Mitchell, Grizzel, & Barnes,
dren in family decisions, the types of foods and the 1998). These teams provide the safest environment
social climate of meals, hygiene, clothing habits to evaluate the medically complex and fragile child.
and choices, behavioral expectations, and discipli- Occupational therapists should develop a link with
nary actions and methods. A child’s ability to par- the nearest feeding team for referrals and consulta-
ticipate in religious ceremonies, cultural activities, tions. A thorough evaluation must be conducted
and school activities may be especially important when an infant is at risk for aspiration. Infants at
for families. In the following section, intervention risk for aspiration often demonstrate apnea, brady-
strategies for feeding, dental care, dressing, and cardia, and an arching or stiffening of the body
toilet training are shared. during meals. Toddlers may present with coughing,
wheezing, congestion, wet burps or wet hiccups,
Feeding frequent swallowing with negative facial expressions,
Feeding is an especially important performance vomiting, difficulty with sleeping, or hoarse voice.
area to evaluate in infants and toddlers because good Coughing and gagging during meals that persists for
nutrition is essential for adequate growth and devel- several weeks, repeated bouts of pneumonia, and
opment. This is one of the key areas in which occu- chronic chest congestion require immediate com-
pational therapists must be well versed for EI prehensive feeding team evaluation (Rudolph &
practice. It is indicated that approximately one third Link, 2002).
of all children with a developmental disability will Feeding intervention involves establishing safe
develop a feeding problem significant enough to and appropriate feeding programs that meet the
interfere with their nutrition, medical well-being, or child’s nutritional and hydration needs and can be
social inclusion (Sullivan, Lambert, Rose, Ford- competently carried out by family members in a rea-
Adams, Johnson, & Griffiths, 2000). Infants who sonable amount of time. Most young infants are fed
have motor delays, immature central nervous sys- very frequently, and even preschoolers eat six times
tems, or gastrointestinal abnormalities may experi- a day when meals and snacks are considered. Inter-
ence significant difficulties with feeding. ventions with infants often begin with non-nutritive
Feeding is an experience rich in sensory stimula- sucking and oral-motor programs to normalize tone,
tion that also demands internal processing to coor- build tolerance for touch in the facial and mouth
dinate breathing, digestion, postural control, and areas, and promote oral motor skills. Knowledge
alignment. Feeding problems are often a result of about positioning options is especially important as
multiple issues such as anatomical abnormalities, positioning continues to change as the infant grows
motor dysfunction, sensory dysfunction, medical and gains head control. Respiratory issues may
complications, psychological conditions, growth promote the infant to push into abnormal patterns
abnormalities, difficulty with social interactions, or to protect or increase the size of the airway. The
behavioral issues. Some infants who take more than ideal position for the older infant involves a firm
30 minutes to suck a bottle may actually be burning base of support with hips symmetrical and neutral,
more calories than they ingest. Morris and Klein adequate trunk support, feet support, and neutral
(2000) suggest that sensory or medical problems head and neck with slight chin tuck. This is often
that interfere with feeding develop into more com- difficult to achieve without additional supports.
plex emotional and behavioral issues. The occupa- Most toddlers become somewhat pickier in
tional therapist working in EI must have a detailed their eating patterns; however, some children with
understanding of normal feeding development, disabilities will exhibit significant food refusal or
experience with pediatric feeding issues, and knowl- selectivity. Food neophobia is a fear of new foods.
edge of common interventions. Many children between the ages of 2 and 3 exhibit
Most children’s hospitals have feeding teams this behavior, but it diminishes by age 5 (Ernsperger
available to conduct feeding evaluations. These & Stegen-Hanson, 2004). They will need repeated
teams are multidisciplinary and take a holistic view, presentations of new foods before the foods will be
involve the parents, and typically have the medical accepted.
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Children with food selectivity accept a very lim- should be documented for the child’s record, with
ited number of foods; may avoid entire food groups; copies for the parent and therapist. Feeding pro-
may avoid specific textures, temperatures, or flavors; grams should be closely monitored and updated
or may refuse to eat foods that are not presented in regularly.
the same manner such as the size, shape, or plate. Effective feeding strategies include:
Complete evaluation of the sensory system and
• minimizing the negative effects of medical
sensory preferences is warranted to determine if
influences,
hyper- or hyposensitivities are part of this problem.
• improving oral motor function,
Some children are unable to focus on feeding
• establishing appropriate positioning,
because of distractions in the environment. An
• modifying the environment as needed,
observation guide can help identify potential
• promoting appetite and desire to eat,
distractions. Wooster (1999) developed a feeding
• promoting eating as a pleasurable and desir-
observation guide to assist the occupational therapist
able experience,
when observing meal times with parents and infants.
• providing adaptive equipment as indicated,
A parent meal time questionnaire was developed by
and
Morris and Klein (2000). In addition, Wooster
• ensuring adequate nutritional and hydration
(2000) described more specific feeding interventions
needs are consistently met.
for children with nonorganic failure to thrive.
Adaptive equipment may include a variety of Not all children will consume enough calories by
types of bottles, nipples, and cups to promote safe mouth; therefore, supplemental feedings may need
nutritional intake and improve sucking skills. As the to continue. The acquisition of skills for oral eating
infant grows older, finger feeding and then feeding and saliva control are often valued by parents and
with utensils will be introduced. Additionally, more may allow children to participate in culturally sig-
children are able to drink from straws at much ear- nificant events, such as tasting their own birthday
lier ages than previously recorded in the literature cake or participating in a religious event.
(Hunt, Lewis, Reisel, Woldrup, & Wooster, 2000).
There are many more pieces of adaptive equipment Dental Care
to consider, which include spoons, cups, bowls, Children with developmental disabilities are at high
plates, and forks. Morris and Klein (2000) offer risk to develop dental disease. Many children have
guidelines for choosing a variety of pieces of feeding dental alterations or malocclusions that make chew-
adaptive equipment. Positioning is usually more ing more difficult and increase risk for decay. Dental
upright, and a variety of commercial products such decay is related to the presence of bacteria. Children
as high chairs and booster seats are commonly used who fall asleep after nursing or drinking a bottle are
and may offer opportunities for adaptations. Some at great risk. A high, narrow palate may become a
styles of high chairs offer a slight tilt as well as more place where food particles lodge. The three most im-
than one tray size and height adjustment. A more portant factors for protecting already formed teeth
physically involved child may still need to be held from decay are maintaining good oral hygiene, lim-
or positioned well in a customized seat. iting ingestion of carbohydrates, and eliminating or
A pre-feeding program may be designed to nor- reducing cavity-causing bacteria (Acs, Ng, Helpin,
malize any abnormal tone and promote cheek, lip, Rosenberg, & Canion, 2007).
and tongue movement and sensory stimulation Young infants can be introduced to a soft baby
prior to eating. If adaptive equipment is required, it toothbrush that fits over the adult’s finger. This is
is set up and ready for the feeding process. Parents used for sensory stimulation of the gums and clean-
should be key members and engage in the decision ing of the gums and emerging teeth. Next, a NUK
making to keep meal times manageable. The feeding brush set is introduced to get the infant used to
program and specific techniques should be demon- longer, brush-like instruments being placed in the
strated and practiced; the parent should carry this mouth. This includes a set of three instruments that
out with the therapist present and garner feedback start out larger and round and end with one resem-
for revisions of the process. The feeding program bling a toothbrush. Once this is tolerated well, the
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child can be transitioned to a regular, soft child- children under age 3 include adaptive skills as com-
sized toothbrush. Most children under the age of 6 ponents, such as the Hawaii Early Learning Profile-
do not have the dexterity to adequately brush their Revised (Furuno, O’Reiley, Hosaka, Zeisloft, &
teeth. Children should be encouraged to participate Allman, 1997), the Early Learning Accomplishment
by holding and moving the toothbrush; however, Profile (Glover, Preminger, & Sanford, 1988), and
an adult needs to go over the entire mouth area to the Carolina Curriculum for Infants and Toddlers
provide adequate cleaning. A child who is willing to (Johnson-Martin, Attermeier, & Hacker, 2004). The
use a battery operated toothbrush may do a more Pediatric Evaluation of Disability Inventory is useful
thorough job. Children need to establish the dental for children 6 months up to age 7 and evaluates
hygiene routines as part of their daily self-care skills. self-care, social, and mobility skills (Haley, Coster,
Ludlow, Haltiwanger, & Andrellos, 1992). The
Dressing Wee-Fim has recently been revised to include two
Parents will be dressing and undressing children sev- versions that evaluate self-care, mobility, and cogni-
eral times daily for diaper changes and cleanliness. tion (Hamilton & Granger, 2000)
Children with specific medical conditions or those
that require extensive procedures daily may do best Toilet Training
with limited clothing or clothing that is adapted to Toilet or “potty” training is a skill often introduced
allow easy access for parents to get to a gastrostomy during the second year of life. It is a complex task
tube (G-Tube), that is large or flexible enough to go and involves identification of sensory signals, com-
around or over braces or casts, or that has enlarged munication, positioning (usually sitting up), and
neck holes to make it easier to get overhead. Some active control of muscles. Bowel control is usually
infants, especially in colder winter months, may achieved first. As the infant’s bowel or bladder fills,
respond negatively to being undressed. Discuss with the muscles relax and release automatically and the
the parents their comfort level with these procedures infant urinates or defecates. However, as the toddler
and the need for any clothing adaptation to speed up gains control over these functions, the cerebral cor-
the process and minimize the discomfort to the child. tex sends signals to inhibit the reflexes and the child
There are multiple opportunities each day for takes over the control. This skill is often identified
practicing undressing and dressing in the natural as a hallmark of development.
context. Going outside in winter often requires put- There are multiple books written about a variety
ting on a sweater, jacket, or coat and removing these of potty training programs for parents to consider;
when we return inside. Going to the bathroom pro- however, none are targeted specifically for the child
motes the partial removal of pants and underpants with a disability. This process takes fine-tuning and
to the knees and then back up. Sometimes parents sometimes months to master in a normally develop-
find it easiest to adapt the clothing by eliminating ing child with the motor control and cognition to
all fasteners and choosing elastic-waist, loose-fitting achieve it. A child with a disability may require a
clothes that are quickly pulled down. Bath time medical evaluation to determine if a bladder prob-
promotes the removal of clothing and afterwards lem exists and if the bladder is trainable before potty
putting on sleepwear. A child who wants to go training can begin. A child with a disability to the
swimming may be motivated to help participate in corticospinal tract or spinal cord may be unable to
changing into a swim suit. Children are encouraged inhibit the autonomic nervous system, resulting in
by parents to partially participate in the dressing difficulty in gaining this control.
process as much as time allows. Infants may lift and Positioning is a key component of potty training.
arm or leg and push it into a sleeve by their first The youngest children are often placed on small, sta-
birthday. This process needs to be facilitated and ble floor-sitting potty chairs as the standard in-home
practiced in children with disabilities. toilets are too high. Children with motor delays and
A thorough evaluation and an understanding abnormal tone will need the occupational therapist
of the dressing routines will help the occupational to evaluate positioning needs for the potty chair.
therapist provide the appropriate interventions and Adaptations may need to be made to a commercially
expectations for parents. Many evaluations for available chair, or a customized potty chair will be
2580_Ch09_133-147 16/07/13 2:50 PM Page 144
required to promote correct sitting alignment. Simeonsson and Bailey (1990) identified a hierar-
Often a tray is helpful to provide some arm stability, chy of parental involvement, representing a contin-
which can assist with sitting up and is useful to place uum from passive to active participation, for EI.
communication cards or devices to indicate when Families will fluctuate in the levels, depending on the
“all done.” At times, trays are helpful to restrict the environmental demands and their coping abilities at
child’s access to touching the feces. the time. At the lowest level is elective noninvolvement,
Tracking success is helpful for both the parent in which the family chooses not to be involved in the
and the child. Often a daily chart with stickers is child’s care. Information seeking is another level of
used to promote success and provide visual rein- involvement in which the family focuses on gathering
forcement for the child. The parents may need to information and developing skills. Partnership is
track more carefully the accidents and determine if when the family views themselves in a reciprocal
the timing of placement on the potty chair needs interaction and decision making process with the
adjusting. Often when clock changes are made to health care providers. At the highest level, the family
accommodate daylight savings time, the adults need assumes the role of advocacy for their child. Some
to remember the child’s body is still on the old families may need the help of the therapist to teach
schedule and will need time to make the adjust- them how to be advocates for their own needs and
ments. Parents must want to work on this skill and empower them to make decisions for themselves and
be committed for success to be achieved. their child. Identifying the level at which the family
After toileting, children need to learn the routine is functioning, at a given time, will assist the occupa-
of hand washing. Some children can easily move to tional therapist in determining appropriate caregiving
the sink, use a step stool, and begin to learn the steps roles within the family.
of hand washing. Often a hand washing song is used The nature of the activity can also affect which
to promote an adequate scrubbing time. Some chil- family members are available to help. Every parent
dren may need to clean their hands with antibacterial needs time for personal hygiene, meal preparation,
germ products while seated on the toilet. These rou- and care of siblings. The therapist can demonstrate
tines need to be established early on in the process to ways the child can be placed in a safe and independ-
minimize the risk of infection and help children ent play position when a parent is most likely to be
establish the connection between the two tasks. Shep- busy. Siblings can be involved by showing them ways
herd (2005) offers a variety of strategies for improving to play with and monitor the child. This, of course,
participation in self-care tasks, including simple depends on the ages and abilities of the siblings.
picture sequences, task adaptations, environmental
modification, clothing adaptation, and task analysis Parent and Caregiver Instruction
with interventions for toileting skill development. Occupational therapy home programs need to be
designed specifically for each child and fit within the
Family Involvement in Intervention family routines and context. Research indicates
A family-centered philosophy is based on the as- home programs are important for children with dis-
sumption that the parents know best. This philosophy abilities (Schreiber, Effgen, & Palisano, 1995). A
is consistent with occupational therapy practice well-designed home program includes therapeutic
(American Occupational Therapy Association, 2008). interventions that are embedded within everyday
The parents, viewed as partners with the service routine tasks to ease the caregiver strain and to pro-
providers, are expected to be advocates for their child. mote the child’s functional skills (Anderson &
The role of service providers is to meet the needs of Schoelkopf, 1996; Hinojosa, 1990; Rainforth &
the family by providing the information and instruc- Salisbury, 1988). Programs that have assisted par-
tion designated as important by the parents. Accepting ents in their interactions with the child have had
parental reports as reliable information, allowing better outcomes than services focused exclusively on
parents to help define goals, letting parents lead the the child (Bonnier, 2008; Hebbeler et al., 2007).
discussions, and allowing parents to have questions Caregiver instruction and written directions in-
ready for the team to problem solve together are all crease the likelihood of carryover by the caregivers
aspects of family-centered care. (Simon, 1988). Parent instruction is an ongoing
2580_Ch09_133-147 16/07/13 2:50 PM Page 145
process that includes modeling the practice of skills In this chapter, the authors reviewed the need for
and specific behaviors, and includes feedback on and role of occupational therapists in EI, the evalu-
performance. Case-Smith and Nastro (1993) found ation process, and strategies for intervention. The
that mothers preferred the use of written handouts skills required of an EI occupational therapist
with pictures of specific activities. Often, simple, include skilled observation and evaluation, flexibility
clear diagrams, placed in strategic locations, can be in scheduling, good time management, knowledge
great aids to reinforce these activities. For example, of community agencies and resources, awareness of
placing pictures near the changing table (and just cultural and religious diversity, and excellent com-
inside the diaper bag) demonstrating how to relax munication skills.
the child with high tone, the best position for the Therapists who desire to work in EI should con-
child during diaper changing, and some simple sider their abilities and seek additional continuing
range of motion exercises may be most effective. education. Experience with children and youth, an
Feeding documentation is placed in the appropriate understanding of medical testing, and knowledge
area of the home, such as in the kitchen on the of pediatric assessment tools are helpful. Know-
refrigerator. It may include a photograph of best ledge of standardized and nonstandardized assess-
positioning, needed equipment, and a bulleted ment tools and their use is essential. Familiarity
reminder of techniques to promote feeding skills. with basal and ceiling age criteria, administering
Practicing techniques with parents and interested and scoring, and the interpretation of test scores is
family members can provide reassurance. also important. Awareness of the expertise that
occupational therapy and other service providers
bring to the EI team is important as well. Each
Conclusion state has created competencies that must be met
by all early intervention team members. Specific
Community-based EI practice can be isolating at continuing education and experiences are usually
times, and unique and challenging at other times. required but can vary by state.
CASE STUDIES
CASE STUDY 9•1 Juan
Juan is a 22-month-old toddler with developmental delay. He has just been referred to early intervention
by his pediatrician. Juan lives in a small apartment with his parents. His mother stays at home to care for
him and she is currently 4 months pregnant. The language spoken at home is Spanish; however, both
parents know some English. Parental concerns include Juan’s lack of eye contact, not eating more foods,
getting upset with noises, and difficulty taking him to unfamiliar environments. His mother reports he
can finger feed, eats fewer than 10 different foods on a regular basis, and only drinks room temperature
water. Some days he will just play with his food, and his mother then attempts to feed him. He has lots
of toys but plays with the same toys each day, mostly dropping them, throwing them, or lining them up
in a pattern. He wakes up two to three times per night. His mother has been leaving him in his crib, and
sometimes he will go back to sleep. Lately he is starting to try to climb out, and the parents are con-
cerned he will get hurt. They want to transition him to a bed before their new baby is born but do not
want him roaming around the apartment at night. They sometimes bring him into their bed, but he is
restless and does not go back to sleep. When outside, he runs around and sometimes spins around. He
likes the sandbox and will sit and watch the sand fall through his fingers. He loves television, especially
Diego, but the TV volume must be low and he wants to stand right at the screen. Your observation of
play identifies repetitive play patterns, lining up of toys, lack of eye contact, inconsistent response to his
name, and some self-stimulation with hand flapping.
Continued
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CASE STUDY 9•1 Juan cont’d
CASE STUDY 9•1 Discussion Questions

1. Which of Juan’s behaviors are indicative of possible sensory dysfunction?
2. Which assessment tools could an occupational therapist utilize to further evaluate Juan’s occupational
performance and developmental level for sensory, motor, self- care, and play skills? Why did you se-
lect these tools?
3. Research the “red flag” warning signs of autism in toddlers. Does Juan demonstrate any of these, and
if so, which ones?
4. What occupations would you observe as part of your skilled observation?
5. What suggestions might you make to help with Juan’s sleeping difficulties and safety?
Learning Activities Bronson, M., & Bundy, A. (2001). A correlational study of

the Test of Playfulness and the Test of Environmental
1. Design a “therapy kit” to keep in your car. Supports. Occupational Therapy Journal of Research, 21,
Name what equipment, supplies, and forms 223–240.
Case-Smith, J., & Nastro, M. (1993). The effect of occupa-
you would include in the kit. tional therapy intervention on mothers of children with
2. Research how to refer a child for early inter- cerebral palsy. American Journal of Occupational Therapy,
vention services in your area. 46, 11–817.
3. Identify local resources that would be available Decker, B. (1992). A comparison of the individualized
to help the early intervention occupational education plan and the individualized family service plan.
American Journal of Occupational Therapy, 46(3), 247–252.
therapist. Degangi, C. (1995). Infant toddler symptom checklist. San
Antonio, TX: Therapy Skill Builders/Psychological
Corporation.
Dunn, W. (2002). Infant toddler sensory profile. San
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Chapter 10
Community-Based Services
for Children and Youth
With Psychosocial Issues
Laurette Olson, PhD, OTR/L, FAOTA, and Courtney S. Sasse, MA EdL, MS, OTR/L
Policymakers and service providers in health, education, social services, and juvenile justice
have become invested in intervening early in children’s lives: they have come to appreciate
that mental health is inexorably linked with general health, child care, and success in the
classroom and inversely related to involvement in the juvenile justice system.
—U.S. Department of Health and Human Services [USDHHS], 1999, p. 133)
Learning Objectives
• Describe common mental health disorders of youth and the behavioral characteristics associated with those
disorders.
• Identify useful assessment tools for children and youth with mental health problems.
• Describe interventions that are appropriate to address the mental health problems of children and youth.
• Understand the role of after school programs and summer camps for the development of children and youth.
• Discuss potential roles for occupational therapy practitioners in community-based services for children and youth
with psychosocial issues.
Key Terms
After school programs (ASPs) Self-regulation
Culturally inclusive climate Sensory modulation programming
Effortful control Supportive parenting
Emotion-related self-regulation Temperament
Parent-child activity group
Introduction common mental health disorders that an occupa-

tional therapist may encounter in community-based
Prior to addressing the occupation-based mental practice, and occupation-based evaluation and in-
health needs of children and youth in community tervention for psychosocial issues will be provided
practice, a practitioner must first recognize the in this chapter. Occupational therapy practitioners
breadth and depth of these needs and then under- may encounter children and youth diagnosed with
stand the most common mental health disorders mental health disorders or youth at risk for devel-
seen in children and youth. Information about oping mental health disorders in a variety of com-
the prevalence of mental health issues, the most munity settings, including schools, after school
148
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Chapter 10 | Community-Based Services for Children and Youth With Psychosocial Issues 149
programs (ASPs), or settings such as day treatment Fisher, Bourdon, & Koretz, 2010). Blanchard,
programs, group homes, or residential treatment Gurka, and Blackman (2006) similarly reported that
facilities (Estes, Fette, & Scaffa, 2005). approximately 36% of parents in a national survey
Unstructured and unsupervised time spent outside of children’s health had concerns about depression
of school places at-risk children in danger of aca- and anxiety in their children. About one-fourth of
demic, behavioral, and social-emotional isolation. parents surveyed identified fears about substance
This increases the likelihood of behavior problems, abuse or eating disorders in their offspring. These
drug use, and risky behavior, as well as the likelihood parental concerns are critical to consider as health
of occupational deprivation. Two community-based and educational professionals develop community-
services that support the healthy development of based services. To address these parental concerns,
children, families, and youth—ASPs and summer occupational therapy practitioners collaborate with
camps—are highlighted in this chapter. other health or education professionals in designing
preventative or health promotion programming for
youth. Occupational therapists also might organize
Mental Health Disorders psycho-educational group programs for parents to
in Children and Youth address ways parents might use co-occupations to
reduce their children’s risk of developing mental
Mental health disorders are more prevalent among health disorders (Olson, 2010).
children and youth than previously acknowledged The most common mental disorders in children
(O’Connell, Boat, & Warner, 2009). A recent U.S. and youth are outlined in Table 10-1, including
epidemiological study found that in a nationally Attention Deficit Disorder, disruptive behavior
representative sample of children ages 8–15 years, disorders (Oppositional Defiant Disorder and
8.6% of the children were diagnosed with attention- Conduct Disorder), and Major Depressive Disor-
deficit/hyperactivity disorder (ADHD), 3.7% with der. Suicidality is a significant concern in this pop-
mood disorders, 2.1% with conduct disorders, 0.7% ulation. The U.S. Surgeon General (USDHHS,
with panic or generalized anxiety disorder, and 1999) reported that 90% of children and youth
0.1% with eating disorders (Merikangas, Brady, who committed suicide had a diagnosable mental
Table 10-1 Common Mental Health Disorders among Children and Youth
Disorder Symptoms Comorbid with Negatively impacts
ADHD • Hyperactivity • Learning disabilities • Academic performance
• Short attention span • Depression • Interpersonal/peer
• Impulsivity • Anxiety relationships
• Insufficient behavioral • Oppositional defiant • Sleep cycles
inhibition disorder • Ability to adapt to change
• Poor organizational skills • Sensory processing
disorders
Conduct Disorder Poor emotional and behav- • Negative mood states • Academic performance
(CD) ioral regulation resulting in: (depression) • Interpersonal/peer
• Aggressive behaviors that • ADHD relationships
violate social norms • Limited frustration • Ability to adapt to change
• Bullying behavior tolerance • Social problem solving
• Destruction of property
• Harming people or
animals
• Stealing
• Truancy
• Running away from home
(continued)
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Table 10-1 Common Mental Health Disorders among Children and Youth—cont’d
Disorder Symptoms Comorbid with Negatively impacts
Oppositional Poor emotional and behav- • Negative mood states • Academic performance
Defiant Disorder ioral regulation resulting in: (depression) • Interpersonal/peer
(ODD) • Negative, hostile, and • ADHD relationships
defiant behavior lasting • Limited frustration • Ability to adapt to change
more than 6 months tolerance • Social problem solving
• Noncompliance and • Substance abuse
argumentativeness with
caregivers
Major Depressive • Depressed and/or irritable • ADHD • Academic performance
Disorder (MDD) mood • Anxiety • Interpersonal/peer
• Loss of interest/pleasure • ODD relationships
in everyday activities • CD • Participation in
• Changes in appetite and play/leisure
sleep patterns • ADL performance
• Low energy levels
• Poor concentration
• Low self-esteem
• Feelings of hopelessness
Data from: American Psychiatric Association (2000), David-Ferdon & Kaslow (2008), Hathaway & Barkley
(2003), Reynolds & Lane (2009), Speltz et al. (1999), USDHHS (1999).
health disorder at the time of their death, with have had multiple exposures to traumatic events,
Major Depressive Disorder being the most com- including sexual or physical abuse, witnessing
mon. Many of these youth, at the time of suicide, community violence, or experiencing natural dis-
also had a concurrent anxiety disorder. Interper- asters such as Hurricane Katrina. Children re-
sonal conflicts and poor communication patterns spond in varied ways to these experiences, and
with parents are considered important risk factors some may show symptoms of post-traumatic stress
that lead to suicide attempts in vulnerable youth. disorder, anxiety, depression, or disruptive behav-
In addition to children formally diagnosed with ior disorders. Reports on the long-term impact
mental disorders, there are numerous children of trauma suggest that many of these children
at risk for mental health issues due to adversities still experience functional deficits into adulthood
related to poverty, family stress, and exposure to (Silverman, Ortiz, Viswesvaran, Burns, Kolko,
traumatic events. These children are not typically Putman, & Amaya-Jackson, 2008).
identified with a mental health disorder but may Children with difficult temperaments may en-
exhibit some of the behaviors consistent with one counter social and behavior difficulties and be at risk
or more disorders. Childhood adversities that for mental health issues (Dodge & Pettit, 2003;
are risk factors for mental health dysfunction Greene & Doyle, 1999). Temperament refers
include: interpersonal loss (e.g., parental death to a person’s inborn natural style and habitual
or divorce), parental maladjustment (e.g., mental way of responding to people, places, and things.
illness, substance abuse, criminality, and violence), Temperament includes such dimensions as activity
harsh parenting (e.g., physical abuse, sexual abuse, level, intensity, adaptability, persistence, mood, dis-
or neglect), and serious physical illness or family tractibility, and sensory threshold. According to
economic adversity. Costello, Erkanli, Fairbank, Chess and Thomas (1996), typical temperamental
and Angold (2002) reported that more than 25% patterns include easygoing or flexible, active or
of youth in the U.S. have been exposed to a trau- feisty, slow to warm up or cautious, and difficult.
matic event by the age of 16, and many youth Children with a difficult temperament are children
2580_Ch10_148-166 16/07/13 2:50 PM Page 151
who may have irregular sleep and eating patterns, Box 10-1 Components of Temperament
high activity levels, and intense negative moods. in Preschoolers
They are more irritable, are less flexible and adapt-
able, and more easily give up on tasks than children Children will have more or less of each of the follow-
with positive affectivity. Building on the earlier ing factors, the configuration of which describes
work of Chess and Thomas (1996), recent research temperament:
Sociability
suggests that temperament consists of “constitution-
ally based individual differences in emotional, Reflects the degree to which the child initiates
and/or dominates interpersonal relationships, and
motor, and attentional reactivity, as measured by the
his or her level of need for affiliation
latency, intensity, and recovery of response, and Positive Affect/Interest
self-regulation—processes such as effortful control
Refers to the child’s degree of engagement in tasks
and executive attention that modulate reactivity” and level of positive affect
(Rueda & Rothbart, 2009, p. 20). Effortful control Dysphoria
refers to “the ability to inhibit a dominant response Reflects the child’s degree and dominance of
in order to perform a subdominant response, detect negative affect, particularly anger and sadness
errors, and engage in planning” (Rueda & Rothbart, Fear/Inhibition
2009, p. 20). In a number of studies, temperament Refers to the child’s level of anticipation or expecta-
has been associated with patterns of coping tion of potential loss or punishment
(Rothbart & Bates, 2006). Constraint versus Impulsivity
Dyson, Olino, Durban, Goldsmith, and Klein Constraint reflects the child’s ability to inhibit a domi-
(2012) conducted a study of temperament in nant response and the tendency to be compliant,
preschoolers that was observational in nature as adhere to rules, and respect authority.
compared to many of the prior studies that were Impulsivity refers to reactive undercontrol and the
based on parental report. Through factor analysis, a inability to delay or wait for a desired goal or object.
five-factor model of temperament was generated
Data from: Dyson, M. W., Olino, T. M., Durbin, C. E., Goldsmith,
that consisted of: H. H., & Klein, D. N. (August 22, 2012). The structure of
temperament in preschoolers: A two-stage factor analytic
• sociability approach. Emotion. doi: 10.1037/a0025023.
• positive affect/interest
• dysphoria
• fear/inhibition
• constraint versus impulsivity (Box 10-1). Evaluation of Children
Children with high negative emotionality tend and Youth in Community-
to experience high levels of arousal in response to
novel or stressful situations and use avoidant cop-
Based Settings
ing strategies. Avoidant coping involves attempting Occupation-based assessments are an important
to escape the stressful situation and/or avoiding part of an interdisciplinary assessment of children
thinking about the problem. Children with higher at risk or those identified with mental health
levels of positive emotionality and effortful control issues. Occupational therapists have developed a
tend to be support seeking and use active cognitive number of tools that provide insight into the
coping. Active cognitive coping involves problem occupational participation, interests, and goals
solving strategies and cognitive reappraisal. Sup- of parents and children. The Short Child Occupa-
port seeking refers to the use of social supports tional Performance Evaluation (SCOPE) (Bowyer,
to solve the problem and/or to reduce negative af- Ross, Schwartz, Kielhofner, & Kramer, 2005) is an
fect (Rueda & Rothbart, 2009). It is important for assessment tool that provides an occupational ther-
parents to understand temperament as an innate apist with a broad overview of a child’s occupational
characteristic and to learn strategies for helping participation. It is structured to systematically eval-
their children express their temperament in ways uate factors that facilitate or restrict occupational
that promote occupational adaptation. participation. The SCOPE is grounded in the
2580_Ch10_148-166 16/07/13 2:50 PM Page 152
Model of Human Occupation (MOHO) (Bowyer, critical complement to other family-based assess-
Ross, Schwartz, Kielhofner, & Kramer, 2005) and ments. Occupational therapists also should in-
focuses assessment on the key constructs of skills, clude observing youth in some of their everyday
volition, habituation, and the environment. It is occupations as part of the assessment process,
simple to use and supports the development of especially those activities that have been identified
occupation-focused interventions. The Pediatric by youth or their caregivers as ones that are chal-
Interest Profile (Henry, 2000), also based on lenging for the youth. Occupational therapists
MOHO constructs, is a simple and time-efficient offer excellent skills in analyzing tasks and match-
assessment that provides an understanding of ing the clients’ skills and those occupational tasks.
children’s play interests and participation. It is a In this way, the need for skill development and/or
self-report tool that facilitates discussion of the task or environmental adaptations or supports can
youth’s leisure activities. be identified.
The Coping Skills Inventory (Zeitlin, 1985) is an
observation instrument that is useful in assessing
children’s behavior patterns and skills that support
a child’s coping strategies to meet personal needs
Considerations in Designing
and adapt to environmental demands. It frames the Interventions for Children
styles of coping strategies that children use into
active versus passive, productive versus nonproduc-
and Youth
tive, and flexible versus rigid styles. Williamson and Cognition (David-Ferdon & Kaslow, 2008;
Szczepanski (1999) developed a frame of reference Dishion & Stormshak, 2007; Eyberg, Nelson, &
for utilizing coping assessments and interventions Boggs, 2008), and coping and emotional regula-
within an occupational therapy framework. tion skills (Silverman et al., 2008) are supported
The Behavior Rating Inventory of Executive by evidenced-based literature and are considered
Functioning (BRIEF) (Gioia, Esquith, Guy, & mediators of positive change for children with
Kenworthy, 2000) includes caregiver and self-rating mental health disorders. Emotion-related self-
assessments that provide therapists with important regulation refers to “the process of initiating,
information about children’s executive functions avoiding, inhibiting, maintaining, or modulating
that are important for behavioral and emotional the occurrence, form, intensity, or duration of in-
regulation, including attention, flexibility, and emo- ternal feeling states, emotion-related physiological
tional control. attentional processes, motivational states, and/or
Sensory processing assessments such as the Sensory the behavioral concomitants of emotion in the
Profile (Dunn, 1999), Sensory Profile School Com- service of accomplishing affect-related biological
panion (Dunn, 2006), and Adolescent/Adult Sensory or social adaptation or achieving individual goals”
Profile (Brown & Dunn, 2002) also are helpful in (Eisenberg & Spinrad, 2004, p. 338).
better understanding children and youth responses to Self-regulation, the ability to modulate emo-
everyday sensory input. When working with youth tion, self-soothe, delay gratification, and tolerate
at risk or diagnosed with a mental health disorder, it change in the environment, is the subject of a
is important to interpret the results of any sensory great deal of developmental research (Clark,
processing assessment in light of the particular youth’s Woodward, Horwood, & Moor, 2008). Children
trauma and attachment histories. Deficits that may with a difficult temperament are more likely to
appear to be sensory-based may be rooted in past exhibit deficits in self-regulation that are related
exposure to trauma and/or inadequate caregiving. to temperament, including attention, approach,
In addition to standardized assessments, it is avoidance, inhibition, and typical mood state.
important that occupational therapists interview Eisenberg, Valiente, Fabes, Smith, Reiser, and
caregivers about the strengths and challenges the Shepart (2003) found that teaching self-regulation
caregivers experience in co-occupation with their strategies to youth prone to negative emotional
children with mental health disorders. Occupation- states is likely to increase the youths’ social compe-
based family assessments can be an effective and tence. Degnan, Calkins, Keane, and Hill-Soderlund
2580_Ch10_148-166 16/07/13 2:50 PM Page 153
(2008) examined how maternal behavior influences sounds, touch, and/or movement, and as a result
a child’s level of frustration, reactivity, emotion reg- children may experience frequent sensations of
ulation, and socially appropriate behavior. They flight, fight, or freeze. Koomar (2009) identified
found mothers might escalate their children’s reac- connections between assessment and intervention
tivity by maternal control, though children demon- methods used within a sensory integration frame-
strating less innate regulatory capacities appeared work with those used within an attachment-
to need increased structure and direction from informed trauma framework.
mothers. When children have difficulty regulating Davis-Kean, Huesmann, Jager, Collins, Bates,
emotions, behavior problems interfere with learn- and Lansford (2008) found links between beliefs
ing new skills as their behaviors alienate them from about one’s ability to perform a task (i.e., self-
peers and adults. As a result, these children may efficacy) and actual ability to perform a task.
have fewer opportunities to learn and practice Children who have positive beliefs about their
socially appropriate behaviors in their everyday own skills relative to a particular task or activity
environments (Hauser-Cram, Warfield, Shonkoff, are more likely to succeed at the task than children
& Krauss, 2001). who have negative beliefs about their own capac-
The developmental research literature also pro- ities. Davis-Kean et al. (2008) suggest that a
vides key insights for occupational therapy practi- primary way to change children’s behaviors related
tioners preparing to provide services for children to task performance and peer relationships is to
with mental illness and their families. Vondra and change their belief system. They recommend that
Barnett (1999) suggest that parenting impacts an in- intervention focus on children’s beliefs about their
fant’s developing neurological system. They found capacities and the effectiveness of their behavioral
that infants who are insecurely attached to their strategies, as these beliefs are in formation and
caregivers have higher cortisol levels than infants are more amenable to change in childhood. In this
who are securely attached to their caregivers. High way, children’s beliefs about their capacities might
cortisol levels are present when a person experiences be supportive of more positive and successful
stress. A principal hypothesis within attachment the- behaviors.
ory is that parental sensitivity impacts the quality of Hauser-Cram et al. (2001) found that mastery
a parent-child attachment relationship. Pettit, Bates, motivation (i.e., persistence on problem-posing
and Dodge (1997) identified supportive parenting tasks) was a positive predictor of change in children
as key to children’s health and positive develop- with disabilities, including growth in mental age and
ment. They correlated supportive parenting with mastery of daily living skills. Bandura (1995) stated
positive school adjustment and potentially buffering that mastery promotes positive emotions. If children
children from the negative effects of family adver- understand their errors, they are more likely to
sity. Supportive parenting is demonstrated in a persist at a task, which supports developmental
number of ways, including parent to child warmth, progress. In the study by Hauser-Cram et al. (2001),
proactive teaching, inductive discipline, and positive children who showed greater growth in mental age
involvement with children. The emphasis placed on and in social and communication skills had mothers
different features of supportive parenting may vary who were more responsive and growth promoting
depending on family context and culture. in parent-child interactions.
LeBel, Champagne, Stromberg, and Coyle
(2010) reviewed the literature on the effects of
trauma on an individual’s capacity to process and
integrate sensory information and regulate emo-
Intervention Approaches
tional states. Early trauma negatively impacts for Community-Based
children’s abilities to sustain or develop secure
attachment relationships. Children experiencing
Programming
trauma are vulnerable to living in a dysregulated Two of many possible approaches in community-
state of arousal. This dysregulation may be accom- based interventions are described below. These ex-
panied by symptoms of sensory sensitivity to amples provide a sampling of the wide array of
2580_Ch10_148-166 16/07/13 2:50 PM Page 154
programs that can be developed and customized to specific categories of sensation, regardless of the ob-
meet the mental health needs of children and youth, ject or person producing the sight, sound, smell, etc.
families, and communities. The origin of children’s behavior affects intervention
choices. Occupational therapists can be important
team members intervening with children with
Interventions to Develop trauma by using their knowledge of sensory organ-
Self-Regulation izing and modulating methods with these children.
Augustyniak, Brooks, Rinaldo, Bogner, and Hodges Developing protective spaces and introducing
(2009) identified self-regulation capacities as a sensory comforts supports children with trauma
central underpinning of social competence. In pro- by lowering their state of arousal, which can en-
moting children’s self-regulatory capacities, an oc- able their participation in classroom activities and
cupational therapy practitioner may apply Williams social activities. Though sensory strategies may help
and Shellenburger’s (1994) structured psychoedu- ameliorate the behavioral symptoms of trauma and
cational group approach to helping children become related sensory modulation dysfunction, it is impor-
aware of how sensory input impacts one’s level of tant to make decisions about interventions with
arousal and physiological state. It is then important these children based upon observations of the child,
to teach children how to use that knowledge to along with information about history of trauma and
regulate their own physiological state for successful attachment disorders (Koomar, 2009).
participation in their daily activities. An occupational therapy practitioner may inter-
Conte, Snyder, and McGuffin (2008) favor vene by teaching children with behavior disorders
developing youth’s internal coping methods, as self-management strategies such as self-monitoring
opposed to using passive or strictly behavioral and self-evaluation. Jenson, Olympia, Farley, and
approaches for controlling the aggressive behavior Clark (2004) found that teaching children how to
of youth with mental illness. Children with mental actively recruit feedback and praise from adults was
illness often experience intervention as being very effective in creating more positive social envi-
forced on them. In response to a staff member’s ronments for these children in academic settings.
demand or limit, the child’s behavior may escalate These researchers also stated that it is critical for stu-
as the child feels threatened and fears restraint. dents to match their own self-evaluations to their
In support of youth developing self-regulatory teachers’ evaluations of their behavior. When these
capacities and learning strategies for coping with students were positively reinforced for close matches
stress, occupational therapists have applied sensory in their evaluation of their own behavior with their
processing strategies (Champagne, 2010; Champagne, teachers’ evaluations, students were more successful
Koomar, & Olson, 2010). They recommend use of in modifying their behavior in ways that led to pos-
sensory processing strategies as a trauma sensitive itive feedback from adults (Jenson et al., 2004).
intervention to help an individual restore a sense of
personal control and safety. Key components of sen-
sory modulation programming are assessing, explor-
Interventions to Increase Social
ing sensory tendencies and preferences, creating and Task Competence
sensory diets, modifying physical environments, and Jackson and Arbesman (2005) reviewed the evidence
educating caregivers (LeBel et al., 2010). related to activity-based interventions for children
Koomar (2009) stated that it is important that and youth and reported that these interventions aid
occupational therapists be trained to recognize the in improving peer and social interaction. Activity
symptoms of trauma and dissociation in order to group participants developed increased ability to re-
avoid incorrect assumptions about behaviors being spond to adult direction, and comply with social
due to underlying sensory modulation or integration norms and expectations. In addition, they exhibited
deficits. Children with trauma backgrounds are trig- increased task-focused behavior. They identified
gered by specific sensory experiences associated with effective interventions, such as direct instruction for
past abuse. Children with sensory modulation dis- targeted skill development, the use of activities to
orders may be moved into a state of overarousal by teach and encourage the practice of new skills, the
2580_Ch10_148-166 16/07/13 2:50 PM Page 155
use of peers to model and promote practice of new Children’s Residential Centers, 2009) advocate
skills, supportive adults to coach and reinforce moving beyond intervening with children to also
appropriate behavior, and sufficient length of time actively partnering with families in meaningful ways
to provide opportunity to experience interventions to support children’s mental health functioning
and practice-emerging skills. (Estes, Fette, & Scaffa, 2005). Research on depres-
Occupation-based groups can be structured to sion, disruptive behavior disorders, and ADHD
support children’s development of self-efficacy has identified interventions that support the devel-
and their positive beliefs about their own abilities opment of parenting skills and family competence
to succeed in their everyday tasks. Bandura (1995) as key elements in effective mental health interven-
describes four pathways to self-efficacy: mastery tions. The American Association of Children’s Res-
experiences, vicarious experiences, social persua- idential Centers (2009) reports that family members
sion, and physiological and emotional state regu- of youth with mental illness exhibit a preference for
lation. Occupation-based groups can be structured hands-on assistance to support their skill develop-
to provide all of these experiences. ment for engaging with their children with mental
Occupational therapy practitioners may also illness as opposed to traditional psychotherapeutic
apply psychoeducational group methods to their in- methods. Affronti and Levinson-Johnson (2009)
terventions. Delucia-Waack (2006) provides clear advocate that programs designed to provide services
guidance on the application of these group methods for youth with serious mental health issues support
for children and youth. When leaders use a psycho- family competence by actively engaging parents in
educational group approach, they focus on applying positive activities and program events.
learning theory to first teach group members specific The literature related to children with ADHD
skills or strategies for everyday occupational partici- and disruptive behavior disorders addresses the
pation, such as social skills or coping with bullies. importance of breaking negative cycles of interac-
Leaders provide a brief lesson and then give members tion and building positive interaction between these
the opportunity to discuss and then practice skills children and their parents. Olson (2006a) describes
within the safety of the group. After exploring skills parent-child activity group interventions that
in activities with peers, group members then discuss support parents in learning how activity and their
how the skills learned and practiced might be useful approach to co-occupation with their children can
in their everyday lives beyond the group. Williamson support or hinder interaction with their children. In
and Dorman (2002) demonstrate the use of psycho- the process of interacting together in a therapeutic
educational methods in an occupation-based group environment, parents and children realize and begin
designed to teach children skills for social participa- to apply new ways of interacting with each other be-
tion. Psychoeducational group methods also are yond the therapeutic group sessions.
helpful as preparatory strategies to support children’s Parent-child occupation-based groups, in the
participation in a task-oriented group. early stages of the change process, ease tensions that
Larson, Hansen, and Moneta (2006) explored how often exist between children with mental health
a variety of organized youth activities promote differ- disorders and their caregivers, increase children’s
ent developmental skills. For example, they identified interest and motivation for participation in play in
the potential of team sports for supporting youth’s the presence of their caregivers, and increase parents’
development of capacities for goal setting, sustaining expectations for positive and playful interactions
effort, and managing emotion. Their analysis of service with their children. Parents and children ready to
learning youth activities suggested that well-run pro- change their everyday patterns of interacting are fa-
grams support interpersonal development and facili- cilitated by a parent-child group that provides them
tate youth’s connections to adult networks. with strategies and activities that can be practiced
and transferred to home and community environ-
ments. A leader of an occupation-based parent-child
Family-Based Interventions group structures the therapeutic group environment
Leaders in the treatment of children with serious so that parents and children experience successful
mental health disorders (American Association of and positive play that is under their own control.
2580_Ch10_148-166 16/07/13 2:50 PM Page 156
The leader assists parents and children in adapting ASPs. Youth who participated in ASPs demon-
activities to support the full participation of both. strated significant positive changes in their feelings
A leader tactfully cues both parents and children in and attitudes towards school, their self-confidence,
actively listening to one another’s verbal and non- and their demonstration of positive social behaviors.
verbal cues as is developmentally and therapeutically These youth also exhibited a decrease in negative
appropriate. Olson (2006b) emphasizes that it is behaviors, including aggression, noncompliance,
important for a group leader to carefully choose and disruptive conduct. The researchers emphasized
activities that promote positive interaction, as well that ASPs that used evidence-based skill training
as ways of facilitating conversation between parents approaches were consistently successful in produc-
and children. ing positive outcomes for youth, while programs
In a qualitative study of one parent-child group that did not use evidenced-based skill training ap-
that included children hospitalized with psychiatric proaches failed to demonstrate success.
disorders and their parents, Olson (2006c) reported Similarly, researchers also suggest that structured,
that parents and children stated the group provided well-organized after school activities have a powerful
them with an opportunity to interact in a positive impact on youths’ transition to adulthood. Larson
way. This was important to both parents and chil- (2007) reported connections between youth partic-
dren, to lessen the impact of recent negative experi- ipation in productive out-of-school activities and
ences with each other that had been argumentative, school completion, adult employment, and civic par-
aggressive, or hostile. ticipation. Youths participating in extracurricular
activities along with their peer network were less
likely to drop out of school and to get involved in
After School Programs antisocial activities. This is especially true among
youth at highest risk for persistent antisocial behavior
After school programs (ASPs) can be key commu- due to multiple disadvantages (Mahoney, 2000).
nity services for supporting positive social develop- ASPs can provide youth with an alternative envi-
ment and preventing negative developmental ronment that is more aligned with their interests,
trajectories, especially for children from low-income motivations, and needs than their academic environ-
families (Marshall et al., 1997; Morrison, Storino, ment during school hours. Effective youth activity
Robertson, Weissglass, & Dondero, 2000; Posner programs are highly organized and structured to
& Vandell, 1994). Children from low-income fam- include regular meeting times, competent adult lead-
ilies who participated in a high-quality ASP demon- ership, and an emphasis on increasingly complex skill
strated better grades, peer relations, and emotional building within group activities.
adaptation (Posner & Vandell, 1994). Academic Mehsy (2002) advocates that leaders of ASPs
performance and conduct were negatively correlated create culturally inclusive climates so that all
with amount of time spent in outdoor unorganized youth, regardless of gender, race, ethnicity, religion,
activities. Posner and Vandell (1999) also conducted or sexual orientation, feel welcome in the program.
a longitudinal study looking at children in grades 3 A number of concrete suggestions are offered to
through 5. It was concluded that African American guide ASP developers in ways to increase youth’s
children who received higher grades in third grade cultural literacy and competency, and civic and
were more likely to participate in structured outdoor moral development. Organized activities can en-
activities after school, as well as more likely to par- courage youth to explore and share different aspects
ticipate in after school extracurricular activities. of their cultural and ethnic background or engage
These successful children were less likely to have par- youth in activities and dialogues that examine and
ticipated in unstructured and unsupervised after challenge media portrayals of different cultural
school activities. In addition, teachers reported that groups or foster examination of their own and their
children who participated in after school activities peers’ family and cultural values and beliefs.
in the third grade adjusted better in the fifth grade. ASPs can promote social development by provid-
Miller (2003) described the Harvard Family ing critical opportunities for youth to socialize out-
Research Project that included a meta-analysis of side of their primary peer group in school or in their
2580_Ch10_148-166 16/07/13 2:50 PM Page 157
neighborhood. Youth can learn and practice positive Box 10-2 Example of an After-School
conflict resolution and learn cooperative behaviors Group
by working in teams. An after school group activity
designed to enhance social skills is outlined in Healthy Snacks and Edible Art Group
Box 10-2. Civic and moral development can be Goals:
supported through the examination of family, cul- Participants will:
tural, and peer group values and beliefs; the sharing • Demonstrate the social skills necessary to work as
of moral dilemmas; and presentations about the way a group, including following group rules, taking
turns in shared activities, and simple, social
in which different cultures might apply their values
problem solving skills.
to solving the dilemmas. Youth also might be en- • Learn to follow simple recipes for healthy snacks.
gaged in activities such as surveying their local com- Overall Group Plan:
munities about current social and political issues or In the first group session, the leaders introduce the
volunteering their time and skills to support the theme of the group and share potential recipes with
functioning of their communities. group members. The leaders then address the im-
portance of rules for getting along and having fun.
Group members are guided in articulating key rules
Family-Based Programming in ASPs and making a group rules poster. The group leaders
ASPs have the potential for strengthening the link give group members choices for recipes for creating
between schools and families. Out-of-school pro- a healthy snack that requires minimal to no cooking.
grams that engage families have shown that parents Child-friendly recipes, such as making a banana-pear
are more involved in children’s education and caterpillar and an edible scooter snack made from
pretzels, string cheese, and vegetables, are used.
school. Parents and children in such programs
In subsequent group sessions:
also demonstrate improved relationships and report 1. Group members read a chosen recipe. The leaders
fewer arguments and increased trust in one another. demonstrate key components of the recipe and
ASPs with family engagement also have improved provide simple pictured and printed instructions.
program outcomes for children socially and academ- 2. The children and leaders identify which key food
ically. Barriers to engaging parents included limited preparation skills are needed, which skills group
professional resources for designing programs to members already have, and which they need to
engage families, and inadequate monetary resources learn or need an adult to do.
for staffing and implementing programs. In 3. They identify key social skills that are needed
one study of ASPs, only 27% had family engage- for group members to work together and have
ment programming (Kakli, Krieder, Little, Buck, fun while successfully creating healthy snacks/
edible art.
& Coffey, 2008).
4. Children follow the recipes working parallel or in
Kakli et al. (2008) surveyed urban African teams of two.
American and Latino parents whose children par- 5. Children and leaders work out social and task
ticipated in ASPs in low-income neighborhoods. problems as a group.
These parents reported that spending more time 6. Children with the help of group leaders take a
with their children would make them better picture of the healthy snack creation.
parents, but they also stated that they were faced 7. Children and leaders share the snack with each
with multiple challenges in their communities other and/or wrap up snacks to bring home.
and had little support beyond their immediate 8. Each child puts a copy of the recipe in his or
families. In response to these research findings, her individual healthy snack recipe book.
Kakli et al. (2008) advocate for rethinking ways 9. Children work with leaders to clean up the
group room.
to support low-income, urban parents of children
10. Group members discuss what happened in the
participating in ASPs. They have suggested that group, what they learned, and what was impor-
ASPs include complementary learning experiences tant to remember for future group sessions.
for families, including engaging parents in advo- They also discuss what they learned that they
cacy, leadership, event organization, parenting could use at home or at school.
workshops, and activities with their children.
2580_Ch10_148-166 16/07/13 2:50 PM Page 158
Interactions with families in ASPs typically ideas of their children. Though parents were ac-
focus on problems rather than child and family quainted with other families participating in the
assets. Though it is important to engage parents ASP Family Night Programs, they stated that they
in individual and group program activities to had not sat down and interacted with these families
address problems, it also is important to engage before the Family Night Program. They reported
them in ways that facilitate use and further devel- that they enjoyed the sense of community that was
opment of their strengths and assets. Parents are typically lacking in their neighborhood.
most often invited to general information sessions, Some parents also reported that their parent-
parent-support or parenting training groups, or child activity experiences within these groups were
GED classes, but they are less often provided with in contrast to their experiences with their children
formal opportunities to participate in group activ- at home, where television and children’s individual
ities with their own children. Providing opportu- use of computers were dominant activities (Olson,
nities to enjoy activities with their children while Agunwa, Anderson, & Evangelista, 2011). In ad-
also expanding their repertoire of inexpensive dition to promoting increased parent-child inter-
family activities is one way to accomplish this action, occupation-based family night programs
goal. Parents of low-income children who attend might also serve as a vehicle to engage and support
ASPs have limited or no access to programs that families as children make, develop, and experience
support and provide opportunities for them to physical and school-based transitions. Dishion,
engage in productive activities with their children Shaw, Connell, Gardner, Weaver, and Wilson
in the company of other parents and children. (2008) highlighted the unique opportunities that
Program staff may wrongly assume that if parents natural transitions in child development provide
are not proactive in engaging with the ASP, they for helping families promote health and reduce
are uninvolved and do not care about their chil- developmental risks for children. Entry into
dren’s learning. When parents are invited to par- kindergarten or middle school and physical matu-
ticipate in engaging, supportive, and proactive ration of preadolescents are events in a child’s life
family-based activities, they are more likely to that make demands on youth and require families
respond and interact with program staff. to reorganize in response to the changes in youth
In addition, engaging parents with their children and societal or community demands. Dishion
in family-based activities is consistent with the et al. (2008) note that parents may be more open
research on the importance of parent-child relation- to interventions and support during these transi-
ships. According to the Institute of Medicine, tions, and stress the importance of identifying and
positive development in children is associated with promoting positive parenting practices to prevent
emotionally responsive parent-child relationships children’s problem behavior. Occupation-based ac-
(O’Connell et al., 2009). A hypothesis of attach- tivities can be structured so that parents have the
ment theory is that parental sensitivity influences opportunity to not only learn and practice positive
the quality of parent-child attachment. Parent- parenting practices but also experience the power
child occupation-based groups engage parents in and benefit of these practices as they interact with
enjoyable, productive, and meaningful interactions their children in mutual activity.
with their children, while also providing opportu-
nities for communicating and understanding their
own children. Parents participating in one urban, Summer Camps
occupation-based Family Night Program provided
as part of an ASP for low-income families reported Over the past few decades, there has been an
that what they enjoyed most was the opportunity increase in focus on developing summer camp
to sit down as a family to do projects and talk experiences for children with disabilities (Briery
together. They reported that they had the chance & Rabian, 1999; Gieri, 2001; Michalski, Mishna,
to observe their children’s creativity and hear the Worthington, & Cummings, 2003; O’Mahar,
2580_Ch10_148-166 16/07/13 2:50 PM Page 159
Holmbeck, Jandasek, & Zukerman, 2010) as well trainers within community-based programs such as
as including children with disabilities in camps ASPs, summer camps, and group homes. There
with typically developing children (Brannan, also is a great need for the staff of these programs
Fullerton, Arick, Robb, & Bender, 2003). In a to understand children’s behavior and learn ways
summer camp, children with disabilities, like to support children’s underlying capacities for self-
other children, have a chance to be viewed in a regulation. Self-regulation has been related to
different light than they are in their home com- adaptive functioning in children from low-income
munity. The children and adults they meet at families (Buckner, Mezzacappa, & Beardsle, 2009).
camp are meeting them for the first time or see An occupational therapist might lead a short-term
them only in the summer. Therefore, the devel- self-regulation group and then provide consulta-
opmental struggles or behavioral challenges that tion and intermittent in-services for staff, so that
the children may have experienced over a number self-regulation strategies become a routine practice
of years at their schools or in their communities within programming.
are irrelevant to their new companions. Though many community-based programs typ-
For parents of children with disabilities, summer ically do not have the funding to have occupa-
camps can provide respite from caregiving respon- tional therapy practitioners as group leaders or as
sibilities, an opportunity to learn about children’s staff members, ASPs and other similar programs
potential for functioning away from home, and can offer excellent fieldwork or service learning
new strategies for supporting children’s indepen- opportunities for occupational therapy students
dence and skill development at home. In addition to working under the supervision of occupational
a 3-week camp experience for youth with learning therapists. Bazyk and Bazyk (2009) described
and emotional disabilities, Michalski et al. (2003) the outcomes of preventative occupation-based
described a program that provided parents with op- groups, developed by graduate students. Through
portunities to learn strategies to support their chil- the group the children develop social-emotional
dren in applying new skills learned at camp to their competencies while also being exposed to new
home and community environments. Participating leisure occupations. Qualitative data collected
parents reported significant gains in children’s skills suggested that children found the groups to be fun
related to social participation, including coopera- and that they learned how to work together and
tion, responsibility, and self-control in follow-up share. Children also stated that they learned how
telephone interviews. to express their feelings and respond in healthy
ways when they became angry. Olson (2010) pro-
vides guidance in developing and implementing
Conclusion groups for children.
Blanchard et al. (2006) emphasize the impor-
A significant number of children in the United tance of participation in everyday activities as
States suffer from mental health adversities and dis- critical for children’s development, as well as for
orders. These issues develop or are exacerbated by their quality of life and life outcomes. They call on
child and environmental factors such as unstruc- health professionals and communities to put more
tured time spent outside of school. Occupational focus on finding creative ways to more fully and
therapy practitioners are well suited for collaborat- productively engage children with developmental
ing with other professionals in identifying and issues, including emotional and behavior disorders,
analyzing the barriers to children’s and youth’s in everyday life within their communities. This is
mental health functioning, as well as for providing at the core of an occupational therapy practi-
occupation-based interventions that support their tioner’s skill set. It is crucial that occupational
physical and mental health and those of their care- therapy practitioners step forward to meet the chal-
givers. Occupational therapy practitioners have lenge along with other health professional groups
a great deal to offer as consultants and in-service and community leaders.
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CASE STUDIES
CASE STUDY 10•1 Sean and Serena
Sean is a 9-year-old boy in the third grade who was recently discharged from a residential facility for
children with serious emotional disturbances. He previously has been diagnosed with Attention Deficit
Disorder and Oppositional Defiant Disorder. He has experienced a number of childhood adversities. His
parents divorced when he was a toddler. His mother suffered from postpartum depression after his birth
and attempted suicide. She was briefly hospitalized after his birth. After Sean’s parents divorced, he and
his mother moved into a shelter and received public assistance until she moved in with a new boyfriend
when he was 3 years old. Sean was placed in the care of his maternal grandparents when he was 4 years
old due to physical abuse by his mother’s boyfriend. He returned to his mother’s care 1 year later after
she completed court mandated parenting classes and psychiatric counseling. Sean was placed in a special
education class at the start of kindergarten and was diagnosed with ADHD.
In second grade, Oppositional Defiant Disorder was added to his diagnoses. When Sean was 8 years
old, he was again removed from his mother’s care due to physical abuse on the part of his mother. After
being placed in foster care for 1 month, he threatened to commit suicide by jumping off the roof of his
foster home. He was then hospitalized for 3 months and subsequently was placed with his foster family
again. He attends school and after-school care and receives intensive individual and family counseling
four times per week with his social worker and foster care counselor. Sean’s therapy team coordinates
their schedules so that two of the days of the week they are able to provide his interventions at the ASP
site and coordinate interventions with the ASP staff. The occupational therapist is the member of Sean’s
team, whose role is to coordinate services.
Sean presents as distractible and disorganized with loose, illogical thinking. He is argumentative,
disrespectful, defiant, and non-compliant with adult caregivers. He is easily provoked to verbally and
physically attacking peers. His psychological testing indicates that his intelligence falls in the low end
of average, but his performance suggests that his mental health issues may have limited his IQ score,
and he may have high average intelligence.
Serena is a 7-year-old African American girl who attends the second grade at the same school that
Sean attends and participates in the ASP that is offered at their elementary school. Serena lives with her
mother in a one-bedroom apartment close to her elementary school. Ms. Smith, Serena’s mother, had
a long-term relationship with Serena’s father Mr. Murphy, but never married him. She terminated the
relationship 2 years ago after experiencing verbal and physical abuse for many years. Mr. Murphy lives
in the neighborhood but rarely sees Serena. He works intermittently and is known to have a drug and
alcohol problem. Ms. Smith works as a waitress in a local coffee shop.
Serena’s teacher describes her as often impulsive and inattentive in class. Serena enjoys group activities and
seeks out friendship, but she tends to get into difficulty with her peers. She has difficulty waiting her turn
and grabs materials from peers when she wants them. When she gets frustrated during group activities on the
playground, she frequently becomes verbally aggressive with peers and storms away from her peer group.
As part of fieldwork education experiences embedded with their academic education, graduate occupa-
tional therapy students from one occupational therapy program provide a series of occupation-based groups
for the ASP that Serena and Sean attend. The ASP director assigned Serena to two occupation-based groups:
Healthy Snacks and Edible Art, and Girls’ Friendship and Crafts group. See Box 10-2 for the Healthy Snacks
and Edible Art Group Protocol; see Box 10-3 for the Girls’ Friendship and Crafts Group Protocol.
Serena enthusiastically participated in both groups with six female peers over the course of the school
year. Serena initially became embroiled in verbal altercations with a few of her fellow group members
over small differences, such as position in line prior to group or taking turns in activities. Group rules
were developed, displayed, and reviewed at each group session. For the first four sessions of each group,
Serena and a few of her peers received at least one time-out because of a verbal altercation between two
girls. To help group members to learn to consciously manage their impulsivity in social interactions, a
2580_Ch10_148-166 16/07/13 2:50 PM Page 161
behavior self-rating form was created and used in both occupation-based groups (Table 10-2). Each group
member filled out an individual form at the end of each group session. The group leaders then facilitated a
discussion about the girls’ overall cooperation with each other. As the girls became accustomed to the rating
form, the leaders also encouraged the girls to positively reinforce one another as the girls demonstrated the
positive behaviors addressed in the form. Over the course of 2 months of group participation, Serena was
successful in participating in most group activities and was able to resolve disagreements with fellow group
members within the structure of the group. Serena’s teacher also reported that Serena was developing more
positive peer interactions within class, especially with her fellow group members.
Sean participated in the occupation-based cooking group where he could learn to bake a variety of
desserts while also learning to collaborate and negotiate with a small group of peers. Although Sean is
often distracted during other activities, following recipes that are task specific has improved his ability
to focus his attention. He seems proud of his culinary efforts.

1. Compare and contrast Sean and Serena’s problems and how they affect each child with regard to their
occupational performance.
2. What strengths are noted in these children? How might potential strengths be highlighted?
3. What interpersonal skills should a child of Sean’s age demonstrate?
4. How might home life have contributed to problems with coping, communication, and peer interaction?
5. In what ways might the occupational therapist collaborate with the special education teacher, other
teachers, family members, and parents to address Sean and Serena’s academic problems? What behav-
ioral suggestions can you make to the occupational therapy students who will work with Sean and
Serena in the ASP?
Box 10-3 Girls’ Friendship and Crafts Group
Goals: In subsequent group sessions:

Participants will: 1. An activity from the list developed by the group is
1. Demonstrate key social skills for supporting the introduced and demonstrated.
development of friendship including turn taking. 2. Group members discuss how the activity relates
2. Demonstrate key task skills for participating in to friendship and their friendships or developing
simple craft activities. friendships with each other.
3. Seek help from adults and peers when challenged 3. The children identify what is going to be easy to
by a group activity. do in the activity and what is likely to be difficult
4. Help peers when peers are challenged by a group or challenging. The leaders facilitate a discussion
activity or part of a group activity that is not as about how the girls will ask for help if they need
challenging to them. help. Group members also discuss how they might
help one another.
In the first group session, the leaders introduce 4. As social or task challenges arise, children and
the theme of the group and lead a discussion with group leaders discuss and choose potential
the girls on what kind of craft activities would best solutions to address the challenges.
represent friendship. The leaders make a few sugges- 5. Group members complete projects and then
tions, such as making friendship bracelets, group clean up.
picture frames, group banners, and keepsake boxes,
and then facilitate the girls brainstorming their own After completing the activity of the day, group
ideas and preferences. The leaders then facilitate a members discuss what occurred in the group, what
discussion about the importance of group rules for they learned, and what is important to remember
getting along and having fun. Group members are for future group sessions. They also discuss how
then guided in articulating key rules and in making they might use what they learned at home or at
a poster of group rules. school.
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Table 10-2 Girls’ Self-Rating Behavior Scale for Occupation-Based Groups

Behavior 3 2 1
I respected the personal space of the other girls and took my place in line.
I waited my turn to speak and listened to the other girls when they were speaking.
I took turns in our group activity.
When I had a problem, I worked with the leaders and other group members to solve it.
I followed our group rules.
3) means that I was a star and regularly demonstrated the behavior throughout the group
without a leader or other group member reminding me.
2) means that I demonstrated the behavior most of the time and needed a reminder
or two.
1) means that I had trouble with this behavior today and need to work on it for our next
group session.
Learning Activities support their occupational functioning? If

there is an occupational therapist working
1. Conduct an online search to locate a local at the camp, what is his or her role? If not,
chapter of a family self-help group for children what potential roles might an occupational
with mental health disorders. Call the chapter therapist fill?
and ask whether you can attend a meeting or
get in touch with a local member so that you
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SECTION IV
Productive Aging
Chapter 11
Driving and Community Mobility

for Older Adults
Wendy B. Stav, PhD, OTR/L, SCDCM, FAOTA
Leave sooner, drive slower, live longer.

—A highway safety billboard message
Learning Objectives
• Identify the contribution of driving and community mobility to occupational engagement, quality of life, and health.
• Describe the occupational and health consequences of not being mobile in the community.
• Discuss the importance of developing referral pathways in the development of a driving rehabilitation program.
• Identify funding sources for driving rehabilitation services.
• Discuss credentialing for driving rehabilitation programs and personnel.
• Identify the range of occupational therapy community mobility interventions.
Key Terms
Community mobility Paratransit
Driving Transportation alternatives
Driving rehabilitation
Occupational enabler
167
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168 SECTION IV | Productive Aging
Introduction do not address the needs of many aging individuals

who do not possess the cognitive, physical, and/or
Community mobility is a critical necessity to occu- sensory performance skills to operate an automo-
pational engagement and fulfillment of life as an bile. The community is the ideal setting in which
occupational being. The American Occupational to address driving and community mobility in its
Therapy Association (AOTA) defines community entirety to enable seniors to remain mobile and
mobility as “moving around in the community and actively engaged in their communities.
using public or private transportation, such as driv-
ing, walking, bicycling, or accessing and riding in
buses, taxi cabs, or other transportation systems” Contributions of Driving
(2008a, p. 631). Attention to community mobility
in the United States is largely focused on driving
and Community Mobility
due to a constellation of factors, including the geo- Driving and community mobility play a vital role in
graphic dispersion of most communities, the auto- the performance of several other areas of occupation,
mobile dependent culture, the lack of transit including Instrumental Activities of Daily Living
infrastructure in most areas, and the need to access (IADL), education, work, leisure, and social partici-
the community in order to engage in several areas pation (AOTA, 2008a, p. 628). Although commu-
of occupation. Driving falls within the domain of nity mobility is classified as an IADL, it is often
community mobility (AOTA, 2008a) and refers necessary to be mobile in the community in order to
specifically to the operation of an automobile, in- engage in other IADL such as care of others, care of
corporating motor performance skills to manipulate pets, child rearing, financial management, health
the vehicle controls, sensory perceptual performance management, home establishment and management,
skills for awareness of the driving environment, and religious observance, and shopping (AOTA, 2008a,
cognitive performance skills to maneuver safely p. 631). Individuals must travel to medical appoint-
throughout a variety of contexts (Pierce, 2002). The ments, places of worship, and retail establishments
driving rehabilitation practice area is currently a to obtain goods and services for successful engage-
high-profile area of specialization due to steady ment in IADLs. Older adults often continue to en-
research funding since the 1990s, politically moti- gage in educational occupations in the form of
vated agendas and advocacy related to senior driver lifelong learning programs, museum trips, and sem-
licensing guidelines, and emotionally charged driv- inars and lectures offered by community centers.
ing outcome decisions for both families and older Travel to the venue of learning in order to actively
adults. The purpose of this chapter is to discuss participate in these educational pursuits is a necessary
issues related to driving and community mobility first step. Work also is an area of occupational en-
for older adults. gagement for older adults as many individuals main-
According to the 2000 census data there were tain their employment for personal or financial
over 49 million people with some type of long-term reasons or enlist in volunteer activities. These occu-
condition or disability, with almost 14 million of pations may require an individual to travel through
them over the age of 65 (Waldrop & Stern, 2003). the community. Engagement in leisure and social
Diagnosis with a disabling condition may not participation occupations often requires access to the
hinder occupational engagement, but for many community whenever the venue is outside of the in-
(18 million), their condition was so disabling it was dividual’s home. For instance, individuals who en-
difficult to travel outside of the home. The inability gage in book club meetings, the theater, and bridge
to travel outside of the home is particularly prob- clubs must travel to congregate with others for en-
lematic for almost 14 million adults age 65 or older gagement. The ability to access services located in the
(Waldrop & Stern, 2003). There is clearly a need community and engage in occupations contributes
for occupational therapy practitioners to be in- to a person’s life, well-being, and quality of life
volved in driving rehabilitation; however, the lim- (Glass, de Leon, Marottoli, & Berkman, 1999). The
ited number of programs and specialized workforce ability to travel within one’s community allows
in driving rehabilitation and community mobility for access to and participation in several areas of
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Chapter 11 | Driving and Community Mobility for Older Adults 169
occupation and elevates driving and community mo- educational pursuits. Although travel into the com-
bility beyond a single category of IADL. Driving and munity for engagement in these occupations is not
community mobility are occupational enablers be- life-sustaining, the lack of engagement in meaning-
cause they enable engagement in other areas of oc- ful occupations can lead to occupational deprivation
cupation (Stav & Lieberman, 2008). and can ultimately affect quality of life, life satisfac-
Engagement in driving or community mobility tion, and health (Glass et al., 1999). Marottoli and
is not required for engagement in sleep and rest. colleagues (1997) examined the health of older
However, one must engage in sufficient sleep and adults and found an increase in depressive symp-
rest in order to safely engage in driving and com- toms as individuals ceased driving. It is possible that
munity mobility. There are precautionary measures the emotional and psychological connection to driv-
related to sleep and driving in that individuals who ing is so strong that the loss of driving resulted in
are sleep deprived, have a sleep disorder, or are ex- depressive symptoms. However, it is more likely that
cessively drowsy due to medication or illness should the loss of driving caused a decrease in occupational
refrain from engaging in driving or community engagement, which reduced quality of life and re-
mobility until the sleep issues have been resolved sulted in depressive symptoms. There is evidence
(Vanlaar, Simpson, & Robertson, 2008). suggesting that engagement in physical, cognitive,
social, leisure, and religious activities; ADL and
IADL; and work/volunteering is associated with or
Consequences of Not even results in improved health compared to a lack
of engagement (Stav, Halleran, Lane, & Arbesman,
Engaging in Community 2012). This body of evidence informs occupational
Mobility therapy practitioners that it is important to promote
community mobility so older adults can continue
Although it is important to recognize the contribu- to be actively engaged in occupations and subse-
tion of community mobility to engagement in oc- quently experience improved health outcomes.
cupation, occupational therapy practitioners should
also be aware of the implications of not engaging in
community mobility. Due to the depth and breadth Alternatives to Driving
of potential negative outcomes following driving
cessation, practitioners and family members should It seems that the obvious solution to support older
carefully consider the individual’s community access adults who can no longer drive would be to transi-
needs, available support network, and transportation them to one of the many transportation alter-
tion options to allow for continued engagement in natives. Transportation alternatives are modes of
the community when making decisions about driv- transportation other than a person’s private automo-
ing retirement or taking away the car keys from an bile that promote travel within the community.
older adult. These may be publicly or privately funded and
The inability to be mobile within the community operated and can include bus or train transit, para-
severely limits access to necessary community-based transit, shared ride programs, volunteer driver pro-
resources such as the grocery store, pharmacy, and grams, shuttles, jitneys, fee-for-service rides such as
medical offices. Decreased access to these necessary taxis, or senior transportation services. Paratransit
destinations can have far-reaching implications, in- refers to flexible transportation that does not follow
cluding limited nutritional intake, poor or nonex- regular schedules or fixed routes and often provides
istent medication management, and insufficient curb-to-curb service. The option of transitioning a
contact with health care providers to manage health senior to a transportation alternative is often not a
needs. Individuals without community mobility are viable option for several reasons. The most common
further limited in their community access to non- problem with transportation alternatives is existence
essential but desired and meaningful destinations for of services in the location of origin, the destination,
religious observance, shopping, socialization, leisure or both. Although large metropolitan areas typically
pursuits, work and volunteer responsibilities, and have a full transit infrastructure and possibly even a
2580_Ch11_167-179 16/07/13 2:51 PM Page 170
subway or rapid transit system, they exist in only a It is also difficult logistically for older adults to
limited number of cities in the United States. Most manage community needs using transportation
of the geographic area of the United States is rural alternatives. A fixed route or even a scheduled
or suburban with limited or no existing transit sys- transportation service will not wait for travelers to
tem. The presence of a fixed-route transit system, complete their business to provide a ride home. In-
such as a bus or subway, is not sufficient to meet the stead, the vehicle continues providing transporta-
needs of an aging traveler if the origin or destination tion services to other users while riders are grocery
is not along that fixed route; therefore, other modes shopping, receiving medical care, or watching a
of transportation would be necessary. show at the theater. From a resource use perspec-
The existence of transportation services alone will tive this is an efficient manner to provide the most
not support community mobility if the individual services for the maximum number of consumers.
is unable to use the service. The very same perfor- However, from the traveler’s perspective it results
mance skills that hinder the ability to safely operate a in long wait times and unexpected delays for return
motor vehicle can also impede use of transportation trips home. An older adult using transit to travel
alternatives. For example, a visually impaired person to the grocery store may be using a bus operating
may be unable to read a bus schedule, complete a on a 45-minute loop, which allows a person
paratransit or accessible transportation application, 45 minutes to complete his or her business and
or travel from the point of drop-off to the destina- return to the front of the store for the return trip
tion independently. Similarly, an older adult with home. If complications arise and the person’s busi-
physical limitations that prevent operation of vehicle ness lasts slightly longer than the duration of the
controls may not be able to ascend or descend the loop, the person needs to wait for up to the full
steps on a bus, manipulate money or a bus pass duration of another loop for his or her return trip.
allowing ridership, or have the endurance to wait at If this were the only implication, it is surmount-
a bus stop. A person lacking the cognitive perfor- able; however, it typically sets off a chain reaction
mance skills to safely drive on public roadways may of missed transfers, extended periods of time sub-
not be able negotiate bus or train transfers, remem- jected to the climatic conditions, fatigue from
ber to call 24 hours in advance to schedule a ride, waiting and holding purchases, and possibly even
or plan the timing of a bus route to arrive at a spoiled or melted food.
destination on time. All of the performance impair- In addition to the complications of travel using
ments that caused an older adult to cease driving transportation alternatives, there are secondary is-
must be taken into consideration when choosing the sues for consideration when an older adult is not
transportation alternative that best fits the individ- able to travel using a private automobile. Access to
ual’s community travel needs. restrooms can become a problem for older adults,
Characteristics of the context such as climate, particularly males with prostate involvement, as
distance, and zoning may be detrimental to a per- buses used for public transportation typically do not
son’s community mobility. Extremes in weather, have restrooms. There is also no opportunity to stop
either very hot or very cold, can encumber a or reroute in response to restroom needs because
traveler’s ability to walk to and from pick-up and travel is occurring with others or on a fixed route.
drop-off locations and wait for buses or transfers. The previously described scenario with difficulty
Travelers also may have to endure long rides if they grocery shopping can ultimately result in poor nu-
live in more rural areas and have to travel farther trition due to difficulty carrying large quantities of
or if fixed routing extends trip durations. A person food or fresh foods that have potential for spoiling.
living in the back of a senior community and one Dairy products, fresh meat, and heavy fruits and
mile from the front gate may have to walk to a vegetables are often sacrificed for lightweight pre-
community shuttle stop to use the community pared foods with lower nutritional value for ease of
shuttle service for transport to the community en- transport home. Choosing lighter weight, preserved
trance, only to wait for an extended period of time foods in a single shopping trip may be preferred to
at the transit bus stop for the next transit bus for multiple smaller shopping trips per week due to the
travel to the destination. duration of each trip on transit, which can last as
2580_Ch11_167-179 16/07/13 2:51 PM Page 171
long as 3 hours depending on distance and required Driving Rehabilitation Program

waiting and transfers. Development
Rather than brave the elements, endure long wait
times, negotiate transfers, and pre-plan multi-step Driving rehabilitation programs are inherently
outings, many older adults choose to remain home community-based because the occupations of driving
and do without the services, resources, socialization, and community mobility occur in the community.
and occupational engagement awaiting them in There are several models for program development
the community. The result can be social isolation, to support a community-based perspective represent-
neglected health care, poor nutrition, depression, ing different settings or host agencies. The most com-
and reduced quality of life. Occupational therapy mon venues for driving rehabilitation programs are
practitioners should interrupt the path to these hospital-based programs, private practice settings,
negative health outcomes by addressing driving and and university-based programs (Finn, Gross, Hunt,
community mobility at a community level. McCarthy, Pierce, & Redepenning, 2004). These
settings, including the typical outpatient department
of hospital-based programs, offer access and connec-
Driving and Community tions to the community for a seamless transition back
to driving.
Mobility Practice The core principles of health program develop-
In 2006, the 30 million licensed drivers over the age ment apply to driving rehabilitation programs with
of 65 represented 15% of all licensed drivers in the the addition of considerations for the high cost of
United States (National Highway Traffic Safety Ad- equipment, specialty trained personnel, automobile
ministration [NHTSA], 2009). Crash data from insurance and liability issues, and state-based cre-
2007 revealed that older adults accounted for dentialing or designation (Stav, 2004). Despite
196,000 of the injuries in traffic crashes and com- the similarities in program development principles,
prised 14% of all traffic-related fatalities for the year individuals and facilities working to develop or sus-
(NHTSA, 2009). Although older adult crash, in- tain a driving rehabilitation or community mobility
jury, and fatality rates are disproportionately higher program encounter several barriers. The top six
compared with those of their younger counterparts barriers, client willingness/ability to privately pay
when controlled for annual miles driven, stereotyp- for services, funds to develop a program, access to
ical age-related driving changes are not the cause. trained specialists to provide services, third-party
Rather, the rates represent the high incidence of age- reimbursement to pay for services, concerns about
related illnesses that impair driving performance and risk and liability, and time to address driving, were
the increased frailty and fragility of an aging body, identified by more than 50% of the 2,800 study
which make it more difficult to sustain the energy respondents (Stav, Snider-Weidley, & Love, 2011).
forces of a crash (Eberhard, 2008). Occupational These issues function as barriers to increasing the
therapy can play a role in reducing the crash, injury, capacity of programs to meet the community
and fatality statistics by determining driving mobility needs of older adults. An expert consensus
capability for drivers with age-related performance panel was convened to generate strategies to over-
issues, providing intervention strategies to improve come the barriers. The outcome of the panel was an
performance or compensate for impairments, or online resource toolkit (AOTA, n.d.).
using individual or population-based injury preven-
tion approaches to reduce injuries and fatalities in Referral Pathways
the event of a crash. This role is fulfilled through the Developing a driving or community mobility pro-
specialty practice area of driving rehabilitation, gram is only the first step in meeting the community
which is the therapeutic approach focusing on the mobility needs of older adults. The next critical step
occupation of driving with consideration for the is developing a comprehensive referral network.
person’s (driver and passengers’) performance skills, Because the establishment of these referral relation-
the context in which driving takes place, and the ships is important and often time-consuming, it is
activity demands of performing the occupation. recommended that new programs invest time and
2580_Ch11_167-179 16/07/13 2:51 PM Page 172
effort developing a referral network before becoming timeliness of services for clients while supporting the
operational (AOTA, 2008c). Continued efforts to business of the facility. Marketing materials should
sustain and further build referral pathways are nec- be developed to create an easy, seamless referral.
essary even for established programs due to the Beyond the obvious brochures, materials containing
location of most community mobility programs the program’s name and contact information, such
outside of an existing health care network. as pens, key chains, sticky notes, and magnets, are
The strategies used to establish and maintain re- easily available, so referring practitioners do not have
ferral pathways are largely marketing techniques in- to search for information to make the referral.
corporating education about older driver safety and Many referrals originate from sources other than
“red flag” issues that should trigger a concern about physicians when social service workers, first respon-
safety and a subsequent referral. The first strategy ders, friends, family, and neighbors recognize the
involves gathering and disseminating information potential for risk with an older driver. Presenting
about the program and services offered; other types educational and marketing materials to a large range
of programs and services available, such as AARP’s of individuals and agencies is an excellent mecha-
Safe Driving Program; the laws related to licensure nism to raise awareness, dispel myths, and inform
in the state; medical reporting guidelines; ethical the public and providers about appropriate referrals.
guidelines for physicians and occupational therapy The range of health care disciplines, community
practitioners; and pertinent evidence related to driv- practitioners, and community organizations that can
ing with specific medical conditions (AOTA, be targeted for educational marketing efforts are
2008c). Providing information to potential referral identified in Box 11-1.
sources about whom to refer and on what basis Traffic incidents involving older adults are pre-
establishes a sound foundation and eliminates ques- sented in the local media through print or television.
tions about responsibility. Informing other depart- It is in the best interest of older adult consumers of
ments within your facility or health care network driving and community mobility services as well as
is equally important as it facilitates access to and the program to establish a relationship with local
Box 11-1 Targets for Education and Marketing Efforts
Health-Care Providers Community Practitioners Community Organizations

• Neurologists • Department of Transportation • Senior Centers
• Physiatrists • Department of Insurance • Offices on Aging
• Geriatricians • Medical Advisory Board at Driver • Community Centers
• Ophthalmologists Licensing Agencies • Civic Organizations
• Optometrists • Department of Children and Families • Lions Club
• Neuro Optometrists • State/County/Municipal Crisis Lines • Rotary Club
• Behavioral Optometrists • Municipal Planning Organizations • Kiwanis
• Orthopedists • Law Enforcement • Masons
• Endocrinologists • Fire Rescue • Support Groups
• Cardiologists • AAA • Stroke
• Internists • AARP • Diabetes
• Occupational Therapists • Jewish/Catholic Family Services • Multiple Sclerosis
• Physical Therapists • Risk Management Professionals • Alzheimer’s/Dementia
• Speech Language Pathologists • Traffic Lawyers • Parkinson’s
• Nurses • Traffic Court Judges • Neighborhood Alliances
• Social Workers • Case Managers • Political Organizations
• Case Managers • Managed Care Groups • Religious Social Groups
• Food/Grocery Delivery
• Pharmacies
• Automobile Dealerships
2580_Ch11_167-179 16/07/13 2:51 PM Page 173
news outlets to serve as a credible, trustworthy support continued community mobility for all
source of information (AOTA, 2008c) rather than members of the community.
fueling the stereotypes that are so frequently sensa-
tionalized. Once these relationships are established, Credentialing of Programs and Personnel
reporters will seek the professional advice of person- To add credibility to a driving or community mo-
nel in the program as it makes for a more credible bility program and assure legal operation, it is essen-
story. After these relationships have been nurtured, tial to secure the credentialing required by the state
the interaction becomes mutually beneficial for and valued by referring entities. There are two levels
the program and the reporter, resulting in special of credentialing; one is related to legitimizing the
interest stories, information pieces, and coverage of program or facility, and the other is credentialing the
community-based events. practitioners working in the program. Credentialing
the facility or the program is mandated by some
Funding states to provide a mechanism of regulation and
Reimbursement for driving rehabilitation services is protect the public. Not all states have such mandates,
limited due to Medicare’s recognition of driving as but states that do require such regulation mandate
“not medically necessary” (AOTA, 2008b). Other the program be designated as a driving school or
reimbursement sources include the Veterans Ad- other officially recognized entity capable of providing
ministration system, Medicaid in select states, and, driving instruction to new drivers. Operation of a
to a lesser extent for older adults, workers’ compen- program without the necessary credentialing is nei-
sation and state vocation rehabilitation agencies ther legal nor ethical. Parties interested in establish-
(AOTA, 2005b). The scarcity of third-party reim- ing a new program should inquire with the state
bursement for driving rehabilitation services has led agency authorized to grant the credential, which is
to the majority of payment for services being out-of typically the state Department of Motor Vehicles,
pocket. This creates obvious inequities and potential Driver Licensing, Highway Safety, or Education.
for occupational injustice for those who cannot Some states additionally mandate the personnel
afford the costly services, but clients and their family who work in the driving rehabilitation program to
members with sufficient resources typically find the be credentialed as certified driving instructors. The
means to pay for services because driving is a critical regulations vary considerably from state to state,
occupation in most people’s lives. ranging from no required credential to a weekend
Community mobility services outside of the pri- course to graduate-level coursework. Similar to op-
vate automobile are often fiscally supported by a erating a program without the required credential,
transportation agency through mandated paratran- it is neither ethical nor legal to practice without the
sit services or grant-funded programs to enhance required certification in a state that mandates such
accessibility. Grant-funding opportunities are avail- a designation. It is therefore imperative that prac-
able to support additional programs and services titioners seek the correct information about re-
through agencies such as United We Ride, which quired credentialing, which can typically be found
is an interagency federal national initiative geared within the same agency that oversees credentialing
toward coordinating transportation services (2006), of a program.
or foundations that support senior health and There are certification programs for personnel that
mobility, including the Beverly Foundation (2009) are voluntary but can add to the credibility of a pro-
and the Robert Wood Johnson Foundation (2009). gram and serve as a selling point for referrals. Efforts
Practitioners can also take creative measures to es- to designate those practitioners who specialize in driv-
tablish a fund for driving and community mobility ing rehabilitation from generalists have resulted in
services through legislation that taps into steady certification programs. The Association of Driver
transportation-related revenue streams, such as a Rehabilitation Specialists (ADED), an interdiscipli-
gas tax or additional fees on moving violations. nary organization, enacted the first certification pro-
Monies generated from a fraction of a cent on every gram in 1995 (ADED, 2007). The certification
gallon of gas sold in a state or from one additional designates individuals as certified driver rehabilitation
dollar on every speeding ticket quickly add up to specialists and awards a credential of CDRS. The
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CDRS credential indicates health care providers, occupations. Practitioners working with organiza-
driver educators/instructors, and equipment dealers tions seek to support transportation services pro-
who have met the certification requirements to “plan, vided by the organization, improve safety of those
develop, coordinate and implement driver rehabilita- traveling with that organization, and improve access
tion services for individuals with disabilities” (ADED, and use of transportation services. Interventions
2009, p. 1). Individuals who meet the educational aimed at serving a population are largely focused on
and experiential criteria and pass the certification injury prevention through educational initiatives
exam are awarded the CDRS credential. and policy development or refinement. The follow-
A certification program was developed by the ing are examples of interventions in the area of
AOTA and initiated in 2006. The certification, driving and community mobility for older adults
available only to occupational therapists and occu- across the three levels.
pational therapy assistants, designates individuals
as specialty certified in driving and community
mobility and awards a credential of SCDCM, or Interventions With the Person
SCADCM for occupational therapy assistants One of the most widely used functions of driving
(AOTA, 2009). The SCDCM or SCADCM iden- rehabilitation services for older adults is determina-
tifies occupational therapy practitioners who focus tion of medical fitness for driving through a com-
their practice on driving and community mobility prehensive evaluation. Driving evaluations typically
as opposed to generalist practice. Earning the cre- consist of a clinical assessment portion during
dential requires individuals to meet the experiential which vision, cognition, and motor performance
criteria and complete the reflective portfolio appli- are measured to identify risk factors and potential
cation according to the established competencies in problems while driving. The second portion of the
the practice area (AOTA, 2009). The SCDCM or evaluation is a behind-the-wheel assessment that
SCADCM certification program is based on a pro- measures driving performance in a naturalistic en-
fessional development program that is grounded vironment. Following both portions of the assess-
in the AOTA Standards of Continuing Competence ment, the occupational therapist synthesizes the
(AOTA, 2005a). Neither the CDRS nor the results combined with the individual’s history, pro-
SCDCM/SCADCM is required to practice in the gressive nature of the diagnosis, and potential for
area of driving rehabilitation. Although not re- rehabilitation, and makes a determination about
quired, a specialization credential is preferred as it medical fitness to drive (Stav, Hunt, & Arbesman,
demonstrates focused knowledge and experience 2006). As a result of the evaluation, recommenda-
and adds credibility when working with other team tions are made to the individual, the family, the
members and state agencies. referring physician, and often to the state Medical
Advisory Board. The permission or requirement to
report to the state, confidentiality of that report,
Role of Occupational and practitioner immunity from legal action de-
pend on state laws and vary considerably across
Therapy Practitioners the United States. A listing of each state’s medical
in Interventions reporting guidelines can be found in the American
Medical Association’s Physician’s Guide to Assessing
Consistent with the Occupational Therapy Practice and Counseling Older Drivers (Wang, Kosinski,
Framework, occupational therapy practitioners pro- Schwartzberg, & Shanklin, 2003) and should be
vide driving and community mobility intervention referred to prior to filing reports with the state
services to three different levels of client: the person, Medical Advisory Board.
organizations, and populations (AOTA, 2008a). In- Following the evaluation, many older drivers are
terventions to the person as a client focus on indi- referred for interventions to facilitate a return to
vidual people or families with limitations in driving. For individuals who have rehabilitation
engagement in community mobility or driving or potential to improve performance skills for a safe
who have a need to access other community-based return to driving, interventions are provided to
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remediate the deficit areas. This type of intervention mobility in support of occupational engagement in
may be focused on one or more of the performance the community.
skill areas to improve sensory perceptual skills,
motor and praxis skills, emotional regulation
skills, cognitive skills, or communication and social Interventions With Organizations
skills. In circumstances in which the client’s per- Occupational therapy practitioners may provide in-
formance skills cannot improve due to a permanent terventions on a larger scale to an entire organization
or progressive condition, the interventions may ad- to assist the organization in providing safe, effective,
dress training in the use of adaptive strategies or and efficient community mobility to its clients.
adaptive equipment to support a return to driving. Organizations that may utilize an occupational ther-
The decision to implement these adaptive interven- apy practitioner either as an employee or a consult-
tions should be made carefully and incorporate con- ant might include transportation agencies, senior
sideration of the client’s abilities for new learning centers, community centers, or places where older
(Stav et al., 2006) and ability to pay for the recom- adults travel for leisure, such as the movie theater.
mended assistive technology and training sessions. The range of services provided includes ensuring
Because Medicare does not reimburse for driving access to the transit, determining ridership eligibi-
rehabilitation services in most states (AOTA, 2005b), lity, and training of personnel.
clients must pay out of pocket for all vehicle modi- All public transportation agencies must meet
fications and training sessions, which can cost over accessibility guidelines set by federal law with regard
$2,000 depending on the equipment needed and to accessible transportation services for those who
the extent of training required. cannot benefit from fixed-route transit services
There are instances when it is no longer safe for (Americans with Disabilities Act of 1990, 1991).
an individual to drive and transportation alternatives Based on the legal requirements, occupational ther-
must be utilized to remain mobile in the commu- apists may work for the transit company to ensure
nity. In such cases, occupational therapy practition- continuous accessibility of bus stops and buses to
ers may facilitate community mobility planning for maximize ridership among travelers with disabilities.
driving retirement, offer travel training to build new Particular attention is paid to roadway shoulders,
skills in the use of transportation alternatives, or integrity of sidewalks, curb cuts, curb heights, and
provide support and assistance in the completion of shelters at bus stops.
paratransit applications. All of these interventions Some individuals are unable to use existing fixed-
take into the consideration the individual’s commu- route services because they cannot travel to bus stops,
nity mobility needs, the context of the community, negotiate the ingress and egress of the vehicle, nor plan
and the capacity of performance skills to negotiate transfers between multiple vehicles and routes. These
different transportation alternative systems. Specific individuals may be eligible for accessible transporta-
interventions may include route planning, money tion services for all their travel needs, only some trips,
management, or transfers on and off a vehicle to or only under certain conditions such as inclement
ensure independence in community mobility, so weather with ice and snow. Because the door-to-door
clients may focus their energies on the occupations service provided through paratransit is substantially
to which they are traveling. Professional training in more expensive than fixed-route transit, agencies are
the practice of travel training is available nationwide often concerned about eligibility of riders and limiting
through Easter Seal’s Project ACTION (2009). use of paratransit to only those who cannot use the
Regardless of the person’s ultimate mode of fixed-route system. This concern has led to the in-
transportation, the occupational therapy practi- volvement of occupational therapy practitioners, who
tioner may use advocacy strategies to help the client evaluate potential or existing users to determine eligi-
achieve optimal transportation. Advocacy efforts bility for the costly service. The role of the occupa-
can include promotion of access on a transit system, tional therapist may lead to simplification of the
requests for funding for adaptive equipment, or eligibility application process as the evaluations can be
support for continued licensure but will always customized to assess only the performance skill areas
focus on the ultimate goal of endorsing community affected by the diagnosis rather than maintaining a
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broad reaching evaluation protocol for every potential in a non-threatening, quick, and easily
rider. accessible manner. (AAA et al., 2008, p. 4)
Organization-based interventions with transit
CarFit uses a 12-point checklist to guide measure-
companies may also include the training of person-
ments and observations of older adults sitting in their
nel with regard to wheelchair management, safety
vehicles and a mechanism for open communication
with wheelchair tie-downs, wheelchair lifts, and
with recommendations specific to the areas of need.
behavioral management with riders. The training
Although the program does examine one individual at
may extend to include sensitivity training for em-
a time, it is not intervention based but provides struc-
ployees who work in scheduling, paratransit appli-
tured education to older drivers throughout the United
cation processors, and transport personnel specific
States. Other similar opportunities for population-
to cognitive issues, sensory loss, and privacy. These
based educational intervention exist within several traf-
same approaches might be used with other organi-
fic safety initiatives, such as Buckle-Up America, Drive
zations that provide transportation to older adults,
Well Toolkit: Promoting Older Driver Safety and
such as senior centers, to ensure fluid operation of
Mobility in Your Community, and Child Passenger
their transportation so travelers can arrive at their
Safety for grandparents who transport grandchildren.
destinations and engage in the intended occupation.
On a macro level, occupational therapy practi-
tioners can provide services in the area of policy de-
Interventions With Populations velopment related to both driving and community
mobility. Several states have state-wide special interest
Interventions with populations are far-reaching as
groups that meet regularly to discuss and modify
they aim to address an issue of all members of a
policies related to driver licensing, license renewal,
group who might be defined by a geographic region,
medical reporting, roadway design, transportation in-
diagnostic category, or experience. The approaches
frastructure, transportation disadvantage, and the role
tend to be preventative in nature and in the area of
of occupational therapy in determining medical fit-
traffic safety are usually aimed at reducing crashes,
ness to drive. Involvement in these groups offers an
injuries, and fatalities. Carfit is one very focused ex-
opportunity to influence policy, change laws, and
ample of a population-based intervention and func-
elevate the perception of occupational therapy in ad-
tions as a community-based educational program
dressing senior mobility issues. Even without the
developed to address driver-vehicle fit and vehicle
operation of these groups, occupational therapy prac-
safety feature use among older drivers in the United
titioners can educate and lobby for their legislators to
States. CarFit is a community-based program offer-
write and modify laws for the inclusion of occupa-
ing assessments of driver-vehicle fit to older drivers
tional therapy as a valuable resource in community
along with education to promote safe use of vehicles
design, medical fitness to drive, and review of driving
(American Automobile Association [AAA], AARP,
licensing standards for medically involved drivers.
AOTA, 2008). The primary purpose of CarFit is
On a smaller scale, although still population based,
to relay safety information, and it does not address
occupational therapists can influence population-
any evaluative functions to determine driver per-
based occupational engagement by working with
formance (AAA et al., 2008). The three objectives
community planners and collaborating with munic-
of CarFit agreed upon by all three collaborating
ipal planning organizations. These entities decide on
agencies and addressed by hundreds of volunteers
zoning and placement of a community’s infrastruc-
all over the United States are:
ture. An occupational therapy perspective is valuable
1. promote continued safe driving and mobil- in understanding the occupational patterns and needs
ity among older drivers by focusing atten- of the senior members of a community to making
tion on senior driver placement in their suggestions related to sidewalk width, curb cuts,
vehicle, crosswalk timing, angle of intersections, inclusion of
2. create an open environment that promotes protected left turn signals and left turn lanes, and the
conversations about driving, and location of residential versus recreational and com-
3. provide information, education, and mercial areas to minimize driving burdens and opti-
community-based resources to older drivers mize walking and biking opportunities. Many of
2580_Ch11_167-179 16/07/13 2:51 PM Page 177
these recommendations have already been suggested The range of therapeutic services related to driving
on a federal level through the Federal Highway Ad- and community mobility is substantial and includes
ministration’s Highway Design Handbook for Older evaluations and interventions specific to driving a pri-
Drivers and Pedestrians (2001); an occupational ther- vate automobile, identifying appropriate transporta-
apist can ensure the need to follow the recommendation alternatives and training in the use of those
tions due to the effects of aging on performance and services, supporting the services provided by transit
when capacity for engagement in activity is known. agencies through accessibility and personnel training,
and injury prevention initiatives to improve the health
and safety within an entire population. The role of the
Conclusion occupational therapy practitioner does not end with
the provision of clinical or consultative services in the
Community mobility is a vital area of occupational area of driving and community mobility. Other skills
engagement that contributes to productive, healthy such as marketing, education, and establishment of
aging for community-dwelling older adults. Not referral pathways and collaborative relationships are
only does community mobility serve as a means to essential. Practitioners working in the area of driving
travel from point A to point B but it also allows for and community mobility describe their programmatic
engagement in other areas of occupation. Because successes as being heavily dependent on these skills
of the significant impact of this one occupation on (Stav, 2012). Occupational therapy practitioners
the health of older adults, occupational therapists should hone their skills that support programs for
should pay particular attention to facilitating or sus- successful endeavors in the community-based practice
taining the community mobility of older adults. of driving and community mobility.
CASE STUDIES
CASE STUDY 11•1 Mr. Martin
Mr. Martin is a 78-year-old gentleman who sustained a left cerebral vascular accident and subsequent right
ankle fracture 3 months ago. He was referred to a driving rehabilitation program after he expressed a desire
to return to driving. An occupational profile reveals that Mr. Martin is married with three adult children
and five grandchildren. He was active in his grandchildren’s lives through attendance at their sporting
events and after-school activities, and through the responsibility of picking them up after school three days
per week. The family car was driven primarily by Mr. Martin to travel to medical appointments for him and
his wife, grocery shopping, and other outings. Mrs. Martin had limited her driving in recent years because
she felt her skills were slipping and had come to rely heavily on her husband for community mobility.
Mr. Martin also enjoyed an active golf hobby with friends every Sunday afternoon, weather permitting. The
primary stated client goal is to “return to driving so I can be myself again.” Assessments revealed intact cog-
nition; adequate vision within the state guidelines but a mild left visual field cut; right upper extremity use
within functional limits; and mildly impaired right lower extremity function due to sensory impairment,
mildly increased extensor tone, and decreased range of motion due to the fracture. A behind-the-wheel as-
sessment revealed that Mr. Martin has a strong foundation in driver safety, is aware of his limitations, but is
not able to safely operate an automobile with the manufacturer’s equipment. Driving rehabilitation services
are recommended for intervention to return Mr. Martin to driving.

1. What areas of occupational loss may Mr. Martin and his significant others experience as a result of his
driving limitations?
2. What types of interventions would be the most appropriate for Mr. Martin?
3. What strategies could be used to facilitate Mrs. Martin’s community mobility?
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CASE STUDY 11•2 Mrs. Brown
Mrs. Brown is a 69-year-old woman recently diagnosed with early stages of dementia whose physician is
concerned about her driving safety and propensity for getting lost. Her neurologist referred her to an oc-
cupational therapist to evaluate potential and develop a community mobility plan. Through the occupa-
tional profile, Mrs. Brown’s social history was revealed and it became apparent that she has limited
family support as she is a widow, has no children, and lives alone in an apartment with her two cats.
However, she does have a niece who lives in town. Since her husband passed away 6 years ago,
Mrs. Brown has been active in the community in a part-time volunteer position at the library two after-
noons per week when she reads to preschool children and assists with scheduling of outside groups that
use library meeting space. In addition, she has been an active member of her church, fulfilling the role of
ministering to the sick in their homes or at the hospital. Clinical assessments of Mrs. Brown’s perform-
ance indicates she has strengths in motor and praxis skills, visual perceptual skills, and communication
skills as well as a strong desire to be independent in community mobility. She does present with limita-
tions to independence due to impaired memory, organizational skills, and judgment, with slightly de-
creased attention span. Mrs. Brown’s community mobility performance was assessed both in driving her
car and negotiating the local transit system for the first time. She was able to operate her motor vehicle
with adequate safety, which is not surprising as she is just in the first stages of dementia; however, she ex-
presses concern about her own abilities. Mrs. Brown was able to navigate to the grocery store and library
using the local transit system in her small suburban town. She expressed comfort riding the bus and
locating her destinations because she knows the streets so well after living in town all her life.

1. Who will be impacted by Mrs. Brown’s limited community mobility and in what ways?
2. What are your concerns for Mrs. Brown regarding use of a fixed-route transit system?
3. What intervention strategies would you recommend to support Mrs. Brown’s continued community
mobility?
4. How could you support a transit agency in providing transportation services for riders with a range of
disabling conditions?
Learning Activities 3. Identify the stakeholders and potential referral

sources in your area if you were to develop a
1. Create a list of community transportation driving or community mobility program,
resources available to older adults in your com- along with strategies to establish a collabora-
munity with names, contact information, eligi- tive relationship.
bility, cost, scheduling guidelines, and travel
limitations such as distance, days, and hours
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pageid=119 adults. American Journal of Occupational Therapy. 66(3),
Association of Driver Rehabilitation Specialists (2009). 301–310.
Candidate handbook. Available from http://www. Stav, W. B., Hunt, L., & Arbesman, M. (2006). Driving and
driver-ed.org/files/public/ADED_Certification_Exam_ community mobility for older adults: Occupational therapy
handbook_2009.pdf practice guidelines. Bethesda, MD: AOTA Press.
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from http://beverlyfoundation.org/ editor. American Journal of Occupational Therapy, 62(2),
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Chapter 12
Adult Day Services Programs

and Assisted Living Facilities
Courtney S. Sasse, MA EdL, MS, OTR/L
How does one keep from “growing old inside”? Surely only in community. The only way
to make friends with time is to stay friends with people.... Taking community seriously
not only gives us the companionship we need, it also relieves us of the notion that we are
indispensable.
—Robert McAfee Brown
Learning Objectives
• Appreciate the impact of the geographic and demographic shifts in families in the United States
• Identify legislation and regulatory bodies that affect nursing homes, assisted living facilities, and adult services
centers.
• Describe the various models of providing services for older adults in day care programs and assisted living
facilities.
• Describe emerging roles for occupational therapy practitioners in adult day services programs and assisted living
facilities.
• Discuss ways that adult day services programs and assisted living facilities can enhance and support successful
aging for older adults, families, and communities.
Key Terms
Adult Day Services Centers/Programs (ADCs) Individualized Services Care Plan
Assisted Living Facilities (ALFs) Productive aging
CARF International Successful aging
Continuing Care Retirement Community (CCRC) The Joint Commission
Independent Living Community (ILC)
Introduction 1997, p. 11). This concept emphasizes productivity

across the aging continuum as a means of increasing
There is increasing emphasis in the literature on pro- quality of life. Successful aging is a more inclusive
ductive and successful aging as the “baby-boomers” term that includes “reaching one’s potential and
advance toward old age. Productive aging typically arriving at a level of physical, social and psycholog-
refers to “a broad perspective of aging that focuses ical well-being in an old age that is pleasing to both
on all valuable contributions that the elderly make self and others” (Gibson, 1995, p. 279). Successful
to our society through paid and unpaid work and aging focuses on optimization of well-being by build-
other occupational roles” (Gerson & Patterson, ing strengths rather than a deficits-based, medical
180
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Chapter 12 | Adult Day Services Programs and Assisted Living Facilities 181
model of aging. The goal of adult day services cen- Commission, formerly the Joint Commission
ters (ADCs) and assisted living facilities (ALFs) is to on Accreditation of Healthcare Organizations
enable successful aging by providing services needed (JCAHO), and CARF International, formerly the
by older adults. These programs are relatively new Commission on Accreditation of Rehabilitation
developments and have not always been available Facilities (McCormack, 2011; MetLife Mature
to seniors. Market Institute [MMMI], 2009).
Assisted Living Facilities (ALFs) are residential The Joint Commission is a private, indepen-
facilities that provide assistance with activities of dent nonprofit organization that provides volun-
daily living (ADLs) for people who do not require tary accreditation for almost 18,000 hospitals and
the skilled nursing or medical care available in nursing other health care agencies in the United States.
homes (United States Department of Health and Facilities are encouraged, if not required, by state
Human Services, (2011). The level of service in governments to attain accreditation from The
ALFs is generally limited to routine general protec- Joint Commission as a condition of licensure and
tive oversight and supportive services. Although receipt of Medicare reimbursement. CARF Inter-
nursing homes were once considered as one of few national is a private, nonprofit organization that
options for care of the elderly and disabled, more focuses primarily on human services organizations.
diverse and client-centered choices have evolved CARF International is widely recognized for
(Board of Scientific Counselors of the National accrediting programs and services in community
Center for Health Statistics [BSCNCHS], 2009; agencies, such as adult day services centers and
Love, 2010). In the 1990s, with changing demo- ALFs. The purpose of CARF is to “promote the
graphics and an increasing number of older adults quality, value, and optimal outcomes of services
living away from their extended families, came the through a consultative accreditation process that
emergence of assisted living facilities (ALFs). Other centers on enhancing the lives of the persons
factors contributing to the recent proliferation of served” (McCormack, 2011, p. 570). The American
ALFs include the aging of the baby-boom genera- Occupational Therapy Association (AOTA) has a
tion, a higher divorce rate, a lower birth rate, and long and well-established relationship with CARF
the increasing number of households with dual International, and the two agencies have collabo-
earners. The increase in women entering the work- rated on the development and revision of CARF
force has led to less care availability within the home standards, best practices, and the definition of
for family members who are elderly or have complex quality performance indicators in a variety of
medical needs (Bruce, 2006). rehabilitation contexts (McCormack, 2011).
Regulatory and Continuum of Care

Accrediting Agencies and Program Models
Because the typical ALF does not provide the A multidimensional approach to assessing, evalu-
extent of medical care that is required in nursing ating, treating, and supporting the elderly, those
homes, ALFs are less stringently regulated than with chronic disabilities, or those who wish to main-
nursing homes. They are typically regulated by tain health and well-being but who are unable to
local and state governments (Golant, 2004). Reg- age-in-place is needed. To meet the needs of older
ulation serves to protect the public and assure a adults in the community, the continuum of care
minimum quality of services. However, nursing consists of many options with differing levels of sup-
homes, ALFs, adult day services centers, and in- port. Three broad residential options exist in the
dependent living communities may also be accred- continuum of care: home care, ALFs, and nursing
ited. Accreditation is a process by which an homes.
agency, program, or institution demonstrates A fourth emerging residential option is the inde-
compliance with standards that exemplify best pendent living community. An independent living
practices. Accreditation agencies include The Joint community (ILC) is a place for senior citizens who
2580_Ch12_180-190 16/07/13 2:51 PM Page 182
desire to live independently, prefer to reside near Adult Day Services Programs
peers, have a need for additional security, and/or no and Home Care Agencies
longer wish to maintain a household or home. The
ILC bridges the gap between maintaining a house- Adult day services centers (ADCs) provide
hold independently and needing home care or as- community-based, client-centered coordinated pro-
sisted living (Tom, 2011). ILCs are sometimes grams that promote social, health care–related, or
referred to as retirement communities. rehabilitative services in a group setting to more
An alternative to residential options, adult day than 260,000 participants and family caregivers in
services centers provide care for adults with cognitive the United States (MMMI , 2009; NADSA, n.d.).
impairments or functional performance challenges ADCs vary in the specific services that they offer,
in a supportive group environment outside of the but most are defined by minimally offering the
home. Adult day services centers/programs, pro- following services: social activities; transportation,
grams that support social integration, community typically door-to-door services; provision of meals
participation, and the highest level of independence and snacks; personal care, which includes assistance
that is safely possible for clients, are an important with toileting, grooming, eating, and other ADLs;
source of support for families and respite from the and therapeutic activities and exercises. Nearly 50%
demands and responsibilities of caregiving. There are of adult day services centers offer comprehensive
approximately 4,600 adult day services programs rehabilitation and therapeutic interventions includ-
operating in the United States that provide a needed ing occupational, physical, and speech therapies
source of respite to family caregivers (National Adult (NADSA, n.d.).
Day Services Association [NADSA] n.d.). There are three models for ADCs: the social
Productive aging can be facilitated in a variety model, the medical or health-related model, and the
of contexts, including home care, adult day services specialized care model. ADCs offer the spectrum
centers, ILCs, ALFs, and nursing homes. All of these of care necessary for the care recipient, which ranges
settings and their various levels of care are compo- from needs that are primarily psychosocial to needs
nents of a broad spectrum of services called a con- that require a more medically complex and involved
tinuing care retirement community (CCRC); plan of care. The social model ADC typically pro-
see Figure 12.1. These settings and services will be vides supervised, structured programs for socializa-
discussed in more detail here. tion, prevention and health promotion services, and
• Care management
• Ongoing home care and monitoring
services such as • Help with ADLs Nursing homes
assistance with ADLs, • Housekeeping and
cooking, shopping, or Independent living laundry
communities • Medication • Room and board
laundry
management • Nursing care
• Adult day centers–
• Recreational • Medication
Social activity, • Independent living
activities management
transportation, • Among peers
• Security • Personal care
meals and snacks, • Additional security
• Transportation (assistance with
personal care, • No home
• Two or more meals ADLs)
therapeutic activities maintenance
per day • Social and
Home care recreational
activities
Adult day services Assisted living
facilities
Fig. 12•1 The Continuum of Care for Productive Aging.

2580_Ch12_180-190 16/07/13 2:51 PM Page 183
meals and transportation (Van Slyke, 2001). to live independently in a single dwelling situation
Approximately 29% of ADCs operate on the social similar to apartment living but wish to be relieved
model. The medical or health-related model ADC of the duties of home maintenance. Members of the
provides comprehensive, skilled health care and community often choose this setting in order to
rehabilitation services (McPhee & Johnson, 2000; maintain relationships with others who are similar
Van Slyke, 2001). Nearly half (48%) of the ADCs in age or life situations. Although the time and
provide a combination of social and medical or schedules within these communities are not struc-
health-related services. The specialized care model tured or supervised, amenities and social events are
ADC represents 16% of ADCs and is the preferred often planned and offered by committees within the
choice for individuals who are managing chronic residential neighborhood.
illnesses. The majority of specialized care model The typical resident of an ILC will not require
ADCs provide services for persons with Alzheimer’s assistance for ADLs; however, several common
disease and other forms of dementia. However, the amenities in this context include the offering of
number and variety of disease-specific programs housekeeping and laundry services. It is common
offered in specialized adult day centers is growing for these communities to provide on-site amenities,
(MMMI, 2009; NADSA, n.d.). such as dining facilities, hair salons, and small con-
Home care agencies are an increasingly popular venience stores, as well as access to transportation
choice for individuals who wish to age in place. Home for off-site destinations. Caregivers and family mem-
care services may include homemaking-related tasks bers often cite increased monitoring and security as
such as cooking, laundry, and shopping, as well as being an important benefit of ILCs. Some commu-
companionship and respite. Services, regulations, and nities have a security officer on-site around the
licensing of home care agencies varies from state to clock, promoting a sense of increased confidence in
state; however, specifications under Medicare require residents should an emergency occur (Tom, 2011).
that Medicare-certified agencies must follow federal
regulations in order to be reimbursed. As people age
and acquire chronic illnesses or other conditions, Assisted Living Facilities
independence within the home is often supplemented Residents of ALFs are provided with an array of
with home care by outside professionals. services, including assistance with ADLs and instru-
Currently many home care services can be pro- mental activities of daily living (IADLs), education,
vided by paraprofessionals. Other home care ser- play, leisure, and social participation. ALFs can also
vices can be provided only by licensed health care be appropriate placements for people with cognitive
professionals such as nurses, occupational thera- impairments related to disorders such as Alzheimer’s
pists, or physical therapists under the direction of disease when safety and supervision is a priority.
a physician. Rehabilitation services are generally Unlike ILCs, age is not typically a determinant
required for follow-up after an acute event, or when considering an ALF (MMMI, 2009).
when a person requires transition services upon There are more than 39,000 ALFs that offer ser-
discharge from a hospital or rehabilitation facility. vices. Services are often determined on the basis of
Home care is also an option for individuals who an individual’s need, and often the cost is dependent
are physically healthy but require supervision for on the level of care chosen. ALFs are categorized by
safety. This is a suitable consideration for individ- the number of services included in the base-rate cost
uals with dementia, Alzheimer’s disease, significant (Fig. 12.2).
cognitive delays, or degenerative or chronic illnesses Based on determined needs, many ALFs pro-
or injuries (MMMI, 2009). duce an individualized services care plan for each
resident that is like a detailed map of required ser-
vices. The plan is reviewed and updated collabora-
Independent Living Communities tively with the client and the family or caregiver.
ILCs are variations of what many recognize as The average resident is between 75 and 84 years
retirement communities. The residents of ILCs old, and the average length of stay is approximately
often transition to this context when they still wish 28 months (MMMI, 2009).
2580_Ch12_180-190 16/07/13 2:51 PM Page 184
Inclusive Level of Care as determined

22%
by the number of services provided.
10 or more services provided. $ $3,469/mo
Standard Level of Care as determined

64%
6–9 services provided. $ $3,133/mo
14% Basic Level of Care as determined

5 services or less provided. $ $2,740/mo
Fig. 12•2 Percentage of Assisted Living Communities Categorized by Levels of Care and
Associated Base Cost. (From MetLife Mature Market Institute. (2009). Market survey of
long-term care costs: The 2009 MetLife market survey of nursing, assisted living, adult
day services, and home care costs. Retrieved from: http://MatureMarket Institue.com)
Unlike nursing homes, which are governed at the medical care that prevents the person from living in
federal level, ALFs and ADCs are regulated by the a less restrictive, and therefore more independent,
state. Advocacy groups like the Assisted Living Fed- secure environment. Patients of nursing homes or
eration of America (ALFA) favor state regulation, long-term-care facilities usually need assistance with
which offers more local control and allows for a multiple ADLs. Incontinence is a common prob-
greater variety of choices and cost-efficient processes lem, as are cognitive limitations due to Alzheimer’s
to be determined locally. This flexibility of admin- disease or dementia. Services provided to patients in
istrators and policy makers at the state level fuels in- nursing homes include room and board, nursing
dustry growth, and the degree of choice is often care, medication management, personal care (assist-
passed along to the ALF residents (Bersani, 2011). tance with ADLs), and social and recreational activ-
Policy makers, care providers, and consumers are in- ities (MMMI, 2009). Comparatively, the nursing
terested in overall costs, the provision of quality home context is characterized by more routines and
services, and care for individuals with increasingly structure and less personal choice for residents than
complex medical needs. The overarching principles other housing and long-term-care options. The tran-
for all stakeholders, however, are outcomes that en- sition to a nursing home often means that limited
hance and improve productive aging by producing choices are traded for supervision and increased
a more satisfying quality of life for older adults and personal safety for residents.
their caregivers. Most forms of care in the continuum of care
are framed by the social model, which highlights in-
dependence and flexibility as well as individual
Nursing Homes choice provided in a home or home-like environ-
Within the continuum of care, nursing homes ment. However, nursing homes were founded based
represent the lowest level of independence for their on the tenets of the medical model of practice and
residents. Residents of nursing homes may have are therefore aligned with fewer consumer-based
chronic conditions or a cognitive impairment that decisions. The medical model tends to encourage
requires a level of services and complex and consistent regulations, structure, fewer personal choices, and
2580_Ch12_180-190 16/07/13 2:51 PM Page 185
patient dependency. Nevertheless, nursing homes ikigai, a personality trait and client factor similar
provide a secure environment and offer a variety of to having optimism or being optimistic, requires
services that promote the comfort and quality of life that a person have meaning in his or her life and a
for patients who require a more complex level of reason to live. If a person is to live life to the fullest,
service (Golant, 2004; MMMI, 2009; Zimmerman, the most highly sought after outcome of occupa-
et al., 2005). tional therapy, the occupational therapy practi-
tioner must enable older adults and their caregivers
to engage in meaningful occupations that make life
Occupational Therapy Roles worth living (Seligman, 2011).
The effect of social support, meaningful engage-
Occupational therapy roles and services for older ment, and access to community resources enhances
adults reflect the context of care. One approach quality of life, producing positive health outcomes.
for assessing the needs of older adults that incor- Older adults who have a more positive perception
porates context is using the H.O.M.E.-E Principle of life and a fulfilling sense of engagement are more
(Box 12-1). This approach explores how occupa- resilient, have improved immune system functions,
tion is meaningful to older adults when engaging experience fewer depressive symptoms, and experi-
in a variety of environments. By considering what ence a better quality of life. Strong social founda-
occupations are meaningful to the client, and the tions provide a sense of self-worth and self-esteem
manner in which the client currently engages in and are therefore a protective factor against stress
the occupations, the occupational therapist can and mental and physical illnesses (Deng, Weber,
better plan the transition to a new HOME, a new Sood, & Kemper, 2010). Best practices in occupa-
context. The natural path to successful transition tional therapy in these contexts are informed by
to a new environment is to adapt the environment research evidence.
while keeping the occupations consistent and rou-
tine. In this way, a disruption of occupations
is avoided, as is the potential for occupational Maintaining and Maximizing
imbalance. Independence
Although direct care may be the role demanded It is well recognized that the broad goal of occupa-
most frequently in the continuing care spectrum, tional therapy is to maximize the client’s indepen-
care planning, case coordination, and rehabilita- dence. In the past, the role of occupational therapy
tion management are all areas in which occupa- in ALFs relied heavily on direct interventions that
tional therapy can make a contribution. Research focused on ADL skills, such as dressing and toilet-
by Cruz (2006) supports the notion that “charac- ing, and IADL activities like household manage-
teristics, experiences, and meanings that partici- ment, cooking, cleaning, and doing laundry. With
pants attributed to the assisted living center’s changing client factors, and cultural and demo-
structure, physical nature, sociocultural nature, graphic demands and expectations, the occupa-
and temporal-occupational nature” (p. 101) are tional therapist now must integrate a more holistic
critical to incorporate into occupation-based prac- approach to care. Occupational therapy practition-
tice to ensure occupational balance for older adults ers also can encourage participation in leisure
and their caregivers. The Japanese concept of activities and social interactions through adaptation
and facilitation of the environment or the activity
to promote or enhance engagement (AOTA,
2006). Occupational therapy can also indirectly
Box 12-1 Occupational Therapy Community maximize or enhance the independence of older
Practice Implication adults by providing staff training on issues that
How is Occupation Meaningful when Engaging most affect the client’s level of independence and
in one’s Environment? participation. Often the most effective way to im-
Remember this as the H.O.M.E.-E. Principle. prove client-centered care is to provide staff educa-
tion that is based on identified needs assessments
2580_Ch12_180-190 16/07/13 2:51 PM Page 186
designed by occupational therapists with occupation- aspects of primary and secondary prevention of
based performance indicators and outcomes in many chronic diseases. Diabetes, as well as coronary
mind. Staff education can include instruction on heart disease, obesity, chronic high blood pressure,
safe transfer techniques, practical applications, and uncontrolled cholesterol levels, arthritis, and osteo-
intervention strategies for individuals with cogni- porosis can result in functional limitations and loss
tive or sensory impairments, or facilitation of dis- of independence (Centers for Disease Control and
cussion groups and focus groups determined by a Prevention, 2001). Community-based interventions
thorough needs assessment (AOTA, 2006; Easton can provide a motivating source of encouraging
& Herge, 2011). physical activity. The successful management of dis-
The elements of person-centered or client-centered abling and chronic conditions is an integral part of
care are important to consider. These elements providing comprehensive care.
include: Specialized care for chronic conditions that can
be addressed by occupational therapists includes
• ensuring that health care practices are
strategies for energy conservation, falls prevention,
ongoing and comprehensive,
home safety, joint protection, stress management,
• transforming organizational operations and
safe driving, and community mobility. Through
cultures into client-centered environments,
adaptation and education, meaningful occupations
• adopting nurturing and empowering
can be reintegrated into the lives of older adults with
practices,
chronic conditions, which further encourage moti-
• enabling elders and those with chronic or
vation to participate (AOTA, 2006). A program
disabling conditions to experience meaning
planning model is illustrated in Figure 12.3.
and purpose in their daily lives,
• offering a relationship-based culture, and
• fulfilling an obligation to make the individual Enhancing Quality of Life
feel at home (Love, 2010).
For much of the aging population, life roles and
responsibilities have been chipped away until age-
Managing Chronic Conditions related dysfunction becomes self-defining. ADCs
Diabetes, the seventh leading cause of death in 2007, and ALFs that provide client-centered care can
creates a myriad of other health problems. New
cases of blindness among adults younger than 75 are
primarily attributed to diabetes, as are increasing Create a Balanced Calendar of Activities
cases of kidney failure, non-accidental injuries of to Create Occupational Balance
the leg, and foot amputations. Increased considera-
tion of prevention and health maintenance has
resulted in nearly 80% of ADCs offering physical Survey
activity programs to address cardiovascular disease, Patient’s interests Plan
and needs Intervention
diabetes, and the related constellation of symptoms
Set goals
(NADSA, n.d.). Occupational therapy can support
successful lifestyle changes, increase functional in-
Intentionally
dependence, and facilitate adjustments to chronic engage each
Support and
health conditions in ADCs, ALFs, and nursing enhance
domain:
Patient’s functional
homes. When developing programs for any of the Intellectual, social,
performance and
physical, spiritual,
settings in the continuum of care, it is important and emotional
well-being
to recognize and address the differing needs of men
and women (American Association for Long-Term Fig. 12•3 O.T. Community Practice Implication:
Care Insurance, 2010; Moss & Moss, 2007). Program Planning. (From McPhee, S. D., & Johnson,
Interventions that incorporate dietary changes, T. (2000). Program planning for an assisted living
coping skills, physical activity, social interactions, community. Occupational Therapy in Health Care,
and group support are perhaps the most important 12(2/3), 1–17.)
2580_Ch12_180-190 16/07/13 2:51 PM Page 187
significantly affect the quality of life of their resi- need to shift paradigms and provide a transitional
dents. When given an opportunity to create mean- bridge to support community-based health care
ing through activity, and when experiencing a sense services, which are cost-effective and focus on an
of belonging followed by action, people feel pleasure increased quality of life for the individual, the care-
(Cutchin, 2003). Experiences such as these provided givers, and the community. The challenge is to
in structured settings contribute to a sense of be- design interventions that promote functional per-
longing, being a part of a community, being needed, formance for the older adult while considering the
and having a place to go. These experiences result in needs of the caregiver and the impact of the context.
an individual’s ability to combat depressive symp- Providing opportunities to enjoy activities in all
toms and manifest personal happiness. Personal areas of occupations is the primary goal of occupa-
happiness in turn provides a meaningful and tional therapy. Nevertheless, lifestyle redesign pro-
personal definition of a life of quality. grams that maximize functional performance and
Occupational therapy interventions in CCRSs interventions that are designed to reduce functional
and adult day settings have tended to be based on decline in the older adult often fail to recognize the
the underlying philosophies of the medical model needs of those who love and care for the individual
of care. In a study by Horowitz and Chang (2004), (Horowitz & Chang, 2004).
evidence supported the need for occupational ther- The number of caregivers for individuals who
apy interventions to reduce the roles of the occupa- choose to age in place and for individuals with
tional therapist in making decisions, planning, and Alzheimer’s disease and other related dementia is
leading groups, a perspective based on the medical growing, yet relatively few post-acute options cur-
model. Rather, it is recommended that the occupa- rently exist to support caregiver needs. It is necessary
tional therapist shift the paradigm for practice to consider the older adult holistically. The practice
toward a social model of intervention and a more of integrative health care emphasizes building a
facilitative leadership style. relationship between the practitioner, the older
A social model of intervention incorporates peer adult, and the caregiver. With this principle in
support networks, group interventions led by group mind, the well-being of the older adult can only be
members, and the use of discussion and consensus achieved by also evaluating the stress, strain, and
building in these settings. Principles of the social burden placed on the caregiver (Deng et al., 2010).
model of practice align more consistently with the Strategies for caregiver intervention can include
community-based model of practice. In addition, use education on advocacy for the older adult, and the
of a more facilitative leadership role provides more provision of information about respite care for the
emphasis on the five recognized domains of quality older adult’s loved ones in community-based set-
of life. These are intellectual, social, physical, spiritual, tings, such as ADCs, ILCs, or ALFs (Perry, Dalton,
and emotional health and well-being. The Healthy & Edwards, 2010).
Generation Model and Morningside Protocol is an
example of a plan used in all LifeTrust America
assisted living communities primarily in the south-
Conclusion
eastern United States (McPhee & Johnson, 2000). Supporting productive aging is now recognized as
Careful consideration of these domains provides the a philosophy of service that maintains a person’s
fundamental foundation for improvement in the dignity in order to enhance his or her quality of
standard of care, opportunities for participation in life. Involvement of the community is an important
meaningful occupations, and enhanced quality of life. element in the provision of care and can be an im-
portant contributor to the psychosocial well-being
of its aging community members. Advances in
Safety, Security, and Support for medicine and technology have extended life ex-
Caregivers and Community pectancy, and much of what is to come with caring
Chronic illness and productive aging interventions for the aging population will require a holistic, mul-
have historically been based on medical model prin- tidisciplinary, whole system intervention approach
ciples. Current research provides evidence for the (Deng et al., 2010). The aforementioned whole
2580_Ch12_180-190 16/07/13 2:51 PM Page 188
system approach means that no single factor, person, that improve the quality of life for clients. The suc-
or discipline will present adequate care, and it will cessful aging process is one in which meaningful
indeed require a community approach to produce occupations are present, where dignity, respect,
improved functional occupational performance. independence, and choice are motivating factors in
With complexity comes change. The aging pop- choosing a place to call home. Within the commu-
ulation is becoming increasingly complex, and nity setting, occupational therapy practitioners
occupational therapy practitioners can support can facilitate seamless transitions throughout the
change by consistently providing integrated services continuum of care.
CASE STUDIES
CASE STUDY 12•1 Nina and Jim
Nina and Jim left their large home on two acres where they had raised six children because they decided
together that they could no longer maintain the home or property of 37 years. Jim is a retired Navy
captain and the picture of health. He leads an active lifestyle, often playing golf with his sons and
grandsons. At 76 years old, Jim shows little sign of slowing down. Nina, however, suffered a stroke
at age 63, which affected her functional mobility. Nevertheless, as a retired librarian, she is an avid
reader and active in a local book club that she attends weekly.
After Nina had her stroke, the couple received occupational therapy services at a subacute rehabilita-
tion center. While making a home visit to prepare for Nina’s discharge to home, the occupational thera-
pist recommended the services of a home care personal attendant, who would be able to assist Nina and
Jim with home care and management activities. Jim’s excellent military benefits had covered much of the
cost of a personal care attendant for the last 5 years. Nevertheless, the care of the home and yard had
become overwhelming. Jim and Nina agreed that they were ready for less responsibility.
After careful research and consideration, Jim and Nina chose Pine Rest, a CCRC. Pine Rest serves
225 residents, with over 150 residing in independent living or assisted living apartments and about
25 residents in 1200-square-foot, two-bedroom detached cottages. The remaining residents have
progressed to a skilled nursing facility located on the same campus that is affiliated with Pine Rest and
a local hospital that provides constant care and emergency medical interventions.
Jim and Nina have resided at Pine Rest for 3 years and have few regrets. They made the decision to
begin their residence at Pine Rest in an independent living cottage, which provided enough space to
allow their grandchildren to take turns spending the weekend with them. Their contract is set up to
guarantee a spot in an assisted living apartment and then in the skilled nursing facility if necessary. The
CCRC has on-site amenities like a health club and wellness center, an auditorium, a convenience store,
a beauty shop, two restaurants, and Nina’s favorite, an on-site library, where she volunteers 3 days per
week.
The cost of the CCRC is dependent upon the location (city and state), but the main goal is for the
residents to not pay more to live in the CCRC than they were spending to live at home. Jim and Nina
were able to sell their home and exchange the resulting amount for the entrance deposit. That is standard
practice and procedure at most CCRCs. That money then returns to the residents if they decide to leave
the community at any time. Monthly fees may apply as residents’ care or services increase, but Jim and
Nina have noted that the cost doesn’t exceed their budget, which was that of an above-average middle-
class retiree. The couple is satisfied with their decision. They continue to live independently without the
cares and concerns of running a household. Jim comments that he feels less anxious about needing help
taking care of Nina in the future.
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CASE STUDY 12•1 Nina and Jim cont’d

1. Do you think the home-care attendant who is helping Nina is a skilled occupational therapy
practitioner? Why or why not?
2. Compare and contrast potential services offered to Nina and Jim in independent living and assisted
living at Pine Rest.
3. As a community-based occupational therapy practitioner, Jim and Nina are your clients. Describe
potential intervention considerations when helping them transition from their home to Pine Rest.
Learning Activities Bruce, P. A. (2006). Ascendancy of assisted living: The case

for federal regulation. The Elder Law Journal, 14, Board
1. Mr. S. is an 86-year-old gentleman who re- of Trustees of the University of Illinois.
ceives home-health services. He cares for his Centers for Disease Control and Prevention. (2001). Promoting
active lifestyles among older adults. Retrieved from
82-year-old wife who has chronic obstructive http://cdc.gov/nccdphp/dnpa/physical/pdf/lifestyles.pdf
pulmonary disease and dementia. His wife fell Cruz, E. D. (2006). Elders’ and family caregivers’ experience
and fractured her hip, and Mr. S. is consider- of place at an assisted living center. Occupational Therapy
ing moving to an ALF with his wife. Research Journal of Research, 26(3), 97–107.
the ALFs in your area. Cutchin, M. P. (2003). The process of mediated aging-in-place:
a theoretically and empirically based model. Social Science &
2. Design a handout that provides a brief descrip- Medicine, 57, 1077–1090. doi: 10.1016/S0277-
tion of the following agencies and resources. 9536(02)00486-0
• American Association of Homes and Deng, G., Weber, W., Sood, A., & Kemper, K. J. (2010).
Services for the Aging Research on integrative healthcare: Context and priorities.
• Assisted Living Federation of America Explore 6(3), 143–158. doi:10.1016/j.explore.2010.03.007
Easton, L., & Herge, E. A. (2011). Adult day care promoting
• Center for Excellence in Assisted Living meaningful and purposeful leisure. OT Practice, 16(1),
• Consumer Consortium of Assisted Living 20–26.
• National Adult Day Services Association Gerson, D., & Patterson, G. (1997). Chapter 2 Productive
• National Council on Aging aging: 1995 White House Conference on Aging, challenges
for public policy and social work practice. Pages 9–26 in
C. C. Saltz (Ed.), Social work response to the White House
Conference on Aging: From issues to actions. Journal
of Gerontological Social Work, 27(3). New York, NY:
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review panel to the NCHS Board of Scientific Counselors. that influence occupational therapy practice. In Jacobs, K.,
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Seligman, M. E. (2011). Flourish. New York, NY: Free Press.
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Chapter 13
Low Vision Services

in the Community
Theresa Marie Smith, PhD, OTR/L, CLVT
It’s not what you look at that matters, it’s what you see.
—Henry David Thoreau
Learning Objectives
• Articulate the reasons for the growing population of persons with low vision.
• Identify the four major causes of low vision and available medical treatment.
• Describe how low vision affects occupational performance.
• Identify low vision team members and the services provided for this population.
• Describe occupational therapy services for clients with low vision.
• Discuss psychosocial aspects of low vision.
• Evaluate local services for clients with low vision.
Key Terms
Age-related macular degeneration (AMD) Low vision
Cataract Ophthalmologist
Certified Low Vision Therapist (CLVT) Optometrist
Diabetic retinopathy Specialty Certification in Low Vision (SCLV)
Glaucoma
Introduction of the eye lens, is the most frequently reported

condition in individuals with low vision and ac-
In the United States, 2.4 million people have low vi- counts for up to 50% of the cases among African
sion, and by 2020, this number is expected to increase American, Caucasian, and Hispanic individuals
by nearly 70% as the population ages (Eye Diseases (EDPRG, 2004). Cataracts cause low vision, and
Prevalence Research Group [EDPRG], 2004). One there is a surgical procedure that can correct this
in eight persons age 65 and older in the United States problem. Cataract removal surgery has an estimated
has an eye disease resulting in low vision (National 97%–98% chance of an excellent result and only a
Eye Institute [NEI], 2006), and the prevalence of 1% chance of achieving no improvement and/or
visual impairment increases with age (EDPRG, worsening vision (Laser Surgery for Eyes, 2000).
2004). The most common eye diseases for those Glaucoma, damage to the eye’s optic nerve, occurs
age 40 and over include cataract, glaucoma, diabetic when the normal fluid pressure inside the eyes rises,
retinopathy, and macular degeneration. resulting in vision loss and blindness (NEI, n.d.).
Etiology, prevalence, and medical treatment for Treatment to save remaining vision may include
the common eye diseases vary. Cataract, or clouding eyedrops, laser trabeculoplasty, and/or conventional
191
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surgery. Diabetic retinopathy develops secon - (Table 13-1). Low vision is irreversible and may be
dary to diabetes and results from a change in the hereditary, congenital, or acquired.
blood vessels of the retina. It is the most frequent Low vision adversely affects an individual’s ability
cause of new cases of blindness among adults age to perform everyday activities (American Academy of
20–74 years (NEI, n.d.). Diabetic retinopathy Ophthalmology Vision Rehabilitation Committee,
can occur as non-proliferative or proliferative 2001). Compared to individuals without disabilities
retinopathy. Proliferative retinopathy is treated (Burmedi, Becker, Heyl, Wahl, & Himmelsbach,
with laser surgery or with a vitrectomy (Johns 2002), individuals with low vision demonstrate a
Hopkins Medicine, n.d.). Lastly, age-related 15%–30% higher dependence on others to perform
macular degeneration (AMD), damage to the activities of daily living (ADLs). Despite their
central part of the retina, occurs in one of two decreased ability to perform ADLs and instrumental
forms, wet or dry. It is the leading cause of vision activities of daily living (IADLs), persons with low
loss in the United States for persons age 60 and vision still have the need and desire to perform
older (NEI, 2007) and is more common in women everyday activities that support their life roles
and Caucasians than in other groups (American (Crews & Campbell, 2001; Heyl & Wahl, 2001;
Society of Retina Specialists, 2009). There is no Horowitz, 2004; Raina, Wong, & Massfeller, 2004;
medical treatment for dry macular degeneration, Travis, Boerner, Reinhardt, & Horowitz, 2004).
but treatment for wet macular degeneration in- The eye diseases that result in low vision affect
cludes laser surgery, photodynamic therapy, and different areas of occupational performance. Clients
eye injections (NEI, n.d.). with cataracts may have difficulty with recognizing
faces, reading, and mobility (Lundström, Fregell, &
Thomas, 1994). Those with glaucoma are likely to
Low Vision and Occupational experience problems with glare or with changes in
Performance light levels as well as outdoor mobility (Burmedi,
Becker, Heyl, Wahl, & Himmelsbach, 2002). Dia-
Vision provides approximately 80% of what indi- betic retinopathy at all levels of severity results in
viduals perceive through their senses (Protect-your- difficulty in reading and driving (Coyne, Margolis,
sight.com, 2008). Using the ICD-9-CM threshold Kennedy-Martin, Baker, Klein, Paul, Revicki, et al.,
criteria, an individual is considered as having low 2004). Persons more severely affected have difficulty
vision if he or she has an uncorrectable and irre- with diabetic care routines, mobility issues, and in-
versible visual acuity of less than 20/60 in the better creased fear of accidents leading to decreased social
eye or a visual field of 20 degrees or less in the better participation (Coyne et al., 2004). AMD adversely
eye (U.S. Department of Health and Human Ser- affects the individual’s ability to read standard
vices [USDHHS], 2004). Levels of impairment are print and can limit his or her independence in
assigned to ranges of acuity and/or visual fields preparing meals, using a telephone, taking care of
Table 13-1 ICD-9-CM Definitions of Low Vision and Blindness

Definition Visual Acuity Visual Field
Moderate visual impairment ⬍20/60 to 20/160 Not considered
Severe visual impairment ⱕ20/200 to 20/400 visual field ⱕ20 degrees
Profound visual impairment ⬍20/400 to 20/1000 visual field ⱕ10 degrees
Near-total vision loss ⱕ20/1250
Total blindness No perception of light
Data from: “Vision rehabilitation for elderly individuals with low vision or blindness,” by U.S. Department of
Health and Human Services, Agency for Healthcare Research and Quality, 2004, p. 20.
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Chapter 13 | Low Vision Services in the Community 193
finances, traveling, shopping, taking medications, that physicians could refer clients for occupational
and washing laundry (Ryan, Anas, Beamer, & therapy with a sole diagnosis of low vision. At that
Bajorek, 2003). time the Health Care Financing Administration
expanded the meaning of “physical impairment”
to include low vision (Warren, 1995). The Balanced
Low Vision Rehabilitation Budget Refinement Act of 1999 allowed optometrists
to refer Medicare Part B patients to occupational
Team therapy for low vision rehabilitation (Johansson,
A number of team members in addition to occupa- 2000). In 2002, Congress created a program mem-
tional therapy practitioners work with clients with orandum to enforce Medicare coverage for benefi-
low vision. Ophthalmologists are medical doctors ciaries with low vision for rehabilitation services
(MDs) who diagnose and treat eye diseases, pre- (USDHHS, Centers for Medicare & Medicaid
scribe medications, and perform surgery. Op- Services, 2002). The AOTA considers low vision
tometrists are doctors of optometry (ODs) and services to be an emerging practice area for occupa-
treat refractive error with glasses, contacts, and tional therapy practitioners and important for pro-
magnifiers. Vision rehabilitation therapists receive ductive aging (Johansson, 2000).
referrals from state or non-profit agencies to pro- Two certifications are available in low vision re-
vide training in the home for adaptive techniques habilitation for occupational therapists. In 2000, the
to perform everyday activities and modify the Academy for Certification of Vision Rehabilitation
environment. Orientation and mobility (O&M) and Education Professionals (ACVREP) developed
specialists are consulted for difficulties in mobility several certifications for low vision providers, includ-
and provide training for people to travel safely ing the Certified Low Vision Therapist (CLVT)
using such devices as canes, guide dogs, and/or (Watson, Qillman, Flax, & Gerritsen, 1999). To
electronic devices. They teach people to take public date, there are 31 occupational therapists who hold
transportation on their own and also receive refer- this certification through ACVREP (J. Treviño,
rals through the state or a nonprofit agency. personal communication, April 8, 2010). To better
Mental health service providers such as psychia- meet the growing need for occupational therapy
trists, psychologists, and/or social workers may services, in 2006 the AOTA established a Specialty
be consulted to assist with psychosocial difficulties Certification in Low Vision (SCLV). The SCLV
in coping and adjusting to low vision. They may credential provides a formal recognition to occupa-
address such issues as anxiety, frustration, fear, tional therapists and occupational therapy assistants
anger, and depression. Finally, family members for their specialized knowledge and practice exper-
often transport the client to appointments, may tise with the low vision population.
perform home modifications for the client, and as-
sist in follow-through with home programs. Family
members of the visually impaired are often more Low Vision Practice Settings
involved than are family members of other popula- Occupational therapy practitioners may provide
tions with functional deficits. services for clients with low vision in a variety of set-
tings, using different business models, and on vision
rehabilitation teams with various service members
Occupational Therapy (Table 13-2). Familiar settings for occupational
for Clients With Low Vision therapy practitioners include outpatient clinics, low
vision centers associated with universities, or private
Participating in occupational therapy may help peo- practices. In these settings, clients with low vision
ple with low vision maintain independent and are scheduled and billed for their care in a manner
meaningful lives (American Occupational Therapy consistent with clients in similar settings. Occupa-
Association [AOTA], 2003). Although occupational tional therapy practitioners working in physicians’
therapy practitioners have worked with persons with offices or eye clinics may need to see clients on the
low vision for decades, it was not until 1990 same day they see the physician. The Veterans
2580_Ch13_191-200 16/07/13 2:52 PM Page 194
Table 13-2 Low Vision Rehabilitation Team Members

Team Member Referral Source Team Function
Low Vision Optometrists Self, physician, and/or Diagnose and treat refractive errors with
ophthalmologist optical devices
Occupational Therapy Physician and in some Teach optical and non-optical device use,
Practitioner states optometrists, and visual skills, and adaptive techniques, and
nonprofit agencies modify the environment
Certified Low Vision Optometrists and nonprofit Teach optical device use and visual skills
Therapist agencies
Vision Rehabilitation State or nonprofit agencies Train in the home for adaptive techniques
Therapists to perform everyday activities and modify
the environment
Orientation & Mobility State or nonprofit agencies Train in safe travel using canes, guide dogs,
Specialists and/or electronic devices, and public
transportation
Psychiatrists, Psychologists, Physician, self, other team Assist with difficulties coping and adjusting
and/or Social Workers members
Family Members Not applicable Transport the client to appointments,
perform home modifications, and assist
in home program
Health Administration (VA) offers outpatient ser- for O&M specialists, and home safety evaluations
vices in Vision Impairment Services in Outpatient and modifications. Occupational therapy practi-
Rehabilitation (VISOR) programs and inpatient tioners can provide many of these services for the
services in Inpatient Blind Rehabilitation Centers community agency. Intervention for those with
(U.S. Department of Veterans Affairs, 2009). visual impairment also includes home therapy.
Veterans are placed in the program most consistent Home visits may be provided in other settings or
with their needs. In the VA system, veterans are occur solely in the home.
provided with the technology they need to become
independent at no cost.
Occupational therapy practitioners also work Referrals for Occupational Therapy
in community agencies serving the blind and As in any other area of occupational therapy prac-
visually impaired. In this type of setting, clients tice, a referral for occupational therapy is required
are considered consumers of the agency’s services. for reimbursement from Medicare or private insur-
Their care may be covered through grant funding ance companies. Exactly what type of low vision
or reimbursed by the state. Interventions may professional (e.g., physician, optometrist) is able to
be provided one-to-one or in a group setting. In refer for occupational therapy depends on state law.
this model, funding may be available not only for Because best practice requires specialized skills by all
therapy but also for some assistive devices. Com- team members, and occupational therapy requires a
munity agencies frequently provide a continuum referral source, an occupational therapist should try
of care for their consumers. They usually offer to partner with an existing low vision provider. The
services that include diagnosis, instruction in vi- low vision referral for occupational therapy should
sual efficiency skills and optical device use, classes state that an evaluation is required and what areas
in ADL and IADL, support groups for coping of occupation are impacted by the individual’s low
with and adjusting to visual impairments, referrals vision.
2580_Ch13_191-200 16/07/13 2:52 PM Page 195
Interventions for Clients When clients’ vision cannot be improved, they

can learn to use their residual vision more efficiently
With Low Vision and adopt the use of optical devices to help in
Occupational therapy service needs are deter- task completion. As in the selection of any type of
mined by a comprehensive evaluation. Relevant assistive device, it is important to know the client’s
background information to collect includes: abilities, heed client preference, work within any
the client’s diagnosis and treatment received, prior financial restraints, understand the purpose of the
level of function, living situation, and social device, and have extensive knowledge on optics.
support system. The evaluation should then focus Due to the many variables affecting assistive device
on the client’s current level of function. The ther- use by persons with low vision, most low vision
apist should determine which areas of occupation clinics allow clients the opportunity to test different
are impacted by low vision. This may be accom- types of equipment before purchasing.
plished with a self-report questionnaire and Several optical devices can aid near-vision tasks.
supplemented with functional tasks. Specific Head-mounted devices such as spectacles free both
skills may be assessed, such as reading with the hands for bilateral activities. However, learning the
Pepper Visual Skills for Reading Test (Watson, working distance or focal distance for spectacles can
Whittaker, Steciw, Baldasare, & Miller-Shaffer, be difficult for the client. Handheld magnifiers can
1995) or writing with the Low Vision Writing have the added advantage of a built-in light. How-
Assessment (Watson, Wright, Wyse, & De l’Aune, ever, one hand is required to hold the magnifier, and
2004). Depending on test results provided by the finding and maintaining the focal distance with
referral source, the occupational therapy practi- handheld magnifiers may also be difficult. Stand
tioner may also assess visual acuity, tracking, and magnifiers provide the correct focal distance for
visual fields. Once the client’s current level of the client, but handheld magnifiers are easier to
function is determined, the therapist works with manipulate and transport. In addition, electronic
the client to develop an intervention plan to pri- devices such as closed-circuit televisions (CCTVs)
oritize and establish his or her goals. Intervention or computer programs can enlarge print so that it
for clients with low vision involves person, envi- is legible to the client. However, CCTVs and com-
ronment, and occupation factors. puters with low vision software are expensive.
Other optical devices are available for distance
viewing and driving. Clients who need devices for
Person distance viewing, such as watching sports, can use
First, clients need to improve their visual efficiency telescopes. Although telescopes provide greater acu-
skills, including eccentric viewing and visual scan- ity, they significantly limit the size of the visual field.
ning. Clients with macular diseases affecting their Clients with visual field deficits may be prescribed
central vision need to be taught eccentric viewing, field enhancement devices, although these devices
or how to use the area of the retina that has not been may be difficult for some to use due to the percep-
damaged (Stelmack, Massof, & Stelmack, 2004). tual adjustment. Bioptic telescopes that are used for
Eccentric viewing is particularly useful in reading driving require training, and their use is dependent
and writing tasks, and for viewing people’s faces. Vi- on state laws.
sual scanning, eye movements designed to locate an In addition to optical devices that allow clients to
object of interest in the environment, is needed to participate in their preferred occupations, there are
complete most tasks (Warren, 1990). Clients with many non-optical devices. Some of these devices are
low vision need to be taught efficient visual scanning dependent on the client’s use of other senses such as
skills to compensate for their decreased visual fields. auditory. There are talking clocks and watches, liquid
As with all new skills, eccentric viewing and visual indicators, books on tape, talking blood glucose me-
scanning need to be incorporated into the perform- ters, and scales. Clients can use their tactile sense by
ance of preferred occupations by clients as a means marking personal care products with rubber bands
of adaptation. and different-colored clothing with safety pins.
2580_Ch13_191-200 16/07/13 2:52 PM Page 196
Other devices utilize the concept of enlargement, mats can be placed over white tub edges or contrast-
such as large print address books, calendars, date ing placemats chosen for the table. To improve con-
books, or fonts on computers. There are personal trast throughout the home, walls can be painted a
care devices that have large print, including pillboxes lighter color and dark furniture selected.
and syringes. Grooming activities, such as applying Creating a system of organization can be very
makeup or shaving, are much easier to perform helpful for those with low vision. Inexpensive high-
using a lighted magnification mirror. Devices with contrast baskets can be used to store like items,
large print to aid with cooking include kitchen including: cleaning supplies, personal care items,
timers and measuring cups and spoons. Clients can medications, and/or leisure activity equipment.
participate in leisure activities by using large print
playing cards, bingo cards, or a big button television
remote. Occupation
Still other devices improve occupational perfor- Many tasks may need modification for a person with
mance using high contrast. Print is much easier to low vision to be able to complete them in a timely
read if a client uses a black felt pen on bold lined and efficient manner. For example, instead of
paper. Signature guides provide an outlined area attempting to apply low-contrast toothpaste to a
within which to sign as check templates do to fill white toothbrush, a more efficient means is to put
out a check. the toothpaste in a small cup and drag the brush in
the cup, or to simply put the toothpaste in the mouth.
Locating one’s food on a plate can be difficult, but
Environment if food is always placed using the clock method, it
In general, an older person needs two to three times is easy to find. Writing can be problematic, but let-
more light than a younger person, but people with ters and cards can be printed more easily. Reading,
some eye diseases may be sensitive to glare (Watson, a leisure activity enjoyed by many, may become too
2001). Therefore, it is important to increase lighting difficult for those with low vision. In addition to
without causing glare, which can be accomplished books on tape available through the Library for the
with lighting placement, choice of lighting, and Blind, many books are now available as audio books.
glare elimination. Light can be aimed to illuminate Clients can “read” while performing other activities
the task at hand by using a gooseneck lamp. The like doing the dishes or taking a bath.
type of lighting used is important. Incandescent Social participation is an important area of occu-
light is commonly used in desk lamps but may not pation (AOTA, 2008). Unfortunately, people with
provide good contrast or color perception. Halogen low vision often become socially isolated secondary
provides a bright white light but generates a lot to difficulties with transportation. People can and
of heat. Fluorescent light is energy efficient but may do engage socially through virtual means. In a study
be harsh and flicker annoyingly (Watson, 2001). by Smith, Ludwig, Andersen, and Copolillo (2009),
Full-spectrum lighting is the closest to sunlight but several participants mentioned that social participa-
is high on the blue light spectrum, which may result tion was achieved on the telephone. Today even
in glare. Glare can be controlled by covering high more virtual means exist, such as communicating
glare surfaces such as tabletops with tablecloths, and via e-mail or with webcams.
windows with sheer drapes (Cole, 2003).
Tactile markings on appliances can be very
effective in facilitating occupational performance. Psychosocial Issues
For example, frequently used settings on the
microwave, washer, and dryer can be marked with
Associated With Low Vision
bump dots. Psychosocial issues are inherent for those diag-
The concepts of enlargement and/or contrast can nosed with low vision due to loss of independence
also be utilized in modifying the environment. and relinquishing of desired occupations. High
Those with low vision can select clocks with large levels of depression have been found to be corre-
numbers on sharp contrast backgrounds. Dark bath lated with severe visual impairment (Brody,
2580_Ch13_191-200 16/07/13 2:52 PM Page 197
Gamst, Williams, Smith, Lau, Dolnak, et al., Low Vision Community

2001), and AMD is a significant risk factor for
depressive disorders. Studies have shown that up Support
to 32%–33% of patients with AMD meet criteria It is important for occupational therapy practition-
for major depressive disorder (Brody et al., 2001; ers to be aware of community resources available
Rovner, Casten, & Tasman, 2002). In addition, for their clients with visual impairments. Is there
visual impairment has been shown to adversely a radio station that reads the daily newspaper or
affect health-related quality of life (Margolis, offers other interesting programming? What are
Coyne, Kennedy-Martin, Baker, Schein, & Revicki, the public and private transportation options? Is
2002). It is important for occupational therapy there a low vision support group? Are there orga-
practitioners to be vigilant for the signs of emo- nizations that provide social support, reading to
tional distress and to facilitate the client’s ability the visually impaired, or light housekeeping duties?
to cope. They must also be ready to refer clients Where can low vision non-optical devices be
to appropriate mental health professionals (see obtained? Knowing where to refer clients who need
Table 13-2). Casten and Rovner (2006) suggest these services is imperative. Keeping on hand
that intervention for depression begin early to pre- forms qualifying clients for services and catalogs
vent severe depression and disability. featuring low vision assistive devices can facilitate
In interviews of persons with visual impair- acquisition of these resources.
ments, Teitelman and Copolillo (2005) noted
three main themes related to the psychosocial
aspects of low vision: emotional challenges, nega-
tive emotional outcomes, and indicators of emo-
Funding and Billing Issues
tional adaptation. Some of the emotional challenges for Low Vision Occupational
identified by interviewees were lost independence,
relinquishing of desired activities, lost spontane-
Therapy Services
ity, and impact on social interactions. In addition, The primary funder for occupational therapy ser-
the participants reported distressing emotional vices in low vision is Medicare Part B. However,
reactions such as depression, stigma and embar- low vision services are also covered by many private
rassment, frustration, and resignation. The most insurance companies and some state or nonprofit
commonly used emotional adaptation strategies agencies serving the blind and visually impaired.
were cognitive restructuring, social support, mak- When billing Medicare for clients with low vision,
ing a contribution to family and friends, and faith. practitioners must follow the same regulations as
The greater the number of favorite activities that for any client receiving Medicare services (AOTA,
could be retained even with adaptations, the easier n.d.; USDHHS, n.d.). Medicare Part B currently
the emotional adjustment appeared to be. Attend- pays 80% of total occupational therapy outpatient
ing to the psychosocial issues related to low vision charges up to $1860 per year, and clients must
is an important aspect of occupational therapy make up the 20% difference unless they have a
services. Medicare Part B supplement policy. It is possible
Low vision rehabilitation services are important that a client with low vision has already used the
in combating psychological effects of visual disabil- $1860 charges for one year depending on other
ity. Horowitz, Reinhardt, and Boerner (2005) health conditions requiring occupational therapy
found that counseling services, low vision clinical outpatient services. Occupational therapists pro-
services, and participants’ use of optical devices viding outpatient services to clients with low vision
were significant contributors in reducing partici- must also be cognizant that other occupational
pants’ depressive symptoms. Unfortunately, people therapy outpatient services may be needed by
with AMD tend to underutilize available rehabil- clients later in the year.
itation services shown to improve their visual Necessary optical and non-optical devices for
function and quality of life (Casten, Maloney, & clients with low vision are not covered by Medicare
Rovner, 2005). or private insurance companies. Most state or
2580_Ch13_191-200 16/07/13 2:52 PM Page 198
non-profit agencies serving the blind and visually the development of new programs. Occupational
impaired are able to provide some optical and non- therapy is one of the disciplines identified as a low
optical devices. They may have loaner programs vision provider by Medicare and by optometrists
for CCTVs or used CCTVs for resale. These agen- and ophthalmologists.
cies also may have donated equipment that can be Occupational therapists are uniquely qualified
distributed. to address the psychosocial and physical rehabilita-
tion needs of persons with low vision through the
provision of meaningful engagement in occupa-
Conclusion tions. Research has shown that “occupational ther-
apists working in low vision can support clients by
The population of persons with low vision is grow- facilitating development of a social network, acting
ing and will increase dramatically with the aging as liaisons between clients and other health practi-
of the baby boomers. Occupational therapy practitioners, especially ophthalmologists, and encourag-
tioners have the skills to facilitate participation in ing policy development that supports barrier-free
all areas of occupation for this expanding popula- LVAD (low vision assistive device) acquisition and
tion. The profession of occupational therapy should use” (Copolillo & Teitelman, 2005, p. 305). The
meet the needs of individuals with low vision to introduction of new models of low vision occupa-
maintain their independence and health. Most tional therapy service provision can expand the
of these services are provided in the community, network of services currently available in the
and there is ample opportunity for occupational community for persons of all ages who have visual
therapists to expand low vision services through impairments.
CASE STUDIES
CASE STUDY 13•1 Mrs. Kindred
Mrs. Kindred is a 72-year-old widow who has dry macular degeneration in her right eye with a visual
acuity of 20/200. She lives in a senior apartment building with an elevator within a half mile from her
only child, Celia. Mrs. Kindred is a grandmother to Celia and her husband’s two children: David, who is
away at college, and Jennifer, who is a junior in high school. Although she spends most major holidays
with Celia and her family, she maintains an active social calendar with her peer group.
During an occupational therapy evaluation, Mrs. Kindred reports difficulties in a number of areas that
she would like to address. Self-care issues for Mrs. Kindred include minimal difficulty styling her hair and
applying her lipstick. Meal preparation for Mrs. Kindred consists primarily of reheating food prepared by
Celia or cooking with a microwave. However, she has minimal difficulty distinguishing cans of food and
operating her microwave. Mrs. Kindred admits to great difficulty locating her friends’ phone numbers and
more frequently dialing wrong numbers. She also would like to be able to communicate via e-mail with both
of her grandchildren. Celia has managed Mrs. Kindred’s finances for some time, and both women are happy
with this arrangement. However, Mrs. Kindred would like to be able to sign her name independently and is
self-conscious as to the level of legibility of her current signature. Mrs. Kindred’s problems with reading small
print have adversely affected engagement in her leisure activities in a number of ways. Every 2 weeks, she goes
out to dinner with a small group of friends to different restaurants. Transportation is not an issue, as several
members of the group still drive. However, she has great difficulty reading the menu and would prefer not
to constantly have to ask that a friend read the menu to her. Mrs. Kindred is a petite lady interested in main-
taining her weight as well as staying within a monthly budget. She also loves to read and wants to keep up
with current releases of her favorite authors. The occupational therapist reports to Mrs. Kindred’s insurance
carrier that she has good potential for rehabilitation and would benefit from occupational therapy services.
2580_Ch13_191-200 16/07/13 2:52 PM Page 199

1. What areas of occupation are affected by Mrs. Kindred’s low vision?
2. How might you improve her occupational performance in those areas?
3. What optical and non-optical devices would you suggest to Mrs. Kindred to improve her occupational
performance?
Learning Activities Casten, R. J., Maloney, E. K, & Rovner, B. W. (2005).

Knowledge and use of low vision services among persons
1. Develop a resource list of transportation with age-related macular degeneration. Journal of Visual
sources available in your community that serve Impairment and Blindness, 99(11), 720–724.
Casten, R. J., & Rovner, B. W. (2006). Vision loss and
the blind or visually impaired. depression in the elderly. Psychiatric Times, 23(13),
2. What are some virtual means that people with 52–60.
low vision might use to engage in social partic- Cole, R. (2003). Lighting for low vision. Retrieved from
ipation? What accommodations might you http://mdsupport.org/library/lighting.html
anticipate to facilitate social engagement Copolillo, A., & Teitelman, J. L. (2005). Acquisition and
integration of low vision assistive devices: Understanding
through virtual means? the decision-making process of older adults with low
3. Choose one room or work area in a home and vision. American Journal of Occupational Therapy, 59(3),
design and depict environmental modifications 305–313.
for a client with low vision. Coyne, K. S., Margolis, M. K., Kennedy-Martin, T.,
Baker, T. M., Klein, R., Paul, M. D., Revicki, D. A.,
et al. (2004). The impact of diabetic retinopathy:
Perspectives from patient focus groups. Family Practice,
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Chapter 14
Fall Prevention
Kimberly Mansfield Caldeira, MS, and Mary Becker-Omvig, MS, OTR/L
Safe and full participation in activities and control over one’s ability to remain
with the home and community are priorities for older adults.
—American Occupational Therapy Association (AOTA), 2004, p. 1
Learning Objectives
• Apply the evidence on fall prevention interventions to occupation-based interventions.
• Explain the role of occupational therapy in an interdisciplinary, health promotion approach to fall prevention.
• Evaluate the advantages and disadvantages of various fall prevention interventions in different community
settings.
• Synthesize fall prevention guidelines to design a locally relevant falls prevention program.
Key Term
Area Health Education Centers
Introduction Fall Prevention in a Rural

According to the AOTA Practice Framework, the Senior Center
primary outcome of occupational therapy is For this example, an overview of Area Health
the support of “health and participation in Education Centers and the project setting is
life through engagement in occupation” (AOTA, provided. This is followed by a description of the
2008, p. 660). In this chapter, the authors present needs assessment, program planning, program
two examples of successful community-based implementation, and program evaluation for a fall
fall prevention programs designed and imple- prevention initiative at a senior center in rural
mented by occupational therapy personnel to Maryland.
provide this outcome. The first example describes
a brief student-led program, and the second is an
ongoing program integrated within a local office Overview of the Project
on aging in suburban Maryland. Readers are Area Health Education Centers (AHECs) were
challenged to identify their own local opportuni- established by Congress in 1971 for the purpose
ties for new falls prevention programs in which of recruiting, training, and retaining health profes-
to implement customized programs based on the sionals in rural and urban health care professional
latest available evidence (Caldeira & Reitz, 2010; shortage areas. The current mission of the AHECs is
Centers for Disease Control and Prevention, “to enhance access to quality health care, particularly
2003; Moreland et al., 2003). primary and preventive care, by improving the supply
201
2580_Ch14_201-209 16/07/13 2:52 PM Page 202
and distribution of health care professionals through the program in mid-July. The evaluation team com-
community/academic educational partnerships” prised two occupational therapy students plus one
(National AHEC Organization [NAO], n.d., ¶ 1). student each from nursing and social work. Evalua-
There are currently more than 54 programs with over tion data were collected on the day of the pilot and
200 centers located in nearly all states and the District later during the formal program evaluation phase in
of Columbia. Information is regularly shared between November. Thus, the entire process, from needs
AHECs through conferences, the Internet, and assessment through evaluation, was completed in
informal networking (NAO, 2009). AHECs are fewer than 6 months (Becker-Omvig et al., 1999).
potential partners for fall prevention and other
community-based prevention programming to serve
vulnerable populations. Needs Assessment
In 1999, the Western Maryland Area Health During the needs assessment phase, the team re-
Education Center (WMAHEC) hosted a group of searched the sociodemographic, cultural, and geo-
students from a variety of health professions for a graphic characteristics of the target population
service-learning opportunity in a course entitled and setting. A senior center located in rural western
“Interdisciplinary Prevention in Rural Communi- Maryland agreed to host the program. Senior center
ties.” This prevention course was followed by a administrators provided valuable background on their
second course focusing on evaluation methods, clients: the majority had low incomes, most were over
entitled “Interdisciplinary Team Research: Applied 70 years old, and a substantial minority had chronic
Outcomes Research by Interdisciplinary Teams.” conditions such as arthritis, visual impairments,
Students and faculty from schools of social work, and hypertension. Other data sources, such as the
nursing, occupational therapy, physical therapy, and Maryland State Office on Rural Health, supplied
respiratory therapy were represented in these two descriptive data about the county of interest, such as
interdisciplinary courses. The efforts of the collabo- the disproportionate numbers of residents who had
rative, interdisciplinary faculty-student-community low incomes and no health insurance, and the under-
teams were coordinated by the WMAHEC’s coor- utilization of preventive health services. Literature
dinator of community education and supported by reviews on rural health and Appalachian culture, par-
a series of federal grants funded by the Quentin N. ticularly as they relate to health behaviors, supplied
Burdick Program for Rural Interdisciplinary Train- the team with further insight into the possible needs
ing, Bureau of Health Professions, Health Resources and interests of the target population. Finally, the
and Services Administration, U.S. Department of team distributed a brief questionnaire to senior center
Health and Human Services. clients to assess their attitudes and beliefs about
What follows is a brief description of a fall pre- falling. The team discovered that many clients were
vention program that was designed, implemented, concerned about falling and interested in reducing
and evaluated by students enrolled in one or their risks (Caldeira et al., 1999).
both of these courses at WMAHEC in 1999.
The program, entitled STEADY As You Go, was
designed and implemented by Caldeira, Gurka, and Program Planning
VanSickel (1999) and subsequently evaluated by The program-planning phase was guided by several
Becker-Omvig, Caldeira, Hockman, and de los theoretical frameworks relevant for health promo-
Santos (1999). tion, which were selected by the students from
The design and implementation of STEADY As descriptions in the textbook for the course by
You Go was completed on a rapid time line. The McKenzie and Smeltzer (1997). The team relied
interdisciplinary planning team consisted of one heavily on constructs from the Health Belief Model
student each from occupational therapy, physical (HBM), especially as related to fear of falling.
therapy, and respiratory therapy. A needs assessment Recognizing that fear of falling can contribute to
was conducted during the first class in early June, falls, the team chose to design an intervention that
and program planning occurred over the next would avoid increasing perceived risk and focus
6 weeks. The project then culminated in a pilot of instead on promoting self-efficacy to reduce fear of
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Chapter 14 | Fall Prevention 203
falling and decreasing any perceived barriers to risk- to the site administrator and completing a rehearsal
reduction activities. Principles from Ajzen’s Theory of the program module. Learning objectives were
of Planned Behavior (McKenzie & Smeltzer, 1997), written to describe the new skills, knowledge, and
such as perceived behavioral control and subjective attitudes the participants were expected to acquire.
norms, were also instrumental in the planning The team also set behavioral, environmental, and pro-
process. The transtheoretical model developed by gram objectives to be attained if the falls prevention
Prochaska and DiClemente (1983; 1992) was used program were implemented on an ongoing basis after
by the team to incorporate messages aimed at par- the pilot and expanded to include multiple modules
ticipants in precontemplation and contemplation and sites. The behavioral objectives outlined specific
who might not be ready to adopt new behaviors for behaviors expected to be observed in participants,
risk reduction (Caldeira et al., 1999). Further infor- such as physical activity, home modifications, and
mation on the HBM and transtheoretical model requesting further information. The environmental
and their applicability to occupational therapy can objectives specified how the program could be
be found in Chapter 3 of this book and other expanded to other sites over time. Lastly, program
sources (Reitz & Scaffa, 2010). objectives included community-level outcomes to be
Another relevant theoretical framework tapped measured over several years, such as reduced inci-
was one from the occupational therapy literature, the dence of falls and rates of fall-related disability
ecology of human performance (EHP). The devel- (Caldeira et al., 1999).
opers of the EHP (Dunn, Brown, & McGuigan, While the challenges and benefits of an interdis-
1994) emphasize the person-environment interac- ciplinary team experience were part of the learning
tions that are fundamental to occupational perform- experience for students in the WMAHEC courses,
ance. This is very apparent in fall prevention, where the interdisciplinary nature of the intervention
in most cases it is the interaction of intrinsic and enhanced the program’s potential to benefit the
extrinsic risk factors, rather than the individual participants at the senior center. The students were
risk factors themselves, that determine a person’s challenged to distinguish the areas of overlap and
likelihood of falling. The EHP was especially helpful areas of unique expertise among their respective dis-
to the team in their interpretation of the evaluation ciplines. The result was a program module presented
results in terms of the physical, cultural, and social as a series of complementary segments, each segment
contexts of the participants, the administrators, and focusing on a different area of expertise from one of
the interdisciplinary student team, all of which the three disciplines. Physical therapy’s contribution
affected the program’s success (Caldeira, 1999). pertained to exercises designed to improve balance,
One of the first steps in program planning is to sensory awareness, and lower extremity strength and
establish goals and objectives. The planning team set flexibility. A respiratory therapist presented breathing
the following four major goals: exercises designed to promote relaxation and focus,
drawing in part on a Tai Chi instructional video. The
• To raise awareness among seniors regarding
occupational therapy student provided an overview
strategies to prevent falling.
of behavioral strategies to reduce the risk of falling
• To alter dangerous behaviors in the everyday
and specific home safety recommendations for falls
life of seniors
prevention (Caldeira et al., 1999).
• To promote seniors’ safety in homes and
Cultural barriers were another consideration
activities
in the planning of this program. In addition to
• To minimize the risk of seniors falling indoors
generational differences that factor into many health
and outdoors (Caldeira et al., 1999, p. 6)
promotion interventions with older adults, other
The goals were to be accomplished on multiple cultural issues also were evident. The planning team
levels in terms of administrative objectives, learning reviewed the literature on the health promotion
objectives, behavioral and environmental objectives, needs and barriers that characterize many rural
and program objectives. Administrative objectives populations. Certain features of Appalachian culture
included specific tasks to be accomplished in prepa- also were relevant in planning this program. For
ration for the pilot, such as sending program materials example, the team attempted to anticipate the
2580_Ch14_201-209 16/07/13 2:52 PM Page 204
cultural traits of self-reliance and low care-seeking visual aids, others were participatory with opportu-
by incorporating many strategies for self-help into nities to practice demonstrated exercises, while the
the program, while also encouraging participants to bingo game was competitive and interactive and
consult with physicians and other resource persons reinforced concepts covered throughout the module.
for additional information (Caldeira, 1999). Illustrated handouts were provided to facilitate indi-
vidual performance of the breathing and balance
Program Implementation exercises at home. Finally, the team prepared a falls
prevention resource guide for the staff of the senior
The STEADY As You Go program was piloted as center, which included recommendations for pro-
scheduled in mid-July at the senior center. A total of gram enhancements at the senior center and copies
17 participants attended the one-hour module, which of various informational resources on falls prevention
was followed by lunch. The module proceeded (Caldeira et al., 1999).
according to the agenda shown in Table 14-1. Each The STEADY acronym provided a unifying theme
segment of the module was interactive with demon- for much of the program. This acronym is displayed
strations, visual aids, and as many opportunities for in Box 14-1. The acronym was designed to be a
discussion as possible. The participants reacted to catchy mnemonic device that could be applied to a
the program with enthusiasm, which contributed more expanded and comprehensive falls prevention
significantly to the program’s success. In a very brief program at the site, possibly incorporating home eval-
amount of time, the program presented a multidisci- uations, ongoing group exercise sessions, and other
plinary approach to falls prevention, including prac- interventions. As part of the pilot curriculum, the
tical suggestions for maintaining balance and physical acronym functioned as a simplified framework for an
fitness, choosing simple home modifications to occupation-based educational component. To rein-
enhance safety, and adopting deliberate behavioral force carry-over of the theme and its principles into
strategies to avoid falls. The team incorporated a wide the home, all participants received a refrigerator mag-
variety of interactive presentation methods to accom- net as a thank-you gift for participating in the pro-
modate diverse learning styles and maximize partici- gram. The acronym appeared on the magnet along
pants’ enjoyment. Some portions were didactic with with an attractive logo designed by the team.
Table 14-1 STEADY As You Go Pilot Module Program Evaluation

Segment Time Student Leader(s) An interdisciplinary student team conducted the pro-
Introduction 5 minutes Occupational Therapy gram evaluation, beginning approximately 1 month
after the program’s pilot implementation. The evalu-
STEADY 5 minutes Occupational Therapy ation team first established that the evaluation’s
theme
purpose was to determine the program’s impact on
Sensory 5 minutes Physical Therapy three outcomes: “consumer satisfaction, participants’
awareness fall prevention behaviors, and senior center program
Breathing 5 minutes Respiratory Therapy enhancements” (Becker-Omvig et al., 1999, p. 46).
exercises The evaluation plan utilized a combined goal-based
Postural 5 minutes Physical Therapy
exercises
Box 14-1 Description of STEADY Acronym
Tai Chi video 5 minutes Respiratory Therapy
Home safety 10 minutes Occupational Therapy S Safe Footing
devices T Take Your Time
Bingo 15 minutes All E Energy Conservation
A Active
Wrap-up 5 minutes Physical Therapy D Devices
Total Time 60 minutes Y You’re in Charge!
2580_Ch14_201-209 16/07/13 2:52 PM Page 205
and goal-free model (McKenzie & Smeltzer, 1997), constructs related to behavior. The data were mixed
which allowed the team to determine whether the on actions taken, given that the majority said
program had achieved its specified goals and assess they had started participating in physical activity to
any unanticipated outcomes in an open-ended way. reduce their risk of falls, but very few had sought
Evaluation data were collected in a variety of out advice and information on fall prevention from
ways during a single visit to the site approximately providers or other sources. Finally, the program’s
4 months after the intervention. Qualitative data impact on enhancements to the senior center
were collected in a brief focus group with 14 of the was less favorable. Data from the focus group and
original participants and in two 30-minute individ- interviews indicated that no environmental changes
ual interviews with two members of the senior cen- had been made at the senior center to enhance
ter’s staff. A schedule of questions for the interviews safety, and the only program enhancements had
and the focus group were developed in advance. been related to exercise (Becker-Omvig et al., 1999).
Quantitative data were collected via a written ques- Ultimately, the lessons learned from the imple-
tionnaire administered to the same 14 participants mentation and evaluation of STEADY As You Go led
(Becker-Omvig et al., 1999). to the development of recommendations for other
The questionnaire was developed to capture the at- similar programs in the future. First, the importance
titudes, beliefs, and behaviors according to the theo- of “buy-in” among the facility staff is critical in
retical constructs of the HBM and Social Cognitive creating momentum from the program. This could
Theory (SCT). It consisted of 20 items with a com- be facilitated through close collaboration with staff
bination of both Likert items and yes/no response during the program planning phase, and periodic
formats. For example, to measure perceived self- follow-up to monitor compliance with recommen-
efficacy, participants were asked to respond to the dations and offer resources and support, possibly
statements “I learned ways to prevent falls from the including an on-site environmental evaluation.
STEADY As You Go program” and “The STEADY As Second, many older adults are highly motivated to
You Go program has helped me to be more steady adopt simple behavior changes to reduce their risk
and safe” from five levels ranging from “strongly of falling and are eager to learn new strategies. More-
disagree” to “strongly agree.” In this way, data from over, while the program might be more effective in
the 20-item questionnaire were compiled into five an expanded multi-session format, the pilot program
HBM subscales: perceived self-efficacy, perceived alone still produced favorable outcomes among a
susceptibility, knowledge, likelihood of taking action, small group of individuals, providing the senior
and actions taken (Becker-Omvig et al., 1999). center with a model for replication and future
All four members of the evaluation team partici- expansion, and the student teams with valuable
pated in theme coding the qualitative data from the experience in program development and evaluation.
interviews and focus group. Coded data were ana-
lyzed according to the same five HBM subscales
used in the questionnaire. The team met to discuss Aging in Place Initiative
emergent themes and identify areas of agreement Many of the lessons learned from the STEADY As
and discrepancy between the three data sources You Go program were transferred to the develop-
(Becker-Omvig et al., 1999). ment of an occupational therapist-led health pro-
Results of the evaluation were analyzed in each motion program for older adults in Howard
of the three main outcome areas. First, consumer County, Maryland. The Howard County Office on
satisfaction was determined to be high, based on Aging (HCOOA) originally funded one full-time
qualitative data from the interviews and focus occupational therapist through a 3-year grant from
group. Second, the impact on participants’ behavior the Horizon Foundation. Following the grant cycle,
was evaluated in terms of the five HBM subscales two full-time positions were permanently funded by
using data from the focus group and questionnaire. local government. The program, entitled the Aging
Respondents scored highly on every subscale except in Place Initiative, was intended to build capacity
actions taken and provided favorable feedback in the in a variety of community agencies to provide
focus group, indicating a positive impact on many gap-filling services for older adults. At the HCOOA,
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the occupational therapist spearheaded the develop- and service plan provided to new clients. In the past,
ment of a new fall prevention program as part of the during the initial service evaluation, once the client’s
countywide Aging in Place Initiative. eligibility was established the client and staff would
Aging in Place programs and initiatives have been select an appropriate combination of supportive serv-
growing in recent years and are supported by older ices. Later, under the Aging in Place Initiative, clients
adults and a variety of stakeholders, including occu- began receiving follow-up evaluations by the occu-
pational therapy. In the following aging in place pational therapist. In these occupational therapy
example, the occupational therapist was responsible evaluations, clients were often found to be capable
for fostering agency collaborations with a comprehen- of functioning at a higher level of independence with
sive geriatric assessment team, conducting home eval- appropriate interventions, and therefore needed
uations and direct client interventions, providing staff fewer supportive services. On the other hand, some
education to facilitate collaborative interdisciplinary clients who had been prescribed many hours of serv-
efforts, and educating the public in multiple commu- ice were found to be fundamentally unsafe in their
nity venues. With the goal of enabling older adults to current living situation due to severe cognitive
continue living in the community for as long as pos- deficits or other irreversible functional limitations.
sible, the program addressed falls prevention in a mul- For these clients, the Aging in Place Initiative pro-
tifactorial way as part of a larger health promotion vided counseling, referrals, and support to the family
strategy. and client to facilitate the transition into a new living
The HCOOA is the local agency that plans, situation. In either case, the occupational therapy
advocates, develops, and coordinates programs and evaluation and intervention provided through the
services for seniors and their family members. Aging in Place Initiative aimed to optimize the match
The HCOOA provides a variety of services and between the client and his/her environment by mod-
resources to the county’s growing population of ifying both the environment and the person, in order
older adults, often at no cost to the county resident. to maximize functional independence and minimize
Multiple funding sources provide subsidized services the need for supportive services.
for eligible residents, including chore services to assist In addition to anecdotal improvements in clients’
with homemaking and personal care services to assist quality of life and consumer satisfaction, the occupa-
with bathing and other activities of daily living. tional therapist’s presence contributed to significant
One of the unique contributions of the occupa- improvements in the program’s cost-effectiveness. A
tional therapist in the Fall Prevention Program was to program pilot demonstrated a 40% reduction in the
initiate a paradigm shift in the overarching strategies cost of chore and personal care services. Unfortu-
of various HCOOA programs. The occupational ther- nately, despite the favorable outcomes of the program
apist’s influence led various HCOOA programs to pilot, institutional barriers prohibited the full adop-
begin focusing on maximizing clients’ ability to function of the occupational therapy recommendations.
tion as independently as possible. This approach grad- Therefore, leveraging her prior experiences with
ually replaced the former strategy of providing as program development and outcome measurement,
many service hours as could be justified by the client’s the therapist initiated a more rigorous method of
current level of disability. The occupational therapist evaluation to promote future “buy-in” from agency
discovered many opportunities for clients to reduce administration. This evaluation study used a ran-
their need for supportive services by increasing their dom experimental design to collect more data on
functional performance through appropriate interven- the occupational-therapy-based model of service
tions. Clients were provided with assistive devices and delivery in an attempt to quantify the value of this
trained in their proper use; home modifications were new model.
performed to enhance safety and functional mobility; The influence of occupational therapy within a
and referrals for more intensive rehabilitation were social service agency has challenged the traditional
made where appropriate. Furthermore, by maximizing idea of aging in place, consistent with a shift from a
functional independence and safety, clients enjoyed a literal interpretation of staying in the “home” to a
higher quality of life and autonomy. much broader perspective of aging in the community
The paradigm shift introduced by the occupa- with a focus on a better person-environment fit.
tional therapist began with the in-home evaluation Often disparity exists between the support costs
2580_Ch14_201-209 16/07/13 2:52 PM Page 207
necessary to keep individuals in an environment with Because falls prevention is widely recognized as a
a poor match to their needs and the ever-decreasing serious concern for older adults, their families,
resources available to provide such services. Through and providers, it may serve as an effective lead-in
the unique lens of occupational therapy evaluation to comprehensive health promotion programs
and interventions incorporated into social service addressing the multifactorial causes of falls. Com-
agencies, public resources in the future may be allo- plex programs such as the Aging in Place Initiative
cated with greater efficiency and better outcomes. provide linkages to a wide range of services, and
Multiple opportunities continue to emerge at the therefore offer maximum flexibility to tailor ser-
HCOOA and in other agencies as the value of occu- vices to the values, interests, and needs of their
pational therapy is realized. The program continues clients. On the other hand, even a simple one-
to grow as new occupational therapy positions are day program in a senior center, like STEADY
created to provide direct services and contribute As You Go, can successfully raise awareness
to overall program development. The occupational and capitalize on the positive attitudes of partici-
therapist’s approach of maximizing clients’ inde- pants. Readers are encouraged to cultivate their
pendence offers both personal and fiscal advantages own opportunities for program development by
that have proved to be desirable for both community conducting community needs assessments and
agencies and the clientele they serve. networking with local public and private stake-
holders (e.g., government agencies, private foun-
dations, consumer groups, health care facilities).
Conclusion Often an initial investment of volunteered time
and expertise (e.g., in the form of a demonstration
Opportunities abound in the community for program) can be enough to stimulate a demand
occupational therapists to provide community- for broader programs with sustainable funding
based health promotion services for older adults. streams.
CASE STUDIES
CASE STUDY 14•1 Ms. Fay
Ms. Fay is a 75-year-old female diagnosed with macular degeneration, rheumatoid arthritis, diabetes, and
neuropathy in both feet. Ms. Fay was widowed 2 years ago and now lives by herself. She was admitted to
the hospital for a right hip replacement 1 year ago. She was discharged from rehabilitation and home
health following 3 months of physical and occupational therapy. Ms. Fay has had two falls over the past
few months while getting up in the middle of the night to use the bathroom. She acknowledges having a
fear of falling that has resulted in a decreased level of daily activity.
Living Situation: She lives in a two-story home with attached garage. The home is located on a quiet
cul-de-sac near a park and local shopping area.
Mobility: She ambulates with a single-prong cane and is able to walk for about 10 minutes without
rest. She can transfer sit to stand with moderate effort. Stairs are difficult for her, which is problematic
because the only bedroom and bathroom are located on the second floor of her home. The home has five
steps at the entrance with one handrail.
Household: Ms. Fay can prepare her own meals. However, she does not drive and requires trans-
portation for shopping. She manages her own finances, and most bills are managed by direct pay-
ment.Neighbors help her with yard work and household maintenance. She has one son who lives
60 miles away, and she sees him once a month.
Bathroom: Ms. Fay showers independently. She transfers in/out of the tub by holding on to a towel
bar outside the bathtub/shower unit. She stands during showering. There are no grab bars or non-slip
mats in the tub.
Continued
2580_Ch14_201-209 16/07/13 2:52 PM Page 208
CASE STUDY 14•1 Ms. Fay cont’d
Medications: She can read large print and has been prepared for total blindness within 2 years. She
struggles with managing six different medications taken twice a day. She currently keeps her medications
in the bathroom and identifies them by the size of the bottle and the number of rubber bands she has
placed around each bottle. Ms. Fay occasionally drinks socially with friends.
Communication: There is only one phone in the home. She remembers her friend’s phone number
and emergency numbers only.
Leisure: Ms. Fay enjoys reading and socializing with friends and family. She participates in faith-based
activities and plays cards at the local senior center weekly.

1. Identify and prioritize fall risk factors.
2. What environmental adaptations would you suggest?
3. Identify community resources you could recommend for fall prevention.
4. Identify barriers that might exist for Ms. Fay as she considers changing her behavior and/or environ-
ment to reduce her risk of falling.
5. Prepare a list of recommendations for Ms. Fay and her son.
6. Evaluate the pros and cons of your recommendations and how they may increase/decrease the likeli-
hood of Ms. Fay adopting a behavior and/or environmental change.
Learning Activities Acknowledgments: The authors wishes to thank

Phyllis Madachy of the Howard County Office on
1. Visit www.stopfalls.org and identify a fall pre- Aging for providing readers with the example of
vention program you could implement in your its Aging in Place program, which has been a
local community. Write a one-page rationale as national model for community-based health
to why you selected the program, addressing the promotion for older adults.
advantages and disadvantages of the program. Example one was part of a Quentin N. Burdick
2. Identify at least 5 community agencies for a Program for Rural Interdisciplinary Training
first-time meeting to propose the implementa- project of the Western Maryland Area Health
tion of a fall prevention program. For one of Education Center in collaboration with the
these agencies: University of Maryland, Baltimore; University
a. Prepare an action list outlining the steps of Pittsburgh; Towson University; Frostburg
you will take prior to the meeting. State University; and Allegany College of
b. Identify specific information will you want Maryland. This project was supported by funds
to gather prior to and during your first from the Department of Health and Human
meeting. Services, Health Resources and Services
c. Identify and prioritize goals for the meet- Administration, Bureau of Health Professions,
ing. What do you hope to accomplish? and Quentin N. Burdick Program for Rural
d. List critical points you will want to com- Interdisciplinary Training. The conclusions are
municate during the meeting. those of the authors and should not be construed
e. Role-play the meeting for the class. as the official position or policy of, and
3. A peer-led support group for older adults with endorsements should not be inferred by, the
arthritis contacts you to present a 1-hour session Department of Health and Human Services,
on fall prevention. Prepare a two-page outline Health Resources and Services Administration,
of your presentation incorporating experiential Bureau of Health Professions, or the U.S.
activities for participants. government.
2580_Ch14_201-209 16/07/13 2:52 PM Page 209
REFERENCES Dunn, W., Brown, C., & McGuigan, A. (1994). The ecology
of human performance: A framework for considering the
American Occupational Therapy Association. (2004).
effect of context. American Journal of Occupational Therapy,
Occupational therapy and prevention of falls: Education for
48(7), 595–607.
older adults, families, caregivers, and healthcare providers.
McKenzie, J. F., & Smeltzer, J. L. (1997). Planning, imple-
[AOTA Fact Sheet]. Bethesda, MD: Author.
menting, and evaluating health promotion programs: A
primer (2nd ed.). Boston, MA: Allyn & Bacon.
Occupational therapy practice framework: Domain and
Moreland, J., Richardson, J., Chan, D. H., O’Neill, J.,
process (2nd ed.). American Journal of Occupational
Bellissimo, A., Grum, R. M., & Shanks, L. (2003).
Therapy, 62, 625–683.
Evidence-based guidelines for the secondary prevention
Becker-Omvig, M., Caldeira, K., Hockman, L., & de los
of falls in older adults. Gerontology, 49(2), 93–116.
Santos, L. (1999). Evaluation of the STEADY As You
National AHEC Organization. (n.d.). About Us: AHEC
Go fall prevention program. Unpublished manuscript.
Mission. Retrieved from http://nationalahec.org/About/
Cumberland, MD: Western Maryland Area Health
AHECMission.asp
Education Center.
National AHEC Organization. (2009). NAO 2009 brochure.
Caldeira, K. (1999). Interdisciplinary prevention in rural
Retrieved from http://nationalahec.org/Publications/
communities: Outcome evaluation of the STEADY As You
NAOBrochure.asp
Go fall prevention program. Unpublished manuscript.
Prochaska, J. O., & DiClemente, C. C. (1983). Stages and
Towson, MD: Towson University.
processes of self-change of smoking: Toward an integrative
Caldeira, K. M., & Reitz, S. M. (2010). Preventing falls
model of change. Journal of Counseling and Clinical
among community-dwelling older adults. In M. E. Scaffa,
Psychology, 51(3), 390–395.
S. M. Reitz, & M. A. Pizzi (Eds.), Occupational therapy in
Prochaska, J. O., & DiClemente, C. C. (1992). Stages of
the promotion of health and wellness (pp. 470–492).
change in the modification of behavior problems. In M.
Philadelphia, PA: F.A. Davis.
Hersen, R. M. Eisler, & P. M. Miller (Eds.), Progress in
Caldeira, K., Gurka, J., & VanSickel, T. (1999). STEADY As
behavior modification (pp. 184–214). Sycamore, IL:
You Go: A community-based program for fall prevention
Sycamore Press.
among older adults in Garrett County, Maryland. Unpub-
Reitz, S. M., Scaffa, M. E., Campbell, R. M., & Rhynders,
lished manuscript. Cumberland, MD: Western Maryland
P. A. (2010). Health behavior frameworks for health
Area Health Education Center.
promotion practice. In M. E. Scaffa, S. M. Reitz, &
Centers for Disease Control and Prevention. (2003). Fatalities
M. A. Pizzi (Eds.), Occupational therapy in the promotion of
and injuries from falls among older adults—United States,
health and wellness (pp. 46–69). Philadelphia: F.A. Davis.
1993–2003 and 2001–2005. Morbidity and Mortality
Weekly Report, 55(45), 1221–1224.
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Chapter 15
Aging in Place and Naturally

Occurring Retirement
Communities
Peggy Strecker Neufeld, PhD, OTR/L, FAOTA
Nobody grows old merely by living a number of years. We grow old by deserting our
ideals. Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul.
—Samuel Ullman
Learning Objectives
• Define aging in place and livable communities.
• Identify aging trends, societal issues, and key policies related to aging in place.
• Describe the concept of Naturally Occurring Retirement Community (NORC), NORC-Supportive Service
Program, and the common elements and differences across NORCs.
• Discuss evidence for benefits to older adults for living in an active senior community or a NORC.
• Discuss roles for occupational therapy practitioners in aging in place communities and NORCs.
Key Terms
Aging-friendly communities NORC-Supportive Service Program (NORC-SSP)
Aging in place Productive aging
Capacity building Self-management
Longevity revolution Social capital
Naturally Occurring Retirement Community (NORC)
Introduction Productive aging may be defined as activities

such as volunteering, caregiving, and employment
With a rapidly growing population of older adults (Hinterlong, Morrow-Howell, & Sherradan, 2001),
in the United States, aging in place has become a but it also refers to living life fully, socially engaged
societal concern (National Association of Area with a positive zest for life and expressing oneself
Agencies on Aging [NAAAA], 2006). National creatively with the ability to achieve positive out-
agencies concerned about “livable” communities for comes (National Center for Creative Aging, n.d.).
all ages define aging in place as continued living in To provide for aging in place, occupational therapy
one’s own home and having needed services to be practitioners, along with other professionals, are
safe, independent, and comfortable while growing called upon to respond to critical concerns for
older. Settings that promote aging in place not proactive planning. Communities across the nation
only provide supportive services for health but also are experimenting with ways to assist older adults to
offer lifestyle opportunities for productive aging. age in place. One approach is through supporting
210
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Chapter 15 | Aging in Place and Naturally Occurring Retirement Communities 211
neighborhoods with a high concentration of seniors year 2050 there will be no single majority racial
who have been living in their own homes for group in the United States.
decades. A geographic area identified as having a One effect of the increased older adult popula-
higher percentage of older adult residents than typ- tion in the United States will be a bigger demand
ical is a naturally occurring retirement community on medical and social services, public health services,
(NORC) (Hunt & Gunter-Hunt, 1985; Hunt & and the related budgets. The CDC (2009) predicts
Ross, 1990). NORCs have the capacity to support that, due to changes in demographics, disease, and
aging in place through a low-cost neighborhood behavioral conditions, health care expenditures will
approach of social networking, meaningful activity increase 25% by 2030. Current chronic diseases that
options, and informal caring to maintain health are leading causes of death include heart disease,
and wellness (Masotti, Fick, Johnson-Masotti, & cancer, stroke, respiratory diseases, and diabetes.
MacLeod, 2006). NORCs and related service Poor health behaviors add to the concerns, with
models (NORC-Supportive Service Programs leading behavioral causes of death and poor health
[NORC-SSPs]) are emerging areas for occupational due to smoking, obesity, physical inactivity, and
therapy practice. falls. The health of the growing senior population is
Societal trends and issues related to aging in place of great concern for the potential for successful
are explored in this chapter along with the potential aging in place.
roles for occupational therapy practitioners. Due to increasing numbers of seniors with incur-
NORCs are described as an innovative setting able diseases, they will find it essential to use a
to support successful aging. A review of research self-management approach in which they manage
evidence linking health, occupations, networks, and their long-term conditions through making healthy
aging has significant implications for practice in lifestyle changes and partnering with medical pro-
aging in place settings. Examples from a specific fessionals (Lorig & Holman, 2003). Self-manage-
NORC-SSP demonstrate integrated occupational ment is defined by Lorig and colleagues as having
therapy practice at individual, interpersonal, and or obtaining the ability to manage the consequences
community levels. of disease. Others recognize that a community
approach with its potential social support and net-
working can further enhance self-management
Societal Trends Impacting knowledge, skills, and confidence (Community Pre-
ventive Services, 2001). Occupational therapy prac-
Aging in Place and titioners can play crucial roles in assisting older
Implications adults manage aging conditions such as transitions
from change or loss in employment, spouse, and
Today’s changing demographics are striking and friends, and maintaining one’s home. To address
have led to a longevity revolution (Butler, 2008; older adults’ chronic health conditions, practitioners
Centers for Disease Control and Prevention [CDC], can teach self-management skills and promote
2008), which is the remarkable gain in life expectan- successful aging.
cies and the significant impact anticipated on society Another societal concern from the increased
overall. In the United States, people are living longer, number of baby boomer retirees leaving the U.S.
with the number of older adults expected to increase work force in the coming decade is the large number
to 72.1 million by the year 2030 (one older adult in of seniors who will be facing this significant life tran-
every five), which is more than twice the number sition at the same time. Many may go through a loss
than in 2000. Seniors at 85 years and older are the of roles and productivity upon leaving full-time
fastest growing segment of the aging population and work responsibilities and may find it challenging to
are expected to increase from 4.6 million in year adopt new lifestyles that are rewarding and mean-
2000 to 9.6 million in 2030 (Ortman & Guarneri, ingful. Studies show that retirees experiencing insta-
2010). The increased numbers of seniors will be bility during the retirement transition or a lack of
more racially and ethnically diverse than the current control may be at risk for adverse health effects
older adult population given predictions that by the (Marshall, Clarke, & Ballantyne, 2001; Solinge,
2580_Ch15_210-222 16/07/13 2:53 PM Page 212
2007). One way to ease the transition into a retire- organizations with similar interests positions occu-
ment lifestyle is for retirees to become professional pational therapy practitioners as critical players
and leadership volunteers (National Council on in addressing societal concerns. Capacity building
Aging [NCOA], 2008). Professional volunteers refers to strategies and actions carried out by an
assume leadership roles and contribute skills agency to continue growth toward its goals and
from their past work into new life roles, such as mission and to achieve sustainability (DeVita &
sharing skills from prior experiences in business, Fleming, 2001).
marketing, education, technology, and their net-
working connections.
In light of the increasing number of baby
NORC: A Solution for Successful
boomer retirees, the NCOA, a national non-profit Aging in Place
organization, asserts that many agencies are poorly Aging in place in a NORC occurs naturally when
prepared to take advantage of the boom of older a person lives in a home for decades that was not
adults as professional volunteer resources (Endres, originally designed for seniors. Living in a NORC
2006). Professional volunteers can significantly means not relocating to a retirement home or a
benefit non-profit agencies and businesses in retiree continuing care retirement community. NORCs
civic engagement roles (Martinson & Minkler, have a substantially higher percentage of older adult
2006). Civic engagement involves volunteering but residents than the national average of 12%–14% of
also includes civic life activities such as community residents aged 60 and over in typical communities
activism, keeping well informed about current (Jewish Federations of North America [JFNA],
events, voting, and caregiving. The NCOA acted 2010a). Others define a NORC as an area with a
on these concerns by launching the RespectAbililty density of older adults that is more than typical in
Initiative to promote older Americans as “untapped their state, or simply that the area is a NORC if it
resources” to help renew communities. The initia- feels like a NORC.
tive has fostered new community models through As NORCs are identified throughout the
establishing innovative partnerships that success- country, NORC-Supportive Service Programs
fully recruit and train “mature adult” volunteers— (NORC-SSPs) are created as structures to maxi-
especially capturing the interests and skills of baby mize opportunities and services to enhance aging
boomer retirees as professional volunteers for civic in place in one’s own home instead of moving to
engagement. a senior-designed and seniors-only setting. In
Aging-friendly communities is an initiative related 1996, the first professionally staffed NORC-SSP
to the worldwide concerns of increased numbers of was created at Penn South in New York City.
seniors. In a global online conference on creating Currently in the state of New York more than
aging-friendly communities, additional important 50 NORCs have been established (United Hospi-
factors were recognized for promoting the health and tal Fund, 2010). In 2001, the United Jewish
well-being of older adults—factors that apply to Communities (UJC) developed a federally funded
countries across the world. In his keynote presenta- initiative of NORC-SSP and more than 40 were
tion, Scharlach (2008) points out the importance of established across the United States (2006) with
communities offering continuity, compensation, and funding from the Administration on Aging and
opportunity for healthy aging. Specifically, these are assistance from state and local funders.
the continuity of continued engagement in life and NORCs differ considerably based on geo-
community, the compensation for any supports or graphic and housing characteristics, neighborhood
accommodations needed for functional limitations cultures, and available services. By virtue of the
due to aging, and opportunities for familiar and new dense senior population in the United States,
activities for enhanced quality of life. many NORCs exist but are not identified as such
Occupational therapy practitioners are good and do not offer supportive services. Vertical
partners for communities of active aging adults NORCs, which are typical of populous cities
due to shared interests in enhancing productive such as New York City or Los Angeles, consist of
aging. The potential to assist capacity building in large apartments or condominiums. These urban
2580_Ch15_210-222 16/07/13 2:53 PM Page 213
NORCs often comprise one or more city blocks, home modifications as needed. Health education
with a number of NORCs existing within the city. activities assist seniors in learning and adopting
Suburban and rural areas have horizontal NORCs, proactive health behaviors such as effective decision
consisting of houses, condominiums, and apart- making, problem solving, and finding resources.
ments that can stretch over a few miles, although NORC group educational opportunities can heighten
not often beyond 3 miles. NORC-SSPs vary awareness for fall prevention, driver safety, and self-
depending on the partnerships available with management strategies to prevent disabilities. Mean-
community agencies, health care professionals, and ingful volunteer opportunities also help strengthen the
existing services. community and provide direct benefits to the volun-
There is a consensus that a NORC-SSP’s five teers and to those receiving assistance.
key defining elements critical to their growth and Outreach within a NORC-SSP includes commu-
sustainability are partnerships, programs, resident nication with its residents and the organizations and
participation, communication/outreach, and evalu- businesses in its larger community. A successful
ation (JFNA, 2010b). Initial development of a NORC will identify shared interests and mutual
NORC benefits from coalescing potential commu- benefits with potential partners for continued
nity partners and stakeholders for purposes of deter- growth. The NORC model typically offers profes-
mining needs, strengths, and resources. Potential sional staff telephone outreach to older adults who
NORC partnerships include health care agencies are frailer and less active to connect them with
and professionals, social service agencies, government needed support and enable them to participate as
agencies (e.g., Area Agencies on Aging, AOA, CDC, possible in programs. Communication with adult
National Institute on Aging), universities, businesses, children, who live either within the NORC or at a
housing complexes, religious organizations, libraries, distance, also helps meet family needs of those who
and the local residents. are providing “long-distance caregiving.”
NORC-SSPs promote older adults’ health by The fifth common element in a NORC is routine
using a comprehensive perspective that addresses program evaluation to determine impact on resi-
physical, social, cognitive, environment, and partici- dents, to inform ongoing program development,
pation factors. This community level of intervention and to provide accountability to residents and
is consistent with the societal trend toward using pre- funders. The NORC Blueprint Web page (United
ventative approaches to health. NORC programs are Hospital Fund, 2006) recommends that NORCs
designed for either individuals or a neighborhood- need sufficient resources allocated for evaluation
wide population or for specific groups of residents, from the start and emphasizes making evaluations
such as those tailored for different age groups practical. It also recommends sharing findings with
(Haight, Schmidt, & Burnside, 2005). partners for assistance in analyzing the program’s
Typically, a NORC offers an assortment of ser- impact on residents and communities and in trans-
vices and programs for socialization, community lating findings to action.
engagement, physical activity, other health con- The costs to older adult residents for NORC-
cerns, lifelong learning, home management, and SSPs vary considerably and are important to con-
safety (JFNA, 2010b). Resident participation is sider in developing a cost-effective model. Some
critical to the success of a NORC, although many neighborhood models, with professional staff
seniors who do not participate in the NORC state coordination, have annual individual membership
they feel comforted that the services will be there fees of $30 to $120 per year for a variety of pro-
whenever needed (Neufeld, 2005). Seniors are en- grams including education and activity sessions for
couraged to become active participants, linking with health and socialization, volunteer services, and
neighbors to enrich lives and make connections to assistance in finding community resources. In con-
decrease social isolation and increase awareness of trast, the village concept, which is a self-governing
resources. Home services include finding trustwor- NORC, charges members up to $1,000 per year
thy services, help with home repair and yard work (Moeller, 2009) primarily for concierge services to
(through volunteer services), assistance in making assist residents in finding needed home services
the home safe, and assessing and implementing and business discounts.
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Research Evidence Linking (Bedney, Schimmel, & Goldberg, 2007). The vari-
ables selected for the UJC impact study were social
Healthy Aging, Community isolation, awareness and use of community services,
Characteristics, and volunteerism, and self-reported health because prior
research supported these as key factors for healthy
Occupations aging and aging in place. Social isolation has shown
Communities for active aging take note of growing to highly correlate with mortality, morbidity, and
research evidence that links health, everyday life dementia occurrence (Hawkley, Burleson, Bernston,
occupations, networks, and positive aging. The & Cacioppo, 2003; Wilson, Krueger, Arnold,
research suggests that communities with increased Schneider, Kelly, Barnes, Tang, & Bennett, 2007).
numbers of senior residents (such as NORCs) may Studies on perceptions of available help showed
have great potential to be an untapped resource for older adults who are aware that help is available
productive aging, health, and wellness in older adults report fewer “physically unhealthy days” than do
(Masotti et al., 2006) by virtue of the concentration those who are unaware of available help (Keyes
of older adults in a specific neighborhood. The et al., 2005). Research documented that providing
potential exists within active aging communities assistance to the oldest-old decreases the need for
for increased social engagement (i.e., participation in their placement in high-cost care settings (Stewart,
social and community activities) and civic engage- 2004). Volunteerism has been shown to have a
ment (Callahan & Lanspery, 1997). Enhancing social positive relationship with older adults’ sense of
engagement in older adults can significantly improve well-being and mortality (Lum & Lightfoot, 2005).
function in daily living activities, decrease disability, Also, self-reported poor health has correlated with
and increase life satisfaction (Bassuk, Glass, & increased occurrence of hospitalization and nursing
Berkman, 1999; Mendes de Leon, 2005). The home placement (Weinberger et al., 1986).
concentration of older adults also suggests increased Findings from the UJC 2007 study, which
possibilities for social capital, which are collective involved 461 older adult participants from
social networks with trustworthy and reciprocal 24 NORC-SSP sites, support NORCs as having
relations (Putnam, 2001). Current research can a positive impact on socialization, use of commu-
inform occupational therapy interventions (see nity services, volunteerism, and perceived health.
Table 15-1). Responses included participants’ strong agreement
Although a community concentration of older (72% to 95%) with statements indicating that
adults suggests that aging in place in a NORC since participating in the NORC they know
would promote health and productive aging, not and talk with more people, participate in more
all NORCs automatically promote social engage- activities, and are more aware of and use available
ment and social capital. A healthy NORC is one in community services. They also report to more
which a “healthy NORC resident feels drawn into likely continue living in their community (88%),
a vibrant active community” (Masotti et al., 2006, feel healthier (70%), and volunteer more (48%).
p. 1167). Masotti et al. asserts “a NORC can be
made healthier by changing [community] charac-
teristics to increase activity, decrease stress and
Occupational Therapy Roles in Aging
provide a sense of community and well-being” in Place Communities and NORCs
(p. 1167). In this way NORCs can become a Occupational therapy community practice is a good
low-cost approach to healthy aging. The potential fit with aging in place programs, including NORCs.
cost-effectiveness of a NORC-SSP is apparent when The occupation-based, context-driven, and client-
compared to fees for alternative senior living. centered interventions of occupational therapy bring
Research on NORCs is beginning to demon- an added benefit and unique perspective when
strate evidence for positive benefits to its older adult working in a multidisciplinary community team.
residents. An IRB-approved national study explored Wilcock (2010) urges occupational therapy practi-
the impact of the United Jewish Council–initiated tioners to apply their occupation focus to popula-
(UJC) NORC-SSPs on older adult participants tion health, defining five occupational therapy
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Table 15-1 Evidence-Based Implications for Occupational Therapy Interventions

Sample Evidence Linking Health,
Occupations, Networks, and Aging Implications for Occupational Therapy
Environmental support enabling • Include assessments of the physical and social environ-
occupations promotes health and ment to investigate enablers and barriers that will inform
prevents functional decline associated programming.
with aging (Everard, Lac, Fisher, & Baum, • Assist development of policies and programs that enhance
2000; Lawton & Nahemow, 1973). active participation, safety, and accessibility in homes,
buildings, and outdoor areas (e.g., neighborhood walkabil-
ity survey, accessibility survey of buildings, education in
self-management for social support needs, etc.).
Increased physical, social, and productive • Assist the design and implementation of programs that
activity is linked to decreased morbidity integrate physical, social, and productive actions (e.g., bus
(Glass, Mendes de Leon, Marottoli, & outings to educational and cultural events, new group
Berkman, 1999). dance step lessons, community activism projects, etc.).
Social engagement related to physical • Design and teach educational sessions that include partici-
health modifies and protects against patory learning and provide opportunities for seniors to
cognitive aging and reduces risk for interact with others with similar interests.
disabilities (Bassuk et al., 1999; Everard • Assist in planning and implementing events that include
et al., 2000; Menec, 2003). opportunities that facilitate socialization.
Social capital in housing areas relates to • Promote gatherings in housing complexes that encourage
positive self-rated health (Cannuscio, socialization and information exchange.
Block, & Kawachi, 2003; Kim, • Foster senior support organizations’ collaborative partner-
Subramanian, & Kawachi, 2006). ships with community (e.g., condo management, realtor
agency, tenant councils, etc.).
Older adults’ meaningful social and • Identify seniors’ occupational interests and the commu-
community occupations are linked to nity’s occupational profile to foster program choices that
self-rated positive health and participation match interests.
(Clark, et al., 1997). • Foster volunteer opportunities that recognize and use sen-
iors’ skills to strengthen the organization’s capacities.
Wellness courses promote confidence for • Design and teach educational and support classes or pro-
self-management skills, proactive behaviors, grams for small groups of older adults.
lifestyle changes, and volunteerism (Clark
et al., 1997; Neufeld & Kniepmann, 2001).
approaches of wellness, preventive medicine, com- To begin a relationship with an aging in place
munity development, occupational justice, and community, initially occupational therapy practi-
ecological sustainability. Her approach suggests tioners can reach out to a community organization
occupational therapy practitioners can contribute to learn about its services, strengths, and chal-
at the individual, group, community, societal, and lenges. Often a relationship develops when shared
global-political levels. Similarly, according to interests are identified and the practitioner gives
the American Occupational Therapy Association advice as a “professional volunteer”; offers an edu-
(AOTA) guiding professional document (AOTA, cational group session on a health, wellness, and
2008), occupational therapy attends to the complex senior living topic; or becomes an advocate by
factors that enable and empower client engagement facilitating partnerships among agencies and pro-
and participation in occupations. fessionals. Once they form a relationship with an
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agency, occupational therapy practitioners may resources to the programs. Other examples of
negotiate reimbursement for services as a consul- possibly needed community policies include bus
tant, program developer, evaluator, research team transportation to programs, use of meeting spaces,
member, or grant writer. routine programming, newsletter articles, program
The occupational therapy process in aging in flyers, systems for phone reminders to seniors, and
place communities involves the steps of assessment, referral methods for occupational therapy in-home
intervention, monitoring, outcome assessment, services that assess needs for home modifications for
and collaboration, similar to individual direct prac- increased independence. Community partners
tice and as outlined by AOTA (2008). An occupa- should be able to count on occupational therapy
tional therapy practitioner’s initial assessment practitioners emphasizing residents’ perspectives and
may be part of a team’s comprehensive needs occupational concerns when planning policies and
assessment to identify enablers and barriers for activities.
aging in place related to the particular community Program evaluation, another occupational ther-
environment and cultural contexts. An occupa- apy role in aging in place communities, includes
tional profile can be conducted to evaluate a com- performing process and outcome evaluations. A
munity and its residents, looking for occupational process evaluation describes the elements, strategies,
routines, opportunities, and gaps as well as inter- and challenges in implementing a program over a
ests and strengths. Possible primary sources of specified time to see if it was carried out as intended.
information for use in a needs assessment include A process evaluation in a new NORC could capture
interviews; written or mailed surveys; focus groups the first year changes in policies, programs, partner-
with residents, family members, and agency staff; ships, and residents’ responses. A more focused
and observation of seniors’ activities in different process evaluation could examine a specific aspect
community contexts. Secondary sources include of a program, such as one carried out recently in a
policies, brochures, and flyers specific to the com- suburban NORC to examine the process of using
munity, as well as research literature on evidence, theoretically based recruitment strategies to encour-
models, and policies that promote aging in place age older adults’ enrollment in a physical activity
in related communities. promotion program (Hildebrand & Neufeld, 2009).
Community occupational therapy interventions Outcome evaluations are used to determine the
foster healthy lifestyle patterns through activities impact of programs. Possible outcomes could
offered on multiple levels. With goals of promoting include residents’ positive self-reports on physical
aging in place and building aging-friendly commu- and mental health, supportive relationships and
nities, practitioners may draw from theories aimed networks, and adoption of healthy lifestyle activi-
at the individual, interpersonal, and community ties. Other desired outcomes in a NORC could
levels. Numerous community theories are available include residents’ awareness of and satisfaction
as tools for capacity building on the community and with opportunities for occupational engagement,
organization level (see Chapter 3). services, and resources; and community participa-
Respecting older adults’ variation in capacities tion. Another occupation-based indicator of success
(from those who are less active, frail, and need in a NORC would be evidence of residents assum-
support services to others who are more active and ing leadership in planning, promoting, and/or
interested in education, prevention, and socializa- delivering programs and assuming advocate roles
tion) is a driving factor for occupational therapy for the community.
practice in aging in place. Customizing interven- Positive outcomes on the organizational level
tions for work with non-profit organizations assists could include enhancing organizational capacities
in developing aging-friendly organizational policies. (e.g., finding resources, recruiting volunteers, strate-
For example, agencies could benefit from occupa- gic planning) and integrated organizational services
tional therapy practitioners’ fresh perspectives on and relationships with agencies and businesses for
ways to involve seniors in models of “significant” sustaining services and programs. For example, a
volunteer service; that is, fostering residents’ volun- successful NORC would look for community part-
teerism and leadership in planning and bringing ners requesting NORC information and forwarding
2580_Ch15_210-222 16/07/13 2:53 PM Page 217
it to their clients or consumers. Also, NORC-SSPs services to aging in place communities. A NORC
would aim for community partners to offer services, may serve as a “living laboratory” for students as they
space, staff support, and/or funds for benefits to the benefit from direct experiences with community-
residents and for the operation of the NORC. residing older adults while practicing professional
Determining outcomes for a healthy community is skills and exploring research questions. Occupa-
best as a collaborative process with its stakeholders tional therapy students at Washington University
identifying intermediate as well as long-term outcomes School of Medicine appreciate learning from direct
(Anderson, Scrimshaw, Fullilove, & Fielding, 2003; interactions with well seniors (that is, older adults
Bauer, 2003). In the example of a NORC-SSP, the living in their own homes) and completing assign-
ultimate outcome is healthy aging and residents able ments within the authentic contexts of the NORC.
to live in their own homes as long as desired. Because While NORC residents are eager to be involved
there is no “gold standard” for measuring the impact with university students, enjoying their energy
of a NORC, establishing multiple intermediate goals and learning contemporary perspectives and knowl-
or outcomes will be important to assess ongoing edge, the residents also enjoy participating in
changes. Some steps toward achieving a healthy research activities because they view it as a form of
NORC include a neighborhood with safe, aging- volunteerism and civic engagement. For examples
friendly environments (e.g., policies; physical and social of occupational therapy student activities, see
environment); residents’ increased access to opportu- Table 15-2.
nities for social engagement, civic engagement, health
promotion, and supportive resources; and residents’
participation and control in decision making related to Conclusion
their community.
Occupational therapy students in a St. Louis Societal concerns for healthy aging and aging
NORC, with faculty supervision, offer additional in place call for occupational therapy practitioners
Table 15-2 Student Experiences in the St. Louis NORC

Research Experiences • Interview older adults within a community-wide needs assessment
(on master’s and • Assist with focus groups to assess occupational profiles of older adults residing in
doctoral levels or the NORC
research course • Case study research to assess impact of initial NORC residents’ participation
assignments) • Assess recruitment for and participation in an ‘Active Living Every Day’ course within
the NORC
• Process evaluation of a mailed version of an OT created NORC wellness course for
older adults
• Participatory action research with OT students and residents creating a storytelling
Web site and using a digital voice recorder to collect stories
• Participant-observation in NORC programs and follow-up field notes
Fieldwork • Assist as co-leader to implement health and wellness courses or sessions within the
Level I and II NORC
• Design, teach, and evaluate health, wellness, and senior living educational sessions; e.g.:
• Friendships—As Times Change
• Cooking Nutritiously for One
• Film Analysis Promoting Self-Management of Home
• Music Reminiscing—Tune Up and Tune In
• Assist in NORC program evaluation (data entry and analysis)
• “Ask the OT student” monthly resource sessions for drop-in visits by NORC seniors
(topics such as seeking work, finding a companion/dating, aging pets, helping adult
children with their health problems, etc.)
Continued
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Table 15-2 Student Experiences in the St. Louis NORC—cont’d

Course • Computer instruction to individuals and groups
Assignments • Searching interests in travel, recipes, etc.
• Searching online health information
• Determining validity of health information
• Learning e-mail skills
• Learning new applications (Excel, Publisher, Word)
• Doctoral students coordinate and supervise a NORC Activity Fair with two MSOT
students per booth on recreational, fitness, social, and health management activities
topics determined via students’ assessment of seniors interests
• Writing letters to legislators
• Grandparenting
• Transportation resources
• Driver safety
• Travel tips for seniors
• Dance demonstration
• Indoor gardening
• Fall prevention
• Smart gadgets—helpful strategies
• Resources to prevent disabilities
to envision and fulfill expanded community roles achieving their missions for older adults. As
in partnership with multidisciplinary profession- an emerging innovative aging in place model,
als. The occupation-focused and strength-based NORC-SSPs are one example where occupational
approach of occupational therapy can bring fresh therapy practitioners can become critical players
perspectives to interventions that can enhance to help build and sustain healthy communities for
community participation and assist programs in active and productive aging.
CASE STUDIES
CASE STUDY 15•1 Morris, Finding Purpose in Helping Others
Morris is in his early 70s and retired about 10 years ago from his work as a salesman. He and his wife
have been married for 50 years and lived for a number of decades in their current home in the suburban
NORC. Their lives have been full, including caring for an adult child with developmental disabilities
who lives with them. Morris’s son has numerous health crises and often Morris is at the hospital with
him. Also, Morris supports his parents who are in their late 90s and live in their own home in another
part of the city. Life became even more challenging when Morris became ill and required serious surgery.
When Morris returned home, his resilience and help from the NORC enabled him to slowly resume
his multiple life roles, although he often has relapses and fatigue. He is quick to thank the NORC for
helping him. He says, “In this high-tech, high-pressure, impersonal world we seem to be living in,
NORC is truly a sigh of relief.” By calling the NORC volunteer coordinator, he can request volunteers
to help with house tasks, such as home repair, moving heavy items in the house, yard work, and com-
puter training. A NORC referral to an occupational therapy in-home visit resulted in home modifica-
tions that increased his safety and function in the home. Morris also enjoys participating in NORC
programs that meet his personal interests. He is an avid storyteller and reflective listener who meets often
with other residents in monthly storytelling sessions. He and his wife enjoy NORC outings to cultural
events for continued learning and engagement with others.
2580_Ch15_210-222 16/07/13 2:53 PM Page 219
CASE STUDY 15•1 Morris, Finding Purpose in Helping Others cont’d
Despite his busy life and family caregiving, Morris willingly assumed the additional role of being a
NORC ambassador for his community. As an ambassador, he volunteers his wisdom and talents from a
lifetime of work and caregiving. He gives his time willingly to help build a healthy community. He finds
a sense of purpose in advocating for the NORC as he shares how he has benefited and encourages others
to become dues-paying members also. He brings his business talents to meetings with other NORC
ambassadors to help plan strategies for building and sustaining the NORC for the years to come in
their community.

1. What type of preventive occupational therapy services may be useful to Morris?
2. How could occupational therapy support the NORC in attracting younger seniors such as Morris
to share their professional skills as volunteers for enhanced productive aging and the good of the
community?
Learning Activities Bedney, B., Schimmel, D., & Goldberg, R. (2007). Rethinking
aging in place: Exploring the impact of NORC supportive
1. Speak to local agencies in your area to find service programs on older adult participants. Paper presented
where there is a concentration of seniors and at the 2007 Joint Conference of the American Society on
Aging and the National Council on Aging. Chicago, IL.
identify the available supportive services. Butler, R. N. (2008). The longevity revolution: The benefits and
Determine if and how occupational therapy challenges of living a long life. New York, NY: PublicAffairs.
has been involved. Callahan, J., & Lanspery, S. (1997, January–March). Density
2. Contact an agency that provides senior services makes a difference: Can we tap the power of NORCs?
and programs to offer assistance in their needs Perspective on Aging, 13–20.
Cannuscio, C., Block, J., & Kawachi, I. (2003). Social capital
assessment related to residents’ aging in place and successful aging: The role of senior housing. Annals of
or the agency’s capacity building activities. Internal Medicine, 139, 395–399.
Identify theories and research that would Centers for Disease Control and Prevention. (2008). Older
inform the issues surrounding the agency’s Americans 2008. Retrieved from http://agingstats.gov/
focused concern. agingstatsdotnet/Main_Site/Data/Data_2008.aspx
Centers for Disease Control and Prevention. (2009). Health,
United States 2009. Retrieved from http://cdc.gov/nchs/
data/hus/hus09.pdf
Clark, F., Azem, S. P., Zemke, R., Jackson, J., Carlson, M.,
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SECTION V
Work and Industry

Chapter 16
Ergonomics and Prevention

of Work-Related Injuries
Peter Bowman, OTD, MHS, OTR/L, OT(C), Dip COT
The economic impact of work-related injury and illness has been estimated to be $171
billion annually, the same as cancer or cardiovascular disease and much greater than
the burden from HIV/AIDS or Alzheimer’s disease.
—National Institute for Occupational Safety and Health [NIOSH], 2009, p. 7
Learning Objectives
• Discuss the issues involved in provision of ergonomic intervention in community settings.
• Differentiate among common ergonomic interventions in work, home, and recreational settings.
• Evaluate positioning for optimal function in a variety of work tasks.
• Apply the seven basic concepts of universal design.
• Describe the implications of cognitive workload and psychosocial factors as they relate to working productively.
• Discuss the role of occupational therapy in providing ergonomic interventions to a variety of community settings.
Key Terms
Client-centered practice Ergonomics
Cognitive workload Transitional return to work model
Community ergonomics Universal design
223
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224 SECTION V | Work and Industry
Introduction the need for workplace analysis and identified po-

tential and actual hazards to workers’ health. He
The practice of ergonomics in occupational therapy summarized his work in 1700 in a publication
is evolving. During entry-level education, occupa- entitled “de Morbis Artificum,” which, when
tional therapists should gain foundational skills in translated, reads, “Disease of Workers” (Franco,
the analysis of client factors; an understanding of 1999). Almost 150 years later, in 1857, Wojciech
principles of biomechanics and ergonomics; and the Jastrzebowski created the term “ergonomics.” The
ability to assess and modify home, work, and com- term “ergonomics” is derived from the Greek words
munity contexts (Accreditation Council for Occu- ergos, or work, and nomos, meaning “study of” or
pational Therapy Education [ACOTE], 2009). The “law” (Ergoweb, 2011a).
intent of the chapter is to build on this knowledge During the Industrial Revolution (1750–1830),
and introduce the components of community er- many machines and types of equipment were up-
gonomic assessment as they apply to prevention and dated and modified as manufacturing became
cure for clients. Clients who can benefit from er- more sophisticated and more efficient. At this stage
gonomic consultation include individuals, families, of industrial development, the major interest was
groups, agencies, governments, businesses, organi- in production, not working conditions. Frederick
zations, and communities. Community ergonomic Taylor pioneered a method called “scientific man-
assessment is specialized, and continued education agement” to find the best method to complete a
is required to develop and maintain the expertise job and all of its component parts. In the early
required to deliver community-based services. 1900s, scientific management became known as
In this chapter, the term “ergonomics” is de- Taylorism and was very popular as a method to
fined, a brief history is provided, and injury rates improve worker efficiency. Taylor also addressed
are reviewed. This is followed by an exploration the issues of human capabilities and limitations
of occupational therapy’s role in community er- relative to the demands of work (Internet Center
gonomics in the home, the workplace, and recre- for Management and Business Administration,
ational venues. Next, detailed information about 2010). The current practice of requiring screening
work-related practice, universal design, and a case tests after job offers is influenced by Taylorism.
study are provided. The Second World War prompted a major inter-
est in ensuring the best interaction between human
and machine to ensure efficiency of increasingly
Ergonomics Definitions sophisticated technology, especially fighter aircraft
and History (Ergoweb, 2011b). Design concepts were imple-
mented that focused on fitting the human to the
“Human factors (ergonomics) is a body of knowl- machine and ensuring that controls were logical and
edge about human abilities, human limitations understandable. After the Second World War, the
and other human characteristics that are relevant focus of ergonomics expanded to include worker
to design” (Chapanis, 1991, p. 2). The imple- safety as well as productivity. Research began to
mentation of ergonomics “is the application of be conducted to examine the factors involved in
human factors information to the design of tools, ergonomics, such as the following:
machines, systems, tasks, jobs, and environments
• Muscular strength required for a task
for safe, comfortable and effective human use”
• Intervertebral disc force on the low back
(Chapanis, 1991, p. 2).
• Cardiovascular response to manual labor
The first documented recognition of the concept
• Maximum weights that can be pushed,
of ergonomics was from an Italian, Bernardino
pulled, and carried
Ramazzini, who had an interest in occupational
health based on his observations of workers prima- Proponents of ergonomics and human-factor
rily in foundries and tanneries. Although his primary concepts include individuals from diverse groups
focus was the relationship between workers and comprised of industrial engineers, industrial
the diseases they contracted, Ramazzini anticipated psychologists, occupational medicine physicians,
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Chapter 16 | Ergonomics and Prevention of Work-Related Injuries 225
industrial hygienists, and safety engineers, among agencies; attorneys; individual clients; family mem-
others. Professions that use ergonomics/human fac- bers; federal, state, and local government agencies;
tors information include architects, health and safety and manufacturing and industrial companies.
officers, occupational therapists, physical therapists, Funding sources for community-based ergonomic
occupational medicine nurses, and insurance loss practice vary tremendously and potentially can
control specialists (Ergoweb, 2011b). A major chal- include: health insurance, fee for service, workers’
lenge for the future is to incorporate evidence-based compensation, legal settlements, Medicare, Medi-
practice into the practice of ergonomics. caid, non-profit organizations, foundations, and
government agencies.
Role of Occupational General Ergonomic

Therapy in Community Considerations
Ergonomics There are many aspects of ergonomics with which
Occupational therapy community ergonomics the occupational practitioner working in the com-
involves the utilization of knowledge of the client’s munity must be familiar. These include posture,
community to expand potential ergonomic inter- positioning, and lifting; cognitive workload; and
ventions in order to maximize the impact on oc- psychosocial factors.
cupational performance and social participation.
These community interventions can include direct
observations of the ergonomic aspects of the Posture, Positioning, and Lifting
client’s activities of daily living (ADLs), instrumen- Positioning in relation to any type of work activity
tal activities of daily living (IADLs), work, and is critical to carrying out sustained activity safely and
leisure activities, as well as the contexts in which without fatigue. All specifics are based on the global
these occupations are performed. During initial rules that a good biomechanical position is required
evaluation of a client, occupational therapists must and that no one position should be adopted for
ascertain subjectively and objectively the future excessive amounts of time. In general, a neutral joint
needs and goals of the client in carrying out his/her position is best (Cornell University Human Factors
ADLs, IADLs, work, and leisure activities. In gen- Group, 1996). The Canadian Center for Occupa-
eral, there are two types of community ergonomic tional Health and Safety (CCOHS) provides a very
practice. One focuses on individual work with good review of issues and solutions for working in a
clients, as will be detailed in the case study at the standing position (2008).
end of this chapter; the other type addresses pro- Prolonged sitting is a considerable challenge,
gram development through consultation with a especially for those with back injuries. Research
business, agency, or other entity. The knowledge shows that sitting places more strain on the back
of and skills in ergonomics necessary to perform than standing. Chaffin, Andersson, and Martin
either role are similar and will be addressed (1984) reported increased disc pressure on the back
throughout this chapter. in a variety of sitting positions when compared with
Providing ergonomic services in the community standing. Although all sitting positions increase disc
setting requires the ability to evaluate a multiplicity pressure, the position and type of chair in use does
of environments where people work, learn, play, make a big difference in the amount of disc pres-
and recuperate. During the evaluation, occupa- sure. The CCOHS (1998/2010) provides a cogent
tional therapists must consider both preventative overview of working in the sitting position. A poor
and curative intervention strategies. In addition, and an improved sitting position when using a
they have to be prepared to work with clients computer laptop are shown in Figure 16.1. The
from a number of referring sources and agencies, improved position illustrates the importance of lean-
including but not limited to physicians; workers’ ing backwards slightly against the back of the chair
compensation; insurance companies; home health and properly positioning the laptop. The worker’s
2580_Ch16_223-242 16/07/13 2:55 PM Page 226
A B
Fig. 16•1 A. Poor sitting position with laptop. B. Improved sitting position with laptop. (Photos
courtesy of Gary Melancon, Audio Visual Production Manager, College of Health Professions, Information and
Educational Technology Team at the Medical University of South Carolina.)
posture could be further improved by uncrossing stability of the materials; the need for gloves to lift;
her ankles and placing both feet flat on the floor. and the presence or absence of handles or cutouts
Many injuries in the community result from lift- to use to lift.
ing too much weight or improper positioning dur-
ing lifting at home, work, and sites of recreation. In
regard to work activities, the official lifting limita- Cognitive Workload
tion set by the NIOSH is 51 pounds in the revised Cognitive workload is an area of work assessment
lifting equation (Waters, Putz-Anderson, & Garg, and ergonomic consideration that is too often
1994). Using the revised NIOSH formula, Waters ignored. Therapists have a tendency to concen-
(2007) reports a 35-pound limitation for patient trate on the biomechanical analysis of lifting, car-
handling tasks; when weight exceeds this limit, as- rying, and reaching and ignore the very important
sistive devices should be used. factors involved in cognition and the psychologi-
Lifting technique is obviously important. Good cal issues involved in the workplace and home
posture must be maintained, and clients should be situation. The level of intensity at which an indi-
instructed to maximize use of the large muscles of vidual works is a functional outcome of cognitive
the legs to assist in raising objects from the floor to workload. For effective cognitive workload pro-
other levels. Lifting symmetrically without twisting cessing to occur, information must be received, in-
the spinal column is important to avoid excessive tegrated, and remembered. The measurement of
strain on the spine, and the ease with which an cognitive workload involves assessing how much
object can be grasped and held with the hands also mental effort is used to accomplish a task, and that
must be considered. Examples of preferred and measurement is based on the worker’s perception
problematic lifting are shown in Figures 16.2 and of work performance and work difficulty. This in-
16.3. The quality of grasp that can be achieved is formation can be obtained by a number of means,
called “coupling” and is described as being good, including self-report of time load, mental effort,
fair, or poor. The rating is assigned based on the and psychological stress load.
size of the object; ease with which the object can be Assessing cognitive workload is most important
held; the object’s texture, such as rough or slippery; when a client reports being either under- or
the presence of an asymmetrical center of mass; the overloaded cognitively. When clients experience
2580_Ch16_223-242 16/07/13 2:55 PM Page 227
A B
Fig. 16•2 A. Poor lift from floor. B. Improved lift from floor. (Photos courtesy of Gary Melancon,
Audio Visual Production Manager, College of Health Professions, Information and Educational Technology Team
at the Medical University of South Carolina.)
A B
Fig. 16•3 A. Poor lift/positioning at workstation. B. Improved lift/positioning at workstation.
(Photos courtesy of Gary Melancon, Audio Visual Production Manager, College of Health Professions, Information
and Educational Technology Team at the Medical University of South Carolina.)
2580_Ch16_223-242 16/07/13 2:55 PM Page 228
cognitive workload issues because of distractions use tools a number of skills must coalesce, such as
such as noise, temperature, and vibration, they are coordination, laterality, endurance, fine and gross
unable to perceive and integrate the excessive motor coordination, strength, and visual integration.
information and occupational performance is To ensure a maximum level of achievement in occu-
affected. The result of feeling or being cognitively pations in all community settings, the therapist needs
overloaded often results in a decrease in work to observe and measure the actual and perceived
capacity, increase in error rate, and an increase in client workload; offer strategies that enable the client
a variety of physical complaints (Jacobs, 1999). To to eliminate, reduce, or ignore extraneous factors;
address cognitive workload in all realms of activity and move the worker from a negative overwhelmed
(e.g., home, work, education, and leisure), the state to one of recognition and familiarity.
occupational therapist needs to either modify the
activity parameters to suit the client or modify and
expand the functional limits of the client. The first
Psychosocial Factors
of these two options is often easier to achieve. The NIOSH (1997) reports three types of psychoso-
Cognitive workload is affected by mental space cial factors or characteristics that have implications
and is determined by intellectual and genetic en- for the client. These include:
dowment, learned knowledge, social status, person- • Factors associated with the job and work
ality, and physical development. These factors vary environment
from person to person; therefore, the occupational • Factors associated with the extra-work envi-
therapist must assess and address these factors in ronment (outside of the work environment)
order to maximize a client’s participation in life • Characteristics of the individual worker
through full engagement in occupation. For exam-
ple, an individual’s personality type has an impact Interactions of factors constitute what is referred
on cognitive workload (Table 16-1). Although most to as a “stress process,” the results of which are
individuals are somewhat of a mix of the A and B thought to affect both health status and job perfor-
personality types, these factors do have implications mance (Sauter & Swanson, 1996). Psychological
for individuals’ self-perception or self-efficacy. factors are influenced by the physical environment,
Factors such as noise, temperature, and vibration factors intrinsic to the job (e.g., workloads), arrange-
can be distracters from full participation in areas of ment of work time (e.g., hours of work), management
occupation and affect cognitive workload. Occupa- of operating practices (e.g., worker roles), and tech-
tions are often carried out with tools. To effectively nology changes. Psychological factors can affect
work performance through reactions to job and work
environment factors, such as intensified workload,
Table 16-1 Type A and Type B Personality monotonous work, levels of job control, level of job
Types clarity, availability and use of social support, and
Type A Personality Type B Personality general level of job satisfaction or dissatisfaction.
Urgency Less urgency
Striving Less striving Sites for Community
High activity level Lower level of activity Ergonomics
Potential to overload Expectations can seem
capacity impossible The overall goal of community ergonomic practice is
to enhance occupational performance in home, recre-
Less likely to report More likely to report
cognitive overload cognitive overload
ation, and work environments. Occupational thera-
pists are trained in the evaluation of human abilities;
More stressed out Less stressed out this training provides the foundation for an occupa-
Data from: Ergonomics for Therapists, 2nd ed. (pp. 112–113),
tional therapy ergonomic practice. The focus of this
by K. Jacobs, 1999, Boston: Butterworth-Heinemann. practice is to fit the work or occupation of the indi-
Copyright 1999. vidual to conditions at the home, recreation site, or
2580_Ch16_223-242 16/07/13 2:55 PM Page 229
workplace, thus enabling the individual to safely, effi- Ergonomics is very important in the kitchen;
ciently, and consistently produce a quality product or positioning of kitchen equipment and a review of
outcome. Enhanced occupational performance is tools used in the kitchen is essential. Use of electrical
consistent with the broad outcomes identified in the kitchen devices, such as can openers and carving
Occupational Therapy Practice Framework: Domain knives, can decrease stress on joints in the hands and
and Process (American Occupational Therapy Associ- wrists. Knife safety is also important; knives with
ation [AOTA], 2008). However, other outcomes large and/or ergonomically shaped handles and pro-
listed in the Framework may also result from com- tective blade guards are very useful. Food processors
munity ergonomic practice, such as adaptation, can be used to reduce the pressure on hands for
health and wellness, participation, prevention, quality intensive chopping, shredding, slicing, and dicing.
of life, role competence, self-advocacy, and occupa- Products such as the OXO Good Grips line (OXO
tional justice (AOTA, 2008, pp. 662–663). International, 2006) offer universally designed
Client-centered practice, also supported by the kitchen implements that have large cushioned
Framework, requires that clients be involved in the handles to minimize the strain on the hands while
process of decision making. Therapists should advo- preparing foods. The old adages to keep frequently
cate both for and with clients to meet their needs in used items within easy reach and to avoid heavy lift-
terms of modifications to environments, tools, or ing remain pertinent. Simple hints, for instance slid-
processes. Client-centered practice ensures respect ing heavy pots and pans along the kitchen counter
for clients, their families, and the choices they make. surface, can save lifting. Successful transfers of tools
The clients have the ultimate responsibility for de- and food from one surface to another are an obvious
cisions about daily occupations and occupational practical concern for many occupational therapy
therapy services. The interventions should be flexible clients to avoid slips and falls due to spills. Prefer-
and individualized to enable clients to solve occupa- ably, these issues should be addressed in the natural
tional performance issues, with a focus on the trans- context of the client’s home. All rooms used by the
action between person-environment-occupation client need to be fully assessed for accessibility and
(Law et al., 1996). Examples of modifications to each safety, including rooms for leisure and education.
of three environments, home, recreation site, and the Advanced community-based ergonomics in the
workplace, follow. home environment necessitates gaining additional
knowledge regarding home environment modifica-
tions to ensure safe, efficient access to all locations in
Home the home at a simple level, which may involve the
Ensuring safe interaction with all everyday tasks at provision of assistive technologies such as raised toilet
home in an effective, efficient manner is one of the seats, bath boards, and grab rails. At a more advanced
major goals of occupational therapy intervention. Ide- level and following mentoring and training, consul-
ally, evaluation of the home would cover a number of tation with architects might be appropriate. Consul-
the areas of occupation from the Framework includ- tations with architects should be sought for major
ing: ADLs, IADLs, rest and sleep, education, work, play, alterations to kitchens and bathrooms, as for wheel-
and social participation (AOTA, 2008, pp. 631–633). chair access, using the concepts of universal design.
Occupational therapists need to enable clients to be
independent in their daily activities and routines with
utilization of good biomechanical positioning, while Recreation Sites
accounting for psychosocial and cognitive factors. Ergonomics in the community is often about access
Whereas occupational therapists ensure that basic for all; able-bodied and disabled populations should
ADLs can be achieved, they may not be as focused on be able to access community activities regardless of
technology tasks, such as computer use in the home. social class, ethnicity, or physical ability. Many
Access to e-mail and Internet resources is very impor- sports and recreational activities can be adapted to
tant to a large percentage of the population, and allow participation for all. Games such as softball
knowledge of ergonomics is essential when trying to can be adapted. Access to equipment and recre-
ensure efficient use of such technology. ational facilities by individuals with varying abilities
2580_Ch16_223-242 16/07/13 2:55 PM Page 230
and ages is possible if adaptations are made. Because relationship between these three elements. When-
occupational justice is a desirable outcome of occu- ever occupational therapists examine the work
pational therapy intervention (AOTA, 2008), occu- situation, they should do so at three levels:
pational therapists should advocate for clients’
1. Micro—worker level; interaction between
abilities to fully integrate in every environment in
the person and the product
their communities, including recreation sites.
2. Meso—task level; environment worked in
When occupational therapists or occupational
by the worker
therapy assistants discover community locations
3. Macro—corporate; impact of the
lacking accessibility, they should notify the local
organization on the worker.
regulatory agency, which may include town, city, or
county officials. Occupational therapy student proj- There are a variety of interventions that can be
ects, such as access studies, have identified issues that used in community ergonomics. In order to provide
can then be addressed to improve access. Input from ergonomic interventions, an understanding of terms
occupational therapists regarding accessibility issues used in this practice area is needed. Definitions of
is not commonly funded, so participation in this terms used in ergonomics are provided by Ergoweb
important role is often on a volunteer basis. Occu- (2011a). Interventions at the workplace can include
pational therapists can provide input on specific a number of options:
projects, such as the Miracle League programs that
• Assessment of the work site, observing another
provide baseball fields where children with disabili-
employee doing the work tasks of the client
ties can play baseball on rubberized surfaces (Miracle
• Assessment of the work site of/with an
League, 2008) and other community projects such
injured worker
as the adaptation of playgrounds.
• Consultation on work site–based prevention
of injury plans
Workplace • Education of management and workers about
risk conditions
A workplace can be any number of environments in
• Facilitation of recommendations from
which work activities take place, including space for
engineers and administration to reduce the
paid employment, volunteer work, and even recre-
identified risk conditions
ational activities that are thought of as work, such
• Identification and control of work site risk
as gardening. The focus should be matching capa-
factors
bilities of the person to work demands through an
• Performance of clinic-based worker
understanding and use of occupational biomechan-
assessment
ics to decrease the risks of mechanical trauma. The
• Provision of early work return program
approach needs to be functional and occupational
• Provision of work return preparation/work
when examining the ability of the worker in relation
hardening programs
to the job demands. Utilization of the systems
approach that examines satisfaction in relation to Potential goals for these interventions are identified
work systems and equipment can be useful. The in Box 16-1. Regardless of the site of community-
ergonomic tool kit (Jacobs, 1999) can be helpful, based ergonomic practice, universal design principles
as it offers the opportunity to examine the many are relevant and useful.
dimensions of the work environment (e.g., the
organization’s culture, motivational factors, and
problems identified by the facility worker). The tool Universal Design
kit addresses stress levels, comfort, and safety.
Use of the Person-Environment-Occupation Many industrialized countries provide infrastructure
Model (Law et al., 1996) enables occupational to implement universal access. There are excellent
therapists to examine not only the broader work positive examples of universal design where locations
environment but also the person and the occupa- have been created to allow a lived-leisure experience
tions being carried out by the person, as well as the for all, such as the sensory garden in Japan (Sensory
2580_Ch16_223-242 16/07/13 2:55 PM Page 231
Box 16-1 Goals of Workplace Community Trust, n.d.). Universal design as defined by Mace is
Ergonomics the purposeful design of products and environments
to ensure they can be used by all people no matter
• Reduction of occupational injury and illness their ability level or age (Center for Universal
• Containment of workers’ compensation costs Design, 2010). These types of initiatives are very use-
• Improvement in productivity ful for accessibility and injury prevention. The seven
• Improvement in work quality
principles of universal design (Connell et al., 1997),
• Reduction in absenteeism
• Compliance with government regulations
which are the gold standard for ensuring maximum
access for all, appear in Table 16-2.
Table 16-2 Principles of Universal Design

Principle Guidelines
PRINCIPLE ONE: Equitable Use 1a. Provide the same means of use for all users: identical
The design is useful and marketable whenever possible; equivalent when not.
to people with diverse abilities. 1b. Avoid segregating or stigmatizing any users.
1c. Provisions for privacy, security, and safety should be equally
available to all users.
1d. Make the design appealing to all users.
PRINCIPLE TWO: Flexibility in Use 2a. Provide choice in methods of use.
The design accommodates a wide 2b. Accommodate right- or left-handed access and use.
range of individual preferences and 2c. Facilitate the user’s accuracy and precision.
abilities. 2d. Provide adaptability to the user’s pace.
PRINCIPLE THREE: Simple and 3a. Eliminate unnecessary complexity.
Intuitive Use 3b. Be consistent with user expectations and intuition.
Use of the design is easy to 3c. Accommodate a wide range of literacy and language skills.
understand, regardless of the user’s 3d. Arrange information consistent with its importance.
experience, knowledge, language 3e. Provide effective prompting and feedback during and after
skills, or current concentration level. task completion.
PRINCIPLE FOUR: Perceptible 4a. Use different modes (pictorial, verbal, tactile) for redundant
Information presentation of essential information.
The design communicates 4b. Provide adequate contrast between essential information
necessary information effectively to and its surroundings.
the user, regardless of ambient 4c. Maximize “legibility” of essential information.
conditions or the user’s sensory 4d. Differentiate elements in ways that can be described
abilities. (i.e., make it easy to give instructions or directions).
4e. Provide compatibility with a variety of techniques or devices
used by people with sensory limitations.
PRINCIPLE FIVE: Tolerance for 5a. Arrange elements to minimize hazards and errors: most used
Error elements, most accessible; hazardous elements eliminated,
The design minimizes hazards and isolated, or shielded.
the adverse consequences of 5b. Provide warnings of hazards and errors.
accidental or unintended actions. 5c. Provide fail safe features.
5d. Discourage unconscious action in tasks that require vigilance.
PRINCIPLE SIX: Low Physical 6a. Allow user to maintain a neutral body position.
Effort 6b. Use reasonable operating forces.
The design can be used efficiently 6c. Minimize repetitive actions.
and comfortably and with a 6d. Minimize sustained physical effort.
minimum of fatigue.
Continued
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Table 16-2 Principles of Universal Design—cont’d

Principle Guidelines
PRINCIPLE SEVEN: Size and 7a. Provide a clear line of sight to important elements for any
Space for Approach and Use seated or standing user.
Appropriate size and space is 7b. Make reach to all components comfortable for any seated
provided for approach, reach, or standing user.
manipulation, and use regardless 7c. Accommodate variations in hand and grip size.
of user’s body size, posture, 7d. Provide adequate space for the use of assistive devices
or mobility. or personal assistance.
Data from: Developed by the Center for Universal Design by B. R. Connell, M. Jones, R. Mace, J. Mueller,
J. Mullick, E. Ostroff, J. Sanford, J. Steinfeld, E. M. Story, & G. Vanderheiden. (1997). The Principles of
Universal Design, Version 2.0. Raleigh, NC: North Carolina State University. Copyright © 1997 NC State
University, The Center for Universal Design.
The Principles of Universal Design were conceived and developed by The Center for Universal Design at
North Carolina State University. Use or application of the Principles in any form by an individual or
organization is separate and distinct from the Principles and does not constitute or imply acceptance or
endorsement by The Center for Universal Design of the use or application.
Occupational Risks and demands of the job. Injuries that occur commonly at
work are CTS, Repetitive Strain Injuries (RSI), and
Common Work Injuries Low Back Pain (LBP). These common diagnoses first
A review of injury statistics can assist in recognizing need to be treated to resolve symptoms. Once symp-
where both prevention and rehabilitation efforts need toms have been resolved, the next important step is
to be targeted. The U.S. Department of Labor, Bureau
of Labor Statistics (USDL, BLS) reports that the 2009
Table 16-3 Missed Work Days by Event
injury rate was 3.7 per 100 full-time workers, a decrease
or Exposure
from 4.0 per 100 in 2008 (USDL, BLS, 2010a). The
total number of incidents requiring days away from Median Number
work decreased in 2009 by 9% to 1,238,490 cases of Days Away
(USDL, BLS, 2010b). One way to determine severity Event or Exposure from Work
of injury or illness, median days away from work, was Contact With Objects 5
8 days in 2009, which was unchanged from the Fall to Lower Level 13
previous year (USDL, BLS, 2010b). Tables 16-3 and
16-4 provide additional data for days away from work Fall on Same Level 9
by injury and type of injury event or exposure. Slips or Trips Without Fall 8
Positive findings in the decreased accident rates Overexertion 10
for 2009 are noted; however, the alarming fact is that Repetitive Motion Injuries 21
injuries caused by repetitive strain, such as carpal
tunnel syndrome (CTS), caused more lost work days Exposure to Harmful 3
Substances
than amputations. Therefore, CTS and other repet-
itive motion injuries are of paramount importance Transportation Accidents 10
in terms of prevention as well as intervention. Fires and Explosions 9
Occupational therapy assistants and occupational Assaults and Violent Acts 7
therapists can have a major impact, not only post-
All Other 10
injury but also in the correction of poorly designed
work sites and work procedures to prevent injuries. Data from: “Table 4: Number, incidence rate, and median days
A number of occupations have higher risk of in- away from work for nonfatal occupational injuries and illnesses
jury. Certain types of work have risks for particular involving days away from work by selected injury or illness
characteristics and private industry, state government, and local
disorders. Table 16-5 provides a list of job types, dis- government,” 2009, by U.S. Department of Labor, Bureau of
orders that commonly occur in each job, and activity Labor Statistics, 2010a.
2580_Ch16_223-242 16/07/13 2:55 PM Page 233
Table 16-4 Missed Work Days by Injury ensuring that the work location that caused the injury
is evaluated and appropriate changes are made to fac-
Median Number tors such as positioning, lifting, repetition, sitting and
of Days Away
Nature of Injury from Work
standing posture, and any other factor that places the
client at risk of re-injury.
Carpal Tunnel Syndrome 21 A number of online ergonomics assessment tools
Fractures 30 that are useful to assess risk factors for common upper
Amputations 20 extremity injuries are provided by NexGen Ergonom-
ics. NexGen’s tool is called the ErgoIntelligence
Tendonitis 14 Upper Extremity Assessment (UEA) and includes the
Multiple Traumatic Injuries 8 Rapid Upper Limb Assessment (RULA), Rapid
Sprains, Strains, Tears 10 Entire Body Assessment (REBA), Strain Index (SI),
Heat Burns 5 Occupational Repetitive Actions Index (OCRA), and
the Cumulative Trauma Disorders (CTD) Risk
Bruises, Contusions 4 Index. Trial versions of these assessments can be
Cuts, Lacerations, Punctures 4 obtained online (NexGen Ergonomics, 2008).
Chemical Burns 3
Data from: “Table 4: Number, incidence rate, and median days Injury Prevention
away from work for nonfatal occupational injuries and illnesses
involving days away from work by selected injury or illness Prevention of injuries in the community should
characteristics and private industry, state government, and local
government,” 2009, by U S. Department of Labor, Bureau of address all aspects of participation in all of areas of
Labor Statistics, 2010a. occupation, including ADLs, IADLs, rest and sleep,
Table 16-5 Job Identified Disorders and Occupational Risk Factors

Type of job Disorders Activity Demands
1. Buffing, Grinding Tenosynovitis Repetitive wrist motions, prolonged flexed
Thoracic Outlet shoulders, vibration, forced ulnar deviation,
Carpal Tunnel repetitive forearm pronation.
De Quervain’s
Pronator Teres
Tendinitis of the Wrist
and Shoulder
2. Punch Press Operators Tendinitis of the Wrist Repetitive forceful wrist extension/flexion.
and Shoulder Repetitive shoulder abduction/flexion,
De Quervain’s forearm supination. Repetitive ulnar
deviation in pushing controls.
3. Overhead Assembly Thoracic Outlet Sustained hyperextension of arms. Hands
(Welders, car mechanics, Shoulder Tendinitis above shoulders.
painters
4. Belt Conveyor Assembly Tendonitis of Shoulder Arms extended, abducted, or flexed more
and Wrist than 60°, repetitive forceful wrist motions.
Carpal Tunnel
Thoracic Outlet
5. Typing, Keypunch, Cashier Tension in Neck Static restricted posture, arms abducted/
Thoracic Outlet flexed, high-speed finger movement, palmar
Carpal Tunnel base pressure, ulnar deviation.
Continued
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Table 16-5 Job Identified Disorders and Occupational Risk Factors—cont’d

Type of job Disorders Activity Demands
6. Sewers and Cutters Thoracic Outlet Repetitive shoulder flexion, repetitive ulnar
De Quervain’s deviation.
Carpal Tunnel Repetitive wrist flexion/palmar base pressure.
7. Small Parts Assembly Tension in Neck Prolonged restricted posture, forceful ulnar
(Wiring, bandaging Thoracic Outlet deviation and thumb pressure, repetitive
wrap) Wrist tendinitis wrist motion, forceful wrist extension and
Epicondylitis pronation.
8. Musicians Wrist Tendinitis Repetitive forceful wrist motions, palmar
Carpal Tunnel base pressure, prolonged shoulder
Epicondylitis abduction/flexion, forceful wrist extension
Thoracic Outlet with forearm pronation.
9. Bench Work (Glass cutters Ulnar Nerve Sustained elbow flexion with pressure on
phone operators) Entrapment ulnar groove.
10. Operating room Thoracic Outlet Prolonged shoulder flexion, repetitive wrist
personnel Carpal Tunnel flexion, ulnar deviation (holding retractors).
De Quervain’s
11. Packing Tendinitis of Shoulder Prolonged load on shoulders, repetitive
and Wrist wrist motions, over-exertion, forceful ulnar
Tension in Neck deviation.
Carpal Tunnel
De Quervain’s
12. Truck Drivers Thoracic Outlet Prolonged shoulder abduction and flexion.
13. Housekeepers, Cooks De Quervain’s Scrubbing, washing, rapid wrist rotational
Carpal Tunnel movements.
14. Carpenters, Bricklayers Carpal Tunnel Hammering, pressure on palm base.
Guyon’s Tunnel
15. Stockroom, Shipping Thoracic Outlet Reaching overhead.
Shoulder Tendinitis Prolonged load on shoulder in unnatural
position.
16. Materials Handling Thoracic Outlet Carrying heavy loads on shoulders.
Shoulder Tendinitis
17. Lumber/Construction Shoulder Tendinitis Repetitive throwing of heavy load.
Epicondylitis
18. Butcher/Meat packing De Quervain’s Carpal Ulnar deviation, flexed wrist with exertion.
Tunnel
19. Letter carriers (most Shoulder Problems Carrying heavy load with shoulder strap.
especially if carrying mail) Thoracic Outlet
education, work, play, leisure, and social participa- (Littleton, 2003). Injury prevention should include
tion. In addition to ensuring individuals are per- education in many environments but especially in
forming work within their safe limitations, injury the work environment. Education regarding not
prevention has been demonstrated to provide sav- only basic safety but also to address the position
ings in a number of workers’ compensation claims of work, work tools, and equipment in the work
2580_Ch16_223-242 16/07/13 2:55 PM Page 235
environment is vital. In general, a neutral joint Comprehensive

position is one of less strain, and placing items closer
to a person is preferable to having to reach excess Work-Related Ergonomic
distances. The role of the therapist is to ensure that Evaluation: Worker
efficiency and safety are incorporated into work or
tasks, and that safety is not viewed as just avoidance Assessment
of hazards. Guidelines for safety positioning for The assessment of the client who needs to return to
work activities are provided by the CCOHS (n.d., work is critical. Initially the occupational therapist
1998/2010, 2008) and the NIOSH (Cohen, should conduct an occupational profile (AOTA,
Gjessing, Fine, Bernard, & McGlothlin, 1997). 2008). The Canadian Occupational Performance
Another aspect of injury prevention is ongoing Measure (COPM) is useful to discover the client’s
ergonomic education of workers. This entails making perspective on important issues, performance rat-
employers aware of issues and ensuring that they ini- ings, and satisfaction with performance (Law et al.,
tiate and continue staff training about appropriate 2005). Assessment should include the use of an
positioning and methodologies for safe, efficient evidence-based functional capacity assessment. Eval-
work activity in their particular industry. In this role uating the areas of occupation identified in the
therapists can either be employed by an industry or Framework (AOTA, 2008) can also be useful. Many
act as consultants to industry. Occupational thera- practitioners also include lists of activities they deem
pists can conduct pre-employment screens, which relevant to the client’s functional status. While con-
have been shown to be effective in preventing ducting an occupational profile, it is important to
injuries (Isernhagen, 2009), and they can perform elicit the client’s perception about his or her occu-
functional capacity assessments that have been effec- pational performance. A list of activity demands and
tive in indicating work activity limitations. In addi- occupations that can be helpful to review in this
tion, occupational therapists may recommend what process is presented in Table 16-6.
is described as ergonomic equipment. This equip-
ment is useful but should be recommended only
after carefully considering the potential benefits and Objective Assessment
adverse effects of using the equipment, furniture, de-
vice, or tool. Evidence shows that many items labeled The objective assessment needs to include observa-
as “ergonomic” either have proved to be ineffective tions of items reported by the client as issues in
or are contraindicated, and even the most highly rec- ADLs, IADLs, and work-related activities. An occu-
ommended items can be used incorrectly, be the pational therapist should evaluate the problem area
wrong size, or be adjusted inappropriately. An exam- to identify which activity demands and performance
ple of poor ergonomics is the provision of computer skills are deficient. An evidence-based functional ca-
keyboard wrist pads. If keyboard operators press pacity assessment should be used to gather accurate,
down on the wrist pad, then they are actually at objective assessment data. A number of functional
increased risk for developing CTS (Hedge, 2011). capacity assessment systems claim to be accurate,
Occupational therapists in the community valid, and have good inter-rater reliability; however,
should be promoting prevention of injuries by offer- the operational definitions in these assessments use
ing educational programs at area businesses and to many terms interchangeably (Soer, van der Schans,
various industries covering various topics: Groothoff, Geertzen, & Reneman, 2008).
The Physical Work Performance Evaluation
• General ergonomics
(PWPE) and the West-Epic (lifting-capacity section
• Office ergonomics for the computer
only) systems have been evaluated for inter-rater
workstation
reliability with results published in peer-reviewed
• On-site exercise and stretching programs for
journals (King, Tuckwell, & Barret, 1998). Other
workers before, during, and after a work shift
systems frequently used (Matheson, 2003) include:
• Prevention of cumulative trauma disorders
• Proper body mechanics and prevention • Blankenship System Functional Capacity
of low back pain Evaluation©
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Table 16-6 Activity Demands and Work Location Assessment

Occupations to Review with
an Ergonomic Client During Review of the work environment, physical demands,
an Occupational Profile task factors, perceptual requirements, and mental
Occupational demands at the jobsite is important. The work en-
Activity Demands Performance vironment includes the following factors: purpose
and Occupations (client’s self-report) of work, layout of work area, dimensions, seating,
Lift
displays and dials, controls, handheld equipment,
climate, lighting, noise, vibration, hazardous expo-
Carry sure, protective clothing requirements, floors, stairs,
Push/Pull ramps, time of day, social interaction, training, and
Stand distractions. The potential physical demands include
Walk
standing, walking, sitting, lifting, carrying, pushing,
pulling, climbing, balancing, stooping, crouching,
Cook kneeling, twisting, turning, crawling, handling/
Clean manipulating, and reaching to a variety of heights.
Vacuum Task factors include the required postures, required
Wash and Dry Laundry
mobility, frequency of activity, duration of activity,
workload, work/rest pattern, range of motion require-
Garden ments, and force requirements. The perceptual
Use Stairs requirements include vision, sensation, audition, bal-
Dress ance, smell, and taste. The mental demands include in-
Reach Up
formation processing, decision making, maintaining
or enhancing knowledge and skills, and the potentially
Reach Down draining impact if the job is monotonous. A work as-
Sit sessment should be structured to provide an evaluation
Other Information of all activity factors within the work location being
Work History
assessed. An example of items for standing, sitting,
driving, lifting, and carrying is provided in Box 16-2.
Other Medical Problems
Additional Information
Intervention Evidence
• Ergo Science Physical Work Performance
Interventions for work-related injuries have not been
Evaluation©
well researched; thus evidence of effectiveness is lim-
• ERGOS Work Simulator©
ited. However, efforts have begun to address this
• Isenhagen Functional Capacity Assessment©
issue. For example, Guzelkucuk et al. (2007) re-
• Key Method Functional Capacity Assessment©
ported that the use of simulated ADL activities was
• LIDO WorkSET Work Simulator©
more effective in treating acute hand injuries than
• Matheson Work Capacity Evaluation©
traditional exercise alone. However, Amini (2011)
• Work Hab©
reports gaps in evidence for the use of techniques
Analysis of occupational performance is com- such as physical agent modalities, splints, and work-
pleted during a functional capacity assessment to place modifications. Bohr (2011, p. 27), when re-
identify the client’s assets, establish goals, and im- porting evidence on elbow injury intervention, states,
plement an intervention plan. Occupational thera- “the findings support the need for OT practitioners
pists should ensure that they have the needed to collect and analyze data related to all aspects of
training or certification to use an assessment in any occupational therapy, particularly as interventions
practice area, including community ergonomics. affect functional outcomes.”
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Box 16-2 Work Assessment, Jobsite Analysis
1. Standing:
a. Required: Either yes or no to do the job safely and normally. If no, put “not applicable.”
b. Frequency: How much time or percentage of shift.
c. Rest periods: How many? And when?
d. Type of floor: Surface such as vinyl, concrete, carpet, etc.
e. Work task(s): The tasks actually performed in the standing position.
2. Sitting:
b. Duration: The amount of time before a break is taken.
c. Location: Place the person is sitting. Sitting height and proximity to other work equipment. If the prime role
is at a computer workstation, a more detailed evaluation, such as the computer workstation evaluation,
should be carried out.
3. Driving:
b. Duration at work: The amount of time before a break is taken. Do note if much stop-start driving is done,
such as by a delivery driver. Time and approximate distance driven.
c. Duration to get to work: Time and approximate distance driven.
d. Type of vehicle: Size and type of vehicle driven.
4. Lifting:
b. Maximum weight: The most lifted during normal work routine measured with a bathroom scale, spring
scale, or exertional scale.
c. Frequency: How much time or percentage of shift.
d. Average weight: Routine amount of weight lifted measured with a bathroom scale, spring scale, or exertional
scale, if possible; if not, ask how much items weigh or, as a last resort, estimate the weight.
e. Bilateral lifting: Lifting using both hands together to lift, such as in lifting a box; weight measured with a
bathroom scale, spring scale, or exertional scale.
f. Body mechanics required: Note if normal good upright positioning can be used and also if there are any
awkward work positions required to carry out the job. Include the horizontal distance away from the body
as a measurement from between the ankles to the object, and also the vertical measurement either with a
tape measure or the body as a guide so vertical reaching may be from knee level to shoulder, or shoulder
to above head height.
g. Work task(s): Tasks actually performed naming the object being lifted.
5. Carrying: Walking with an object such as a bucket.
b. Duration: The amount of time before a break is taken.
c. Frequency: How much time or percentage of shift.
d. Type of object(s): Name and or describe object(s).
e. Weight of object(s): Actually weigh the object(s) with a bathroom scale, spring scale, or exertional scale if
possible; if not, ask how much they weigh or, as a last resort, estimate the weight.
f. Distance: Vertical height of lift and horizontal distance.
g. Work task(s): Tasks actually performed, naming the object being carried.
Return to Work and Work return to the job and after one year of disability
Modification 85% do not return to work (Basich, Driscoll, &
Wickstrom, 2007). Ergonomic intervention and
Returning an injured worker to the job should be work site accommodations make it possible for a
done as soon as possible. Research has shown that worker to return to the job sooner and be produc-
after 12 weeks of disability only 50% of workers tive. If a client has been injured or sick, a successful
2580_Ch16_223-242 16/07/13 2:55 PM Page 238
return to work is dependent upon multiple factors done in a standing position should use these
to ensure that the individual is able to work safely guidelines (CCOHS, 2008, “What is an Example
and productively in the workplace. If at all possi- of a Workstation,” ¶ 2):
ble, an early return to work is most beneficial to
• Precision work, such as writing or electronic
keep the client in the habit of going to work. The
assembly, should be positioned approxi-
work may have to be reduced to part time or mod-
mately 5 cm above elbow height and elbow
ified to light work duties. The worker’s initial ac-
support should be provided.
tivity tolerance would be ascertained from a work
• Light work, such as assembly line or mechan-
assessment by the occupational therapist, and if
ical jobs, requires that the work be positioned
needed, some clinic-based work hardening activity
about 5–10 cm below elbow height.
should be instituted. Work modifications could in-
• Heavy work that demands downward force
clude the initial alteration in hours at work with a
should be positioned from 20–40 cm below
program to progressively increase them. Duties at
elbow height.
work may be altered or the equipment used may
be adapted to better fit the client. Issues of cogni-
tive challenges and psychosocial stress also must be
addressed at this time. Computer Equipment
According to Basich et al. (2007), the transi- and Accessories
tional model of return to work has significant ad-
vantages over the traditional medical/clinical model Computers have become such an integral part of
of return to work programs. The transitional re- time spent at work and at home that safe use of
turn to work model is a job-specific intervention them is key for the health of a large proportion
approach that increases the worker’s functional of the population. The use of the computer work-
capacities, teaches safe work methods to prevent re- station is about much more than the computer
injury, and provides and modifies job accommoda- alone; the use of all of the accessories present in a
tions as needed. When this model is used, injured work or home office context affects function and
workers go back to work to get well. Services are comfort. Therefore, the positioning and accessi-
provided at the jobsite instead of in medical facili- bility of the document holder, telephone, stapler,
ties. The transitional return to work model involves hole puncher, tape dispenser, and any other fre-
a job analysis and thorough evaluation of the quently used tool are just as important as the as-
worker. Job tasks are then assigned based on what pects of computer ergonomics. Those individuals
the worker is capable of performing safely and pro- using a phone frequently should use a lightweight
ductively. Safe performance means that the work phone headset to avoid poor head and neck
will not cause re-injury, so work activities are as- positioning. The traditional computer worksta-
sessed in light of the specific injury. Productive tion can be adjusted to fit well to the client to en-
work duties are those that contribute to the needs sure good positioning. There are numerous Web
of the employer and the purpose of the job posi- sites that provide ergonomic recommendations,
tion. Some job tasks are also therapeutic and may such as the USDL, OSHA (n.d.), and CCOHS
improve strength, endurance, and flexibility. Iden- (1998/2010, 2008).
tification of the job tasks that the worker is not
capable of performing also is important. This infor-
mation can be used to guide intervention planning. Laptop/Notebook Computer Issues
An effective intervention usually consists of three Marked increase in use of laptop/notebook com-
elements: therapy services provided at the jobsite, puters has created a major problem, because the
participation in work tasks that have therapeutic vast majority of laptop/notebook computer screens
benefit, and job accommodations. and keyboards are not able to be separated. This
An important component of successfully car- means that either the keyboard or the screen is
rying out work activity is ensuring that work being used in an inappropriate position unless a
space reach can be accomplished with ease and docking station or separate keyboard is used to ad-
without excess repetition. For example, work dress this issue. University of California at Berkeley
2580_Ch16_223-242 16/07/13 2:55 PM Page 239
(2007) provides some very good information Conclusion

through its Ergonomics@Work program.
Community ergonomics can positively affect clients
at work or at home during ADLs, IADLs, and
Program Development leisure activities. The ergonomics movement primar-
and Business Consultation ily grew out of increased knowledge of human
factors and physical limitations in the workplace.
As noted earlier in this chapter, community er- Although these characteristics are important, occu-
gonomic practice is situated in the community. It can pational therapists must have knowledge of factors
include interventions with individuals and consulta- other than physical limitations, such as psychosocial
tions with groups, agencies, governments, businesses, and cognitive dimensions of work. As modern tech-
organizations, and communities. Whereas occupa- nology continues to change not only the work en-
tional therapy ergonomic practice often focuses on the vironment but also the tools used to accomplish
individual worker, growing numbers of practitioners that work, the role of ergonomics and the use of er-
are using this expertise to provide services at the com- gonomic principles will become even more signifi-
munity level. Examples include providing ergonomic cant. Advances in health care and life expectancy
consultative services at a university (Scaffa et al., 2010) make it possible for older adults to continue to
and for an engineering firm (Goodman et al., 2005). work at advanced ages, either by choice or because
Using the steps outlined in Chapters 5–7 in this text, of economic conditions, and underscores the in-
together with knowledge of the specific mission and creasing need for occupational therapy ergonomic
needs of a community business (or other institutions) practitioners. The future for community occupa-
as well as current and sufficient expertise in ergonom- tional therapy practice absolutely must include
ics, occupational therapists can provide community knowledge and application of ergonomics to indi-
ergonomic consultation that improves productivity viduals, businesses, government agencies, and other
and social participation. institutions.
CASE STUDIES
CASE STUDY 16•1 Sandy
Sandy, a 35-year-old woman, was diagnosed with CTS in her right, dominant hand. For the 10 years
prior to this diagnosis she had worked in a variety of clerical positions, using a computer for the majority
of the workday. Approximately one year before her diagnosis, she received a promotion that she reported
increased her workload considerably, making it essential for her to take work home to complete the work
her employer expected her to perform.
Sandy described her workstation and reported that she would like her work situation to be evaluated
because she was sure it was not set up correctly for her small stature. At work she used a laptop/notebook
computer in a docking station, which she stated is set up like a regular computer workstation. She reported
that her computer workstation has a nice chair, but the chair seems not to fit her well. She also indicated
that nobody has instructed her in how to adjust the chair correctly. At home she uses the laptop/notebook
computer placed on a dining room table.
Sandy reported that she had seen a hand surgeon, who remarked that if her current symptoms worsen,
it would be necessary to carry out a surgical release of the flexor retinaculum to remove pressure from the
median nerve, which is causing considerable pain on the palmer surface of her right hand. The client
stated that she told the doctor she did not want surgery unless it was absolutely essential. Her hand
surgeon gave her a cortisone injection and referred her to occupational therapy. He also referred her for
nerve conduction studies. The occupational therapy referral requested an evaluation of her symptoms;
wrist cock-up splinting; a computer workstation evaluation, specific to CTS; therapeutic exercises; and
precautionary and preventative education.
Continued
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CASE STUDY 16•1 Sandy cont’d
Sandy completed the COPM with her occupational therapist. She reported that the pain was worst at
night and at work; she also reported having difficulty sleeping, feeling overwhelmed at work, and feeling
inadequate to perform her current job. She had missed work on three separate occasions due to her
symptoms in the recent past, had been absent from work for the last two days, and was in the process of
submitting a claim for workers’ compensation. Her COPM importance scores were all high, and her
performance and satisfaction scores were all relatively low. During the completion of the COPM, she
reported her major problems to be difficulty sleeping and completing work tasks; she noted that she was
bothered by feelings of inadequacy at work and difficulties carrying out routine ADLs due to pain in
her right wrist. Cognitively, she reported she could not cope with the complexity of her work since her
promotion and believed she was less than competent at her job. She could not see a way of overcoming
her work performance deficits.
In addition to the COPM, her physical function was assessed, and education and a splint were pro-
vided. Active range of motion was within normal limits in the right hand, wrist, and elbow. Tinel’s test
and Phalen’s test were both positive. Her sensation testing had positive finding in the right median nerve
distribution, and she had stereognosis deficits. Her grip and pinch strengths were slightly lower in the
right hand than the left. A right wrist splint was fabricated and fitted; a schedule for splint wearing and
positioning information to enable her to sleep more comfortably were also provided. In addition, Sandy
was instructed in tendon gliding and median nerve gliding exercises.
A computer work assessment was carried out at her work location, and her chair and other workstation
devices were adjusted to fit well. In addition, the following items were requested to ensure a good fit at her
workstation:
• Foot rest
• Back support filler (Obus-Forme cushion)
• Document holder
• Phone headset
The computer wrist pad in front of her keyboard was removed because she was pressing down on it
very firmly. She was educated about the importance of positioning the whole upper extremity to gain
as good a position as possible without placing excess pressure on the palmer surface of her hand in the
region of the flexor retinaculum.
Education was provided with handouts to reinforce the importance of proper positioning at work
and home. Educational materials were also provided regarding easy adaptations to make at home to
correct the screen height of her laptop/notebook computer and on the use of a separate keyboard and
mouse. A consultation with her work supervisor occurred, and he reported that he was not aware of
the client’s concerns. He noted that he would provide instruction to the client and intended to send
her to two training courses to enable her to feel more competent in her new role. He reported that
she was a good worker and capable of carrying out the work in her new job role. The occupational
therapist discussed with Sandy the difficulties with routine ADLs by reviewing the tasks she reported
to be difficult or those that caused pain. The tasks reported as most difficult were opening cans with
a manual can opener and lifting heavy pots and pans. Ways to avoid aggravating her injury were
discussed, and it was suggested she use an electric can opener and avoid lifting heavy pans when
cooking.
After 3 weeks of intervention, the client was reassessed and her COPM findings were much improved,
so intervention was discontinued. She had returned to work one week prior to discharge and was manag-
ing much better at work using her modified workstation location. She reported that she was pleased that
she was scheduled to complete training courses at work. She had tried using her laptop at home on a box
2580_Ch16_223-242 16/07/13 2:55 PM Page 241
with a separate keyboard and mouse and had found this much better than using the laptop/notebook
alone. After doing her exercises at home, she had completed some of her routine ADLs and was now
managing all routine ADL and IADL tasks without difficulty when using the suggested modified methods
and electronic equipment.

1. What was the impact of ergonomic interventions on Sandy’s work, leisure, ADL, and IADL
performance?
2. How do the overall framework, constructs, and principles of a theoretical model match the
interventions provided?
Learning Activities information. Retrieved from http://ccohs.ca/oshanswers/

ergonomics/sitting/sitting_overview.html
1. Compare and contrast how ergonomics could Canadian Center for Occupational Health and Safety. (2008).
affect a work situation from biomechanical, Working from a standing position: Basic information.
Retrieved from http://ccohs.ca/oshanswers/ergonomics/
cognitive, and psychosocial perspectives. standing/standing_basic.html
2. Identify the work sites at your college, univer- Center for Universal Design. (2010). Ronald L. Mace.
sity, or institution that could benefit from an Retrieved from North Carolina State University, College
ergonomic consultation. of Design Web Site: http://ncsu.edu/project/design-
3. Review the safety and ergonomic concerns of a projects/udi/cente-for-universal-design/ron-mace/
Chaffin, D. B., Andersson, G., & Martin, B. J. (1984). Occu-
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Cohen, A. L., Gjessing, C. C., Fine, L. J., Bernard, B. P.,
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Chapter 17
Work and Career Transitions

Susan M. Nochajski, PhD, OTR/L, and S. Maggie Reitz, PhD, OTR/L, FAOTA
Real success is finding your lifework in the work that you love.
—David McCullough
Learning Objectives
• Describe the role of federal legislation in the employment of persons with disabilities.
• Identify trends within occupational therapy that influence work transitions.
• Formulate plans to address issues related to transition to work by students with disabilities.
• Identify issues related to return to work by persons with disabilities, including those of returning warriors.
• Facilitate individual and group transition to partial employment and retirement.
• Describe the role of the occupational therapy practitioner in various aspects of work transition and work
transition programs.
Key Terms
Americans with Disabilities Act (ADA) Ticket to Work and Work Incentives Improvement
Individuals with Disabilities Education Act Act of 1999
School to Work Opportunities Act Transition
Secretaries Commission on Achieving Necessary Skills Warrior Transition Unit
(SCANS) Work and Careers Opportunities Program (WCOP)
Self-determination
Introduction societal issue that can be addressed by occupational

therapy. Data indicate that approximately 78% of
All individuals experience transitions in a variety of adults between 18 and 64 years of age are employed,
areas throughout their life span. Transition can be compared with only 37% of persons with disabilities;
described as a process of change or movement from employment rates are even lower for individuals with
one place, situation, or context to another. Work severe disabilities (Long-Bellil & Henry, 2009;
transitions include transitioning into and out of the Wehman, 2001). Current economic conditions
workplace. It can include the transition of youth exacerbate the problem for students with disabilities
with disabilities from school to employment or the transitioning into work roles and for persons with dis-
transition of people returning to or starting work abilities who want to return to work. Potential lifetime
following a disability, injury, or illness. Other types costs due to a lack of vocational skills and subsequent
of work transition include wounded warriors return- unemployment or low employment rates include
ing to post-military service employment as well lower wages and increased dependence on social
as older adults transitioning from the workforce to programs (Lehr, 2004; Wagner & Cameto, 2004).
retirement. The American Occupational Therapy Association
The transition of persons with disabilities into (AOTA) Occupational Therapy Practice Framework
or out of community employment is an important (AOTA, 2008) guides both the domain and process
243
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of occupational therapy practice. Within the context all children regardless of their disability status. How-
of the Framework, work is identified as a primary ever, it was not until 1990 with the passage of the
domain of occupational therapy practice. In con- IDEA (PL 101-476) that transition services were
junction with the Framework, several pieces of mandated. With its subsequent amendments (IDEA
federal legislation, such as the Individuals with Dis- 1997, 2004), there has been a greater emphasis
abilities Education Act (IDEA), provide a basis for placed on transition planning and services for stu-
the vital role occupational therapy practitioners can dents with disabilities and the utilization of related
play in facilitating various work transitions. In this service providers, including occupational therapists.
chapter, information on key issues related to various Transition from secondary education was a partic-
types of work transition and the relevance or con- ularly strong component of the IDEA 1997, which
nection to community-based occupational therapy mandated that transition planning in the Individu-
practice is provided. alized Education Program (IEP) process was to
begin at the time of the student’s 14th birthday; this
has since been changed to age 16 in IDEA 2004.
Transitioning From School
to Employment Role of Occupational Therapy
For adolescents and young adults, the transition from in School to Work Transition
high school to employment or post-secondary educa- Occupational therapists are related service personnel
tion is very significant (Orentlicher & Michaels, who possess skills and knowledge that can be very
2000). However, transitioning from secondary schools beneficial to the secondary transition process. Al-
to adult roles remains problematic for many students though occupational therapy practitioners have the
with disabilities; school to work transitioning has been skills necessary to support their involvement in
far from optimal for many of these students. Statistics school to work transition programs, a relatively small
indicate that students with disabilities have signifi- percentage are involved in the actual provision of
cantly less successful outcomes related to employment transition services (Kardos & White, 2005; Spencer,
rates and retention, advancement in employment, Emery, & Schneck, 2003; Swinth, Chandler, Hanft,
independent living, and community participation Jackson, & Shepard, 2003). Spencer and colleagues
than students without disabilities (Kohler & Field, (2003) reported that occupational therapists pro-
2003; Wagner & Davis; 2006; Wagner, Newman, vided only about 3.3% to 11.7 % of the services for
Cameto, Levine, & Garza, 2006). Growing numbers school to work transition. Two reasons provided for
of students with disabilities are exiting the public the lack of involvement of occupational therapy in
school system without the occupational skills needed transition planning and delivery included a lack of
to succeed in entry-level jobs. Due to an increase in demand from parents or teachers and a lack of un-
high-performance businesses across the nation, there derstanding of the role that occupational therapists
is also an increasing demand for employees with a could play. This lack of understanding was demon-
combination of academic and occupational skills strated by educators and related service personnel,
(Benz, Yovanoff, & Doren, 1997). including occupational therapists.
Federal legislation has been enacted in an effort The potential role of occupational therapy in school
to improve the school to work transition outcomes to work transition appears to be poorly understood by
of students with disabilities. Aspects of the Individ- a majority of school-based occupational therapists.
uals with Disabilities Education Act and its sub- Kardos and White (2005) surveyed 80 occupational
sequent amendments (IDEA 1990, 1997, 2004) therapists who worked in secondary transition on their
that have a relationship to school to work transition knowledge of and degree of participation in secondary
are briefly discussed. transition planning. The majority of respondents
The Education for All Handicapped Children indicated that they understood the terminology of the
Act of 1975 (PL 94-142) was the first enacted fed- 1990 and 1997 IDEA amendments but reported min-
eral legislation mandating educational services, par- imal participation in secondary transition planning,
ticularly a free and appropriate public education, for assessment, and intervention. Their involvement in
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Chapter 17 | Work and Career Transitions 245
secondary transition was more frequent in relation to foundation for the program: school-based learning
working with students pursuing post-secondary edu- and activities, community-based learning and ac-
cation (20%) than with those students pursuing post- tivities, and linking or connecting activities. The
secondary employment (16%). Overall, only 30% of program was also based on self-determination and
the respondents indicated that they thought their in- identified best practices related to school to work
volvement with transition service maximized their transition.
professional skills and abilities in any area of secondary Self-determination can be described as a set of
transition. behaviors that includes skills such as decision mak-
Spencer et al. (2003) noted that occupational ther- ing, problem solving, goal setting and attainment,
apists need to explore expansion of their current roles self-observation and awareness, self-instruction,
to more fully utilize their skills and qualifications self-advocacy and leadership, positive attitudes about
to improve secondary transitioning. Students with outcomes, and internal self-control (Blancher, 2004;
disabilities require more than a transition program Browder, Wood, Test, Karvonen, & Algozzine, 2001;
focusing on work skills to enable them to have suc- Wehmeyer, Agran, & Hughes, 2000). Activities in-
cessful transition outcomes. They may need assistance corporating these characteristics of self-determination
with activities of daily living, instrumental activities of were embedded within the program.
daily living, communication and social skills, emo- The program also was based on best practices sug-
tional regulation skills, and cognitive skills, all of gested by Sample (1998) and Kohler’s Taxonomy
which are areas within the domain of occupational for Transition Planning (1996). Sample (1998)
therapy practice (AOTA, 2008). A community-based identified six best practices that were correlated with
school to work transition program developed by positive post-school employment outcomes for
occupational therapists is discussed below. youth with disabilities. These practices included:
1. vocational intervention;
Community-Based School 2. paid work experience;
to Work Transition Programs 3. social skills training;
4. interagency collaboration;
Several model programs have been developed to assist
5. parent involvement; and
schools in the development and implementation of
6. individualized planning.
transition programs and services for students with dis-
abilities. However, relatively few of these programs Kohler’s taxonomy was used to provide a concep-
have had occupational therapy practitioners as pri- tual framework for the program model. Similar to
mary program developers or an occupation-based Sample’s best practices, the conceptual framework
focus on school to work transition. used includes the following four components: stu-
dent development, student-focused planning, family
involvement, and interagency collaboration.
School to Work Transitions Program Student-focused planning and student develop-
The School to Work Transitions Program was de- ment are primary features of the program. Success-
veloped through a 4-year model demonstration ful transition outcomes for students with disabilities,
project funded by the U.S. Department of Educa- particularly employment in an area related to stu-
tion (Nochajski, Schweitzer, & Chelluri, 2003). dents’ interests, is the paramount theme toward
This program was developed by occupational ther- which all program activities were directed. School-
apists and included a significant role for occupa- based and work activities were developed taking
tional therapy in a transition program for students the interests and needs of the students into
classified as having emotional and behavioral dis- account. Student development is a core feature of
abilities (EBD). The program ensured that children the model and is exemplified in all phases of the
with EBD had educational and vocational training project. Likewise, family involvement must be
opportunities to obtain necessary skills for work and viewed as an important aspect of the transition
adult roles. Three components of the School to process (Chadsey-Rusch & Rusch, 1996) and is
Work Opportunities Act of 1994 provided the another important component of the program.
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Collaboration, both interagency and interdiscipli- the assistance of a job coach while making gains
nary, is essential in order to facilitate successful toward the goal of competitive employment.
transition outcomes. This program had a strong Overall, the program was highly effective in
focus on collaboration between the university, helping students with EBD obtain employment.
school personnel, and community businesses as Over 70% of the participants were employed in
well as between students, families, and program a variety of positions after completing the program.
personnel. They reported satisfaction with the program, and
The program consisted of four sequential employers were extremely satisfied with their pro-
phases of training and work-related experiences, ductivity. This program was developed and imple-
which are depicted in Table 17-1. Each phase was mented with students with EBDs who attended an
approximately 10 weeks in length with weekly educational day program. After the grant funding
activities totaling approximately 10 hours. Stu- ended, the agency hired an occupational therapist
dents were expected to use and generalize the skills to continue the program.
learned in previous phases. In the last phase, the Subsequent federal funding was received to
on-site role of the job coach faded as the student revise and evaluate the effectiveness of the program
gained self-respect by performing the job inde- with students with a variety of disabilities who
pendently. In place of the job coach, the student were attending regular education programs in an
now took direction from an employed supervisor urban school district. The “new” program was
(i.e., boss). However, if the student was not ready called the Work and Careers Opportunities Pro-
for independent work, he or she could continue gram (WCOP). The conceptual foundation and
with the supported work experience and utilize overall structure of the WCOP remained the same.
Table 17-1 Phases of the School to Work Transitions Program

Phase Focus/Activities
Phase 1: School-Based Job Acquisition Skills
Learning Strategies • Completing job applications
• Interviewing
• Developing community-access strategies
• Identifying job interests and aptitudes
Identification with Worker Role
• Temporal organization
• Organization of space and objects
Bi-weekly individual and small-group instruction
Phase 2: Volunteer Experience Assuming Responsibility for Initiation, Continuation, and Termination
in Community-Based Agency of Volunteer Tasks
Agencies Involved
• Community theater
• Day-care center
• Nursing home
• Refugee agency
• Habitat for humanity
• Retail agencies
Phase 3: Paid, Supported-Work Supervised by job coach
Experience
Phase 4: Acquisition of Paid, Supervised by employer
Competitive Employment
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However, skills identified by the Secretaries Com- and post-secondary school and work opportunities
mission on Achieving Necessary Skills (SCANS) for students with disabilities (Nochajski, Nerber, &
were included as part of the program. Patterson, 2008). Similarly, the WCOP is a very
The SCANS has been the leading force in the good example of the positive role that occupational
improvement of work-related skills over the past therapy can play in providing school to work tran-
decade (Packard & Brainard, 2003). The founda- sition services to students with disabilities. How-
tion skills and competencies that are necessary for ever, the WCOP is not readily replicable due to the
these entry-level positions (Nash & Korte, 1997) intensive resources needed for implementation. The
were identified by the SCANS. The SCANS initia- WCOP needs to be revised to make it more time
tive was designed to assist students in a successful and cost-effective and to better address student
transition from school to work (Nash & Korte, needs. The program had a paid work experience
1997). Stone and Jossaim (2000) reported that pos- whereby students were paid a minimum wage
itive work attitudes were consistently linked to par- stipend through the grant for a total of 80 hours.
ticipation in jobs where SCANS skills were being In order to be sustainable in a school district, the
developed. The SCANS skills have been successfully paid work experience might be replaced with addi-
incorporated into several vocational exploration pro- tional volunteer activities. However, the stipend
grams with excellent results and were included in was a very strong extrinsic motivator and might be
the WCOP. The SCANS skills include basic skills, difficult to replace. A focus on health promotion
thinking skills, personal qualities, identification and also should be included in the program activities.
appropriate use of resources, interpersonal skills de- Students need information related to health and
velopment, information processing, understanding wellness and a better understanding of the impact
of systems, and using technology. that health and lifestyle choices made today have
The effectiveness of the WCOP was evaluated on their future employability. These are areas that
using a randomized control trial. Students in three are within the scope of practice of occupational
schools were randomly assigned to either the WCOP therapy.
intervention group (n=56) or a control group The current economic environment and the
(n=55). The students in the control group did not potential for layoffs is another topic that needs to
participate in any specialized transition programs be discussed with students in the program. Two
and received general information about transition students who completed the WCOP were hired in
and transition services from special education local businesses. They were able to complete the
personnel. The majority of students in both the requirements of the job, and the employer was very
WCOP group and the control group had a learning satisfied with their performance. However, the
disability. The WCOP was found to be highly effec- business needed to downsize, and those employees
tive. Seventy five-percent of the students in the with the least seniority were laid off. The students
WCOP group were competitively employed post- had considerable difficulty understanding why they
WCOP versus 9% in the control group. Addition- were being let go. This type of situation would be
ally, 51% of the students in the WCOP group better addressed proactively rather than reactively.
obtained employment within the first 3 months after Employers value teamwork, interpersonal skills,
completion of the program, 19% within 3–6 months, and behavior more than traditional work-related
and 3% within 6–9 months. In the WCOP group, skills addressed by high school occupational educa-
33% of the students sustained their competitive part- tion curriculums (Allred & Baker, 1997). Transition
time and/or full-time jobs compared with 18% of planning and services must focus on students’
the students in the control group 6 months after strengths and abilities that they will one day try to
completion of the program. The school district was market to prospective employers (McKenna, 2000).
very satisfied with and interested in continuing the Occupational therapists have the skills and knowl-
program. edge to do this and can become vital members
Outcomes from the WCOP Evaluation Study of the transition team. The case study that appears
have shown the program to be effective in fostering at the end of this chapter describes a student’s
independence, self-advocacy, self-determination, experience in the WCOP.
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Transitioning to Work These activities, while focusing on occupation, are

typically more rehabilitation center–based than
Following a Disability community-based.
Similar to school to work transition, federal legisla- In community-based practice focusing on the tran-
tion has also been enacted in an effort to facilitate and sition to work by persons with disabilities, there are
enable persons with disabilities to return to work. The numerous roles for occupational therapy practitioners,
Americans with Disabilities Act (ADA) and its including:
2008 Amendments and the Ticket to Work and • completing ergonomic evaluations and
Work Incentives Improvement Act (TWWIIA) of interventions in the workplace;
1999 have important implications for individuals • consulting on community and transportation
transitioning to work following a disability. accessibility;
Stapleton and Burkhauser (2003) view the ADA • making recommendations for reasonable
of 1990 as a driving force in changing disability pol- accommodations; and
icy so that individuals with disabilities can become • providing direct service with the individual
competitively employed rather than relying on var- focusing on the occupational performance
ious types of disability benefits. The ADA and its areas related to activities of daily living and
reauthorization in 2008 and 2010 protect the civil instrumental activities of daily living.
rights of and prohibit discrimination against workers
with disabilities. The ADA also mandates the pro- An increasing number of occupational therapy
vision of reasonable accommodations to enable practitioners are involved in workplace ergonomic
workers with disabilities to be successful in the evaluations and interventions (AOTA, 2004), which
workplace. The 2010 amendment also clarifies the are described in detail in Chapter 16 of this text.
use of service animals; wheelchairs; manual mobility Evaluations might include the identification and
devices, which include canes, crutches, and walkers; minimization of factors that contribute to accidents
and other types of power-driven mobility devices, or injury in the workplace. Interventions might
such as Segways, which are not designed for the focus on modification of tools and equipment, and
exclusive use of persons with disabilities (Resource the provision of education and training on injury
Centers on Independent Living, n.d.). Although the prevention.
purpose of the ADA was well intended, research has An accessible community and transportation are
suggested that employment rates of persons with necessary in order for a person with a disability to
disabilities did not increase significantly after the return to work. Although still relatively uncommon,
passage of this legislation. One potential reason sug- consulting on community and transportation acces-
gested was that many persons with disabilities were sibility is an emerging role for occupational therapy
concerned about the loss of benefits, particularly practitioners (Iwarsson, Stahl, & Carlsson, 2003).
health benefits. Many persons with disabilities, Occupational therapy practitioners frequently are
because of the nature of their disability, are able to called upon to make recommendations for workplace
work only on a part-time basis. However, in many accommodations. The Job Accommodation Network
situations, a person must be employed full-time in (JAN, 2009) is a program under the auspices of the
order to be covered by health insurance plans Office of Disability Employment Policy in the U.S.
offered by the employer. The TWWIIA legislation, Department of Labor whose major purpose is to
discussed in greater detail in Chapter 18, was an facilitate the employment and retention of workers
attempt to address this issue. Under this legislation, with disabilities. The JAN provides a valuable
persons with disabilities could return to work resource that can be used by occupational therapy
and continue to receive health care coverage from practitioners for their own information or to share
programs such as Medicaid. with persons with disabilities or employers. Through
Historically, occupational therapy practitioners its Web site, JAN addresses physical, cognitive, sen-
have been involved in return to work programs sory, and mental conditions and disabilities, includ-
by performing functional capacity evaluations ing etiology, symptoms, and treatment. Whether or
and implementing work hardening programs. not the disability or condition is covered under the
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ADA, numerous examples of accommodations for a A trial program somewhat similar to the one
variety of disabilities or conditions are included on mentioned above in World War I was implemented
this Web site. Extensive resources and references are in Afghanistan in 2010 to provide occupational
also provided. therapy evaluation and intervention services to mil-
Occupational therapy practitioners continue to itary personnel immediately following a mild head
have a crucial role in providing direct service to per- injury (Johnson, n.d.). The goals of this program
sons with disabilities in order to enable them to were to facilitate the quick return to action for those
return to work. Depending on the nature of their soldiers who were medically fit and the evacuation
disability, people may need assistance or suggestions of those in need of a higher level of care (E. Johnson,
for activities of daily living (ADLs) related to getting personal communication, November 21, 2009;
ready for work or instrumental activities of daily Barth, Whitney, & Johnson, 2011).
living (IADLs) related to getting to work. They Increasing attention is being placed on facilitat-
might also need assistance with assertiveness and ing the transition of military service personnel back
self-advocacy in asking for reasonable accommoda- to active service or civilian life. Based on the results
tions or information on what accommodations of a 2007 congressionally mandated review of care
might be reasonable to request. These tasks are all for “warriors in transition,” 35 warrior transition
within the domain of occupational therapy. units (WTUs) were developed by the Army to bet-
ter meet the rehabilitation and vocational training
needs of injured soldiers. The WTUs were designed
Transitioning to Active Duty for soldiers who required more than 6 months
or Civilian Employment of medical care and were located close to medical
treatment facilities across the United States as well
Occupational therapy has been actively involved in as in a few international locations. The philosophy
providing services to military personnel since the early of the WTUs was to band together in units, a tradi-
years of the profession (McDaniel, 1968). Beginning tional organizational structure in the military, sol-
in World War I, its practitioners have responded to diers who have the same duty, to train them in order
the reconstruction and rehabilitation needs of injured to return to active military duty or to gain civilian
soldiers, both stateside and abroad. The goal of the employment (Erickson, Secrest, & Gray, 2008).
reconstruction work in World War I was to enable Active and reserve duty troops, whether they are
soldiers to return to either active service or paid deployed in areas of conflict or are based within the
employment following discharge from the military. United States, are eligible for services provided
While the majority of occupational therapy practition- through WTUs. In 2008, the most common injuries
ers worked in the United States, 55 occupational ther- for which soldiers were assigned to a WTU included
apy reconstruction aides were stationed in France and orthopedic conditions, mainly injuries to the back
Germany by May 1919 with the American Expedi- and knees, “followed by internal and neurological
tionary Forces. Their duty was to work with those conditions. About 1% of the soldiers have sustained
soldiers most likely to be enabled to transition back to some of the most devastating conditions, such as
battle or other support roles near but behind the battle burns or amputations” (Erickson et al., 2008, p. 11).
lines. The most common injuries of these soldiers Injury rates for traumatic brain injury (TBI) and
included orthopedic cases and neuropsychiatric disor- post-traumatic stress disorder (PTSD) are increasing
ders (McDaniel, 1968). In addition to the services among soldiers, as are suicide rates, according to U.S.
provide at the base hospitals, occupational therapy Army data (Table 17-2). These increases have been
was carried out experimentally in a neuropsychiatric observed for 5 consecutive years (Starr, 2010; U.S.
hospital in the forward area. The experiment lasted Army, 2009). There were 115 suicide deaths in 2007
only 2 weeks but the medical officer in charge indi- and at least 128 in 2008. In 2009 there were 249
cated that, through the assistance of workshop treat- suicides and 1,713 attempted suicides (Starr, 2010;
ment, men were returned to duty who had previously U.S. Army, 2009). Injury rates from TBI and PTSD
been listed for evacuation to base hospitals for further and the continuing rise in suicides among military
treatment (McDaniel, 1968, p. 90). personnel indicate an increasing need for transitional
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services before and during deployment, as well as facilitating his assimilation. He received this shelter
prior to and following return stateside. While the dog through a program called P2V.org (Pets to
army has increased its efforts in this area in recent Vets). A retired airman named Sharpe established
years, civilian occupational therapy practitioners the non-profit program to reduce the time and cost
need to be aware of the possibility of groups of for veterans to access trained service dogs. He
wounded warriors in their communities who may no thought each could assist the other; “Eighteen vets
longer be receiving services from the military. commit suicide every day in this country, and one
Although occupational therapy interventions for animal is put to sleep every eight seconds. They can
wounded warriors, regardless of their diagnoses, help save each other” (Sharpe quoted by Hendrix,
may be similar to those for their civilian counter- 2011, p. B1). Programs such as this can be a first
parts, these individuals also need access to special- step in the transition back to life and work, and
ized transitional services. Occupational therapy could benefit from the skills of occupational therapy
practitioners who wish to seek funding and support practitioners as volunteers.
for developing such programs in their community A variety of initiatives are being developed to
must ensure they have an understanding of military meet the needs of wounded warriors. A review
lifestyle and culture as well as of resources such as of the Conference Guide from the 2011 AOTA
Pets to Vets. This knowledge can be gained through Conference and Exposition (AOTA, 2011) revealed
a variety of ways, including: that at least 10 education sessions or posters were
presented at that conference regarding initiatives for
• communicating via e-mail (e.g., Johnson,
wounded warriors. Examples of topics of sessions
n.d.) or Facebook with occupational
included post-combat driving anxiety, vision impair-
therapists in the military
ments, community reintegration programs, warrior
• seeking evidence-based articles on
transition units, and outcome measures development
interventions with military personnel
for the military population. Articles are also appear-
• reviewing military Web sites, such as
ing in the occupational therapy literature. Hofmann
www.army.mil
(2008) reviewed the needs of veterans, and Sheffield
• reading current related literature
(2009) described a joint venture between Scripps
• attending state and national conferences
Memorial Hospital and Camp Pendleton in
sessions on this population
California to provide specialized driving services
• volunteering with organizations that provide
and community mobility services as well as a day
assistance to veterans
treatment program for wounded warriors. The
Jimmy Childers, who sustained a leg amputation potential to facilitate transitions of military per-
while serving as a marine in Afghanistan, noted “the sonnel to civilian paid work or volunteer positions
toughest thing is not the physical, it’s the mental is being partially realized but requires expansion;
assimilation into society” (quoted by Hendrix, occupational therapy practitioners are well equipped
2011, p. B1). Childers credits his dog, Tidus, with to meet this growing need.
Table 17-2 TBI and PTSD Rates

Number of Soldiers in
Army Wounded Warrior Percentage Diagnosed with
Reporting Period Program TBI or PTSD
Fall 2008 3,800 38%
Fall 2009 5,200 52%
Spring 2010 6,500 58%
Data from: “Invisible Wounds,” by C. Rivero, in “Diagnosis: Battle Wound,” by G. Jaffe, 2010, July 18.
Washington Post, pp. A1, A6–A7.
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Transitioning to Retirement Activity Planning (TAP) developed by Cantor

(1981) can serve as a basis for an updated process
The movie The Bucket List (Reiner & Zackham, based on the occupational profile as outlined in the
2007) drew attention to the need for retirement AOTA Framework (2008), Canadian Occupational
planning with an eye toward eventual death via a Performance Measure (Law et al., 2005), or similar
humorous but poignant tale of two strangers’ joint client-centered assessment.
exploration of new occupations. The characters, both
with terminal illnesses, embarked on a quest to com-
plete as many items on their bucket lists (i.e., “to do” Bridge Employment
lists before they “kick the bucket”) as possible. They A phased or graded approach to retirement, known
gained a sense of mastery and fulfillment through as bridge employment, can aid in the transition to
mutually explored occupations. Occupational ther- the retirement role. Bridge employment is less than
apy practitioners are equipped to assist individuals full-time employment in which people engage prior
in designing their unique bucket list as part of a com- to their full retirement (Feldman, 1994). Zhan,
prehensive, occupation-based retirement strategy. Wang, Liu, and Shultz (2009) found that bridge
In addition, these practitioners can provide strategies employees had improved mental health if they con-
for engagement in the chosen occupations where and tinued their employment in the same career and
when adaptations or an alteration of the occupation decreased functional limitations if they worked
itself is required. There is no need to await a terminal either in their original career or a new career. An
illness diagnosis to begin preparing a bucket list. In occupational therapist may recommend a graded
fact, the earlier people start their list, the more likely approach to bridge employment, where a person
they are to complete some of the occupations. While progressively decreases his or her work hours until
there are many possible reasons for individuals or full retirement. Bridge employment can be a planned
couples to postpone retirement discussions, such as reduction in both work hours and responsibility
an irrational fear that planning for the future will in order to provide for increased time with family,
hasten their death or a desire to ignore the process volunteer activities, or other desired occupations.
of aging, a bucket list–style approach may be used as Individuals may wish to retire but due to un-
an occupation-based method to introduce the topic. planned circumstances, such as a disadvantageous
This strategy also could be used by occupational ther- financial situation, need to continue bridge employ-
apy practitioners themselves, to ensure they too “live ment or full-time work. Given the current and
like you ... [are] dying” (Nichols & Wiseman, 2004). recurring recessions, often employees find them-
In this section of the chapter, occupation-based selves continuing to work beyond their planned
retirement will be further discussed, along with the retirement date due to the impact on retirement sav-
ideas of bridge employment and legacy planning at ings from financial downturns or the illness or loss
the employment site. of a partner or spouse. While these are painful pos-
sibilities, they need to be addressed in both financial
and occupation retirement planning. In reality,
Occupation-Based more than one plan is needed. The first plan is
Retirement Planning based on the individual or the individual and his or
The need for comprehensive pre-retirement (Cantor, her partner remaining healthy and able to work
1981) and retirement planning (Broderick & Glazer, until their desired time frame for full retirement
1983) beyond solely financial planning has been or bridge employment. The second is a plan that
appreciated by occupational therapists for some time. accounts for the possibility that one becomes ill and
While financial planning is essential for a quality needs care.
retirement, an activity or occupation engagement Occupational therapy practitioners can offer
plan also is needed. However, the financial planning community-based retirement planning that comprises
portion of retirement planning must occur first, as both types of plans. In the “ideal” plan, a decision to
occupation planning will be constrained by the pro- decrease work hours gradually versus stopping work
jected financial resources for retirement. The Tactical suddenly might help with the adjustment to the
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retirement role and allow old habits to support self- smooth transition. The eventual transition can be
identity as new habits or a resumption of old habits eased by ensuring that the individuals who will be
is formalized. In the second or “contingency” plan, assigned the work tasks in the future are oriented
having a relationship with an employer as a success- to them while the expert is still available for ques-
ful part-time employee or being known as someone tions and guidance. This type of planning may
who is available to fill in for others’ vacations may make it easier for individuals to leave roles and not
be helpful if a return to work for financial reasons feel they need to stay to protect the work or volun-
is needed. teer unit. Erickson’s developmental stage of older
In both plans, the possibility of future limitations adults referred to as generativity has been shown to
should be taken into consideration. After a bucket be met through bridge employment (Dendinger,
list or occupation “to do” list is formed, the occupa- Adams, & Jacobson, 2005); legacy planning might
tions should be ranked in order of desired perfor- be fashioned in a manner that also meets this
mance based on financial cost, time needed, available developmental task. Legacy planning is another sit-
resources, and energy expenditure. Possible questions uation where activity analysis can assist in work
to help prioritize the list include the following: transitions by helping to determine when and how
to initiate the legacy plan.
• Which occupations may be better to com-
With the projected workforce needs in the near
plete while having employer provided health
future, individuals, including occupational therapy
insurance or when you can afford travel
practitioners, will have many options regarding
insurance?
when and how they choose to transition to retire-
• Which occupations can be done while
ment. Community-based retirement programs can
working part-time?
be developed that focus on individuals with similar
• Which occupations are likely to experience a
financial and occupation plans. While individuals
future increase in financial cost to the point
with upper-middle incomes and above may have
where they become cost prohibitive?
funds to pay for these services, others may not. Seek-
• Which occupations can be graded, with the
ing grant funding to ensure that people in other
more strenuous options completed at an
economic brackets also can benefit from such plan-
earlier age?
ning and support programs would be an important
For example, if hiking is a favorite lifetime occu- contribution of the profession based on the values
pation, list all the hikes the person wants to under- of its founders. Occupational profiles, occupation-
take and their associated costs. Then, place those based assessments, and activity analysis are useful
hikes that require more physical effort (and possibly tools for occupational therapy practitioners in facil-
more money) earlier on the list. Also ask questions itating transitions to work in both their personal and
such as “Are any of the hikes close to places where professional lives.
you may attend a business meeting or a conference
in the future?” This type of questioning helps fiscal
decision making. This activity analysis can be very Conclusion
helpful in assisting people in being strategic in their
pre-retirement and retirement occupation planning. “Work can offer a person a sense of mastery over
the environment, as well as a sense of accomplish-
ment and competence leading to an improved
Legacy Planning in Employment quality of life” (Siporin, 1999, p. 23). Quality of
and Volunteer Settings life, participation, prevention, and other outcomes
In many ways, legacy planning is a type of phased of the occupational therapy process (AOTA,
retirement. It is simply projecting when one wants 2008) are well matched to outcomes of transi-
to no longer be responsible for specific roles or tional work programs. Whether it is focusing
tasks, and then working with the appropriate peo- on school to work transition, transition into
ple in the organization proactively to ensure a employment, or transition into partial or complete
2580_Ch17_243-256 16/07/13 2:56 PM Page 253
retirement, occupational therapy practitioners can by the profession’s commitment to social and
play an important role in facilitating positive out- occupational justice and the prevention of occu-
comes. However, the services of occupational pational imbalance (AOTA, 2008, 2010; Scaffa,
therapy practitioners often are not used to the Van Slyke, & Brownson, 2008). Increasing access
fullest potential, especially in school systems to transitional work services, collecting data on
where occupational therapy practitioners are al- results of these services, and disseminating out-
ready present. Increasing the visibility of the pro- come data from such efforts is one very important
fession in the provision of occupational therapy step along the road to fulfilling the Centennial
transitional work services and programs is supported Vision of the AOTA.
CASE STUDIES
CASE STUDY 17•1 Carol
The following case study describes the experiences of a student participant in the Work and Careers
Opportunities Program (WCOP) discussed earlier in this chapter. Carol (pseudonym) was a 17-year-old
woman who was classified as having a mild intellectual disability and attention deficit disorder. She was
in 11th grade at an urban area school that was participating in the WCOP program. Carol attended
regular education classes and received special education services in the school’s resource room. At the
time the WCOP started in her school, she was not receiving occupational therapy services and had not
since the fifth grade. Her transition plan indicated that she would receive “traditional” transition services,
including meeting monthly with a guidance counselor. Carol had difficulty focusing on activities and
maintaining attention to detail. Her handwriting was not legible, and she read at approximately the
sixth-grade level. She generally had positive social interactions with peers and adults.
As part of the work interest profile completed by Carol during Phase 1 of the WCOP, she discovered
and expressed an interest in becoming an elementary school teacher. As is seen with the career goals of
many youth, Carol’s career goal of becoming a teacher was not currently realistic for her as she would
most likely not be accepted at a college or university based on her academic performance. However, it
was important not to “squash” her career aspirations. The occupational therapist working with the
program discussed several options with Carol. Field trips were used during Phase 1 to explore different
job possibilities, and Carol visited several day-care centers and after-school programs for children.
During Phase 2 of the WCOP, Carol completed a volunteer experience at a local day-care center. She
worked with preschool children at the center and involved them in several games and activities under the
supervision of her job coach and an aide. Over the course of the 10-week volunteer experience, Carol was
able to function with greater independence and less direct supervision. She related very well with the
children and the children with her.
The director of the day-care center was very satisfied with Carol’s performance and agreed to let her
complete the internship associated with Phase 3 of the WCOP at the center. During this time, the
occupational therapist also worked with Carol on computer skills so she could use word processing to
complete job applications, develop a resume, and perform other work-related tasks. Carol and the
occupational therapist also worked on using public transportation to and from her home to the day-care
center.
When she completed the WCOP, Carol was hired as a part-time day-care aide; she worked 3 hours a
day after school, 3 days a week and 4 hours on Saturday mornings. After she graduated from high school,
she was hired in a full-time position at the center and is investigating the possibility of attending a com-
munity college to earn an associate’s degree in human services with a focus on early childhood education.
Continued
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CASE STUDY 17•1 Carol cont’d

1. How can the role of occupational therapy in providing school to work transition services to high
school students with and without disabilities be expanded?
2. What skill sets and competencies do occupational therapy practitioners have that enable them to
provide community-based work transition services and programs?
3. What skill sets and competencies do occupational therapy practitioners need in order to enable them
to provide community-based work transition services and programs?
Learning Activities Barth, J., Whitney, R., & Johnson, E. (2011, April). Lead
with your heart and spirit: People will follow. Short course
1. Investigate your community or county and presented at the American Occupational Therapy Associa-
determine what work transition programs are tion 91st Annual Conference & Expo, Philadelphia, PA.
available for youth, retirees, returning warriors, Benz, M. R., Yovanoff, P., & Doren, B. (1997). School-
parents re-entering the work force, and retirees to-work components that predict post-school success
for students with and without disabilities. Exceptional
exiting the work force. Summarize your Children, 63(2), 151–165.
findings in a table. Blancher, J. (2004). Self-determination: Why is it impor-
2. Develop an interview protocol and then tant for your child? Exceptional Parent, 34(3), 80–82.
conduct an interview with a manager or Broderisk, T., & Glazer, B. (1983). Lesiure participation and
director of one of the programs. the retirement process. American Journal of Occupational
Therapy, 37(1), 15–22.
3. Based on the interview, develop an outline for Browder, D. M., Wood, W. M., Test, D. W., Karvonen,
a potential proposal to describe occupational M., & Algozzine, B. (2001). Reviewing resources on
therapy’s contribution to the program. self-determination: A map for teachers. Remedial and
Special Education, 22(4), 233–244.
Cantor, S. G. (1981). Occupational therapists as members
of pre-retirement resource teams. American Journal of
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Chapter 18
Welfare to Work and Ticket

to Work Programs
Emily Wilson Mowrey, MS, OTR/L, and Lauren Ashley Riels, MS, OTR/L
Give a man a fish and you feed him for a day. Teach a man to fish and you feed him
for a lifetime.
—Chinese Proverb
Learning Objectives
• Discuss issues relating to Welfare to Work reform, causes of low job retention, and possible solutions for improving
return to work.
• Identify potential roles of and implications for occupational therapists and occupational therapy assistants within
Welfare to Work and Ticket to Work Programs.
• Describe the five main focus areas of the Ticket to Work Program.
• Discuss the different payment system options associated with the Ticket to Work Program.
• Identify the benefits and limitations of the Ticket to Work Program.
Key Terms
Continuing Disability Reviews (CDRs) Substantial Gainful Activity (SGA)
Employment Networks (ENs) Temporary Assistance for Needy Families (TANF)
Individual Work Plan (IWP) Ticket
Milestones-Outcomes payment system Ticket holder
Outcomes-Only payment system
Personal Responsibility and Work Opportunity
Reconciliation Act (PRWORA)
Introduction are individuals and families on welfare and persons

with disabilities. The Welfare to Work program is
Poverty is one of the major social issues in the designed to help persons receiving government aid
United States today. As of 2009, about 14.3% to find and secure long-term employment, and the
of the population (42.9 million individuals) lived Ticket to Work Program has the same goal for per-
below the poverty line (Bishaw & Macartney, sons with disabilities. The history of welfare reform,
2010). This social problem has afforded new oppor- characteristics of the Welfare to Work and Ticket
tunities for occupational therapists and occupational to Work programs, and potential roles for occupa-
therapy assistants to come to the service of the dis- tional therapy practitioners in these programs will
enfranchised. Two such disenfranchised populations be discussed in this chapter.
257
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Welfare to Work meant that federal Welfare to Work funds could not
be used for education and job skills training prior
History of Welfare Reform to job placement (Trutko, Nightingale, & Barnow,
1999).
The welfare system was created in 1935 as the gov- Statistically speaking, PRWORA has been one of
ernment offered Aid for Families with Dependent the most successful pieces of legislation in history.
Children (AFDC) for children who experienced Between August 1996 and September 2003, the num-
poverty after the absence or death of their father, or ber of families receiving welfare benefits decreased by
if their father could no longer work (Blank & Blum, 54% (U.S. Department of Health and Human Ser-
1997). Over time, AFDC provided needy families vices [USDHHS], 2004). There is much debate, how-
with food stamps, Medicaid health coverage, and ever, about how much of that decline was due to the
assistance for other essential needs such as housing welfare reform legislation and how much was due to
expenses. As a pattern of dependency on federal a booming economy and healthy labor markets during
assistance developed, taxpayers expressed concerns that time (Lichter & Jayakody, 2002).
that the welfare system was not assisting people to In 2010, the 108th Congress approved the Per-
gain financial independence but rather was creating sonal Responsibility and Individual Development
a population of families who could not live without for Everyone (PRIDE) Act, which reauthorized the
this support. PRWORA. Some changes that occurred from this
Reform of the welfare system was spurred by reauthorization included extending the time that
Governor Thompson in Wisconsin, who began a rehabilitation counts as work from 3 to 6 months,
program called Work Not Welfare in 1995. This allowing states to include child care or caregiving for
Welfare to Work program was the first to require other family members as work, and requiring states
recipients to work in order to receive benefits, and to make an attempt to contact the family before
its success encouraged the U.S. Congress to consider imposing sanctions (National Association of Social
welfare reform. Workers, 2005). These changes to the original leg-
In 1996, the most significant welfare reform bill islation decreased the fear that the requirements
to date was passed. Under the Personal Respon- would force welfare offices to push recipients into
sibility and Work Opportunity Reconciliation jobs that are not appropriate matches to their skills
Act (PRWORA), former benefit programs such as (Fonte, 2002).
AFDC and the welfare-to-work program called Job
Opportunities and Basic Skills (JOBS) were elim-
inated. These were replaced with a grant to each
Recipient and Participant
state to establish Temporary Assistance for Needy Demographics
Families (TANF) (Pavetti, 1997). Each state Recipients of TANF services are families. Of the
was now responsible for distributing benefits and families who received TANF during fiscal year (FY)
offering employment services. Other changes in- 2008, only 3.6% had two or more adult recipients
cluded time limits on the receipt of benefits. A in the household, and only 6% of the adult recipi-
family could not exceed 2 years of receiving bene- ents were men. Thirteen percent of the adult recip-
fits at one time or a total of 5 years of benefits in a ients were exempt from the mandatory work
lifetime (Gittleman, 1999). These caps on welfare requirement. In addition, another 30% of adults
assistance were meant to encourage recipients to who were required to participate in mandatory work
enter the workforce and become financially inde- did not. The remaining 40% of all adults partici-
pendent without eliminating the temporary assis- pated in work activities for an average of 25 hours
tance families needed during a crisis. per week (USDHHS, 2009). Other demographics
The new guidelines outlined in PRWORA re- are outlined in Box 18-1.
quired federally funded state programs to have 50% In FY 2009, the average number of families receiv-
of their welfare recipients participate in work activ- ing TANF each month was 4.3 million (although the
ities for 30 hours per week by the year 2002 (Pavetti, number of actual recipients is estimated at 1.0 million
1997). Training programs could only be paid for adults and 3.3 million children) (USDHHS, 2011).
after the recipient had begun work activities, which Of the families receiving TANF benefits, 29.4%
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Chapter 18 | Welfare to Work and Ticket to Work Programs 259
Box 18-1 Demographics of Recipients argued that education and skills training should
of Welfare take place before the recipient enters the workforce,
in order to prepare the recipient for increased suc-
• Family: 90% female heads of household cess. The U.S. government preferred a WorkFirst
• Average number of children: 1.8 approach, however, which placed recipients into
• Average age of children: 7.8 years jobs immediately. Any training and education
• Ethnicity: 37% black adults, 38% white adults, 20%
under these programs was to occur after the recip-
Hispanic or Latino adults, 1.5% Native American,
1.7% Asian
ient was participating in “work activities.” Work
• Work: 45% participated in work activities for average activities are clearly defined in welfare policy as a
of 25 hours per week certain number of hours that must be spent in paid
employment, skills training, or educational activi-
Data from: USDHHS (2009b). Characteristics and Financial ties (Cohen, 1998).
Circumstances of TANF Recipients Report 2006. Retrieved Throughout the 1990s, the Manpower Demon-
from http://acf.hhs.gov/programs/ofa/character/FY2008/
indexfy08.htm stration Research Corporation (MDRC) conducted
a 5-year study of 11 Welfare to Work programs across
the country to examine their effectiveness in remov-
ing individuals from welfare and increasing their
were participating in work activities. Of those overall income. This National Evaluation of Welfare
participating, 66% were involved in unsubsidized to Work Strategies (NEWWS) compared the pro-
employment, 8% were gaining work experience, grams that used the WorkFirst strategy and the HCD
and another 11% were receiving vocational educa- strategy. The studies indicated that although the pro-
tion. The remaining participants are involved in grams had a positive effect on individuals moving
either job search or other waiver activities. Averages from welfare to work, the employment-based pro-
vary greatly among states, as do caseloads. For grams were more effective than the education-based
example, California and New York combined make programs in increasing income and maintaining
up one-third of the total recipients of TANF and employment. These employment-focused programs
almost half of the total cash payments made by the were also cheaper to operate, while the more expen-
U.S. government (USDHHS, 2010). sive programs did not necessarily produce better
According to the National Evaluation of Welfare results (Hamilton, 2002).
to Work Strategies, the average participant was a
30-year-old single woman with two children. Most
of these women had one child less than 6 years of Issues Related to Welfare
age. They were of varied racial/ethnic backgrounds
depending on location. The average number of to Work Transition
years of school completed was fewer than 10. The
barriers to employment that most of the women in Causes of Low Job Retention
these programs faced were having no high school It is important to examine how Welfare to Work pro-
diploma, being unemployed for 5 or more years, or grams can be successful at increasing job retention,
receiving welfare for 5 or more years. One fourth or the ability of a person to maintain employment
of the women had health or emotional problems in after placement. Rangarajan (1996) summarized the
the family, and one fourth of the women also had challenges that a person moving from welfare to work
a reluctance to leave their children to go to work commonly experiences, including difficulties with
(Hamilton, 2002). budgeting, adjusting to a work environment and
demands that come with full-time employment, and
a lack of a strong emotional support system. These
Assessment of Welfare to Work challenges, unfortunately, often result in a loss of
Programs employment and a return to welfare. This life change
This distribution of funds created a two-sided debate can be a dramatic adjustment for families, and many
among Welfare to Work professionals. One side, the welfare recipients do not have the personal or social
Human Capital Development (HCD) approach, resources that facilitate success.
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Another group of barriers that are prevalent offices could provide support for clients in three
within the welfare community may be hidden. ways. First is with intensive case management that
Hidden barriers include mental health impair- would connect each individual to the support ser-
ments, domestic violence, and substance abuse, all vices that would best fit his or her needs. Next, direct
of which have a significant impact on an indivi- intervention could be used to provide treatment for
dual’s ability to transition to the workforce (East, substance abuse, learning disabilities, or mental
1999; Pavetti, 1997). Mental health problems, health impairments, utilizing professionals with ex-
especially undiagnosed, can have a negative impact pertise outside the welfare office. Finally, the system
on a recipient’s employability. These clients may could provide supported and transitional work pro-
experience depression, anxiety, severe stress, sub- grams. These include a gradual support system to
stance abuse, or posttraumatic stress disorder (East, move a person into independent work, with the use
1999). Lack of diagnosis and treatment, combined of a job coach or supervised work experience.
with the stressors of returning to work, could result
in difficulties in the workplace.
Enhancing Success in Welfare in Welfare to Work Programs
to Work Programs Wilson (2000) identified services currently offered
The literature indicates that many programs have in 23 Welfare to Work programs and examined the
taken the quickest route to decrease caseloads rather role of occupational therapy. Programs were selected
than examining needs of recipients and providing ap- from Welfare to Work literature and studied from
propriate services. According to Meckstroth, Pavetti, materials provided by the programs upon request.
and Johnson (2000), Welfare to Work programs The services provided were categorized into themes
should have a screening process to identify recipients’ and analyzed for frequency and relation to occupa-
barriers to employment. For example, trained tional therapy domain. The 22 services are described
practitioners could screen clients for learning disabil- in Box 18-2.
ities, domestic violence, substance abuse, and mental Of the services offered, many are occupational
health disorders, all of which are prominent concerns therapy–related, including: job skills, case manage-
for a person’s employability. Once identified, welfare ment, assessment, job coaching, career planning, job
Box 18-2 Services Offered by Welfare to Work Programs
Job skills: Training in technical skills that are specifically designed to be used on the job.
Soft skills: Training in the skills needed to be an employee at any job, such as customer service
skills, conflict management, interpersonal communication with co-workers, time
management, and promptness.
Counseling: Personal and professional advice about the decisions that the recipient makes regarding
work.
Case management: One-on-one assistance in organizing the recipient’s job search, placement, training,
financial assistance, or other services.
Assessment: Evaluation of the recipient’s skills, education, interests, or abilities.
Job coaching: Assistance for the recipient from a program staff person while he or she is actually on
the job.
Career planning: Creation of goals and a plan for long-term employment and self-sufficiency.
Job seeking: Assistance in searching for an appropriate job, as well as training in the skills that are
needed to acquire a job, such as searching the classified ads, creating a resume, and
interviewing techniques.
Self-esteem: Counseling provided either individually or in a group that focuses primarily on increasing
the recipient’s self-esteem.
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Box 18-2 Services Offered by Welfare to Work Programs—cont’d
Life skills: Training in the areas that are essential to self-sufficiency but not directly related to
performance at the workplace. For example, some life skills training may include
budgeting, home management, family planning, and crisis prevention.
Support group: Personal support and counseling provided by a group of peers that may or may not be
accompanied by a professional.
Parenting: Classes or support groups that specifically focus on improving the recipient’s parenting
skills.
Child care: Assistance in seeking child care or placing a child in care, financial subsidies for use in
child care, or direct care for children while the recipient is working.
Mentoring: Providing contact with a person in the community, a volunteer, or another member of
the Welfare to Work program who gives the recipient advice, counseling, support, or
other assistance.
Basic education: Classroom training in basic reading and math skills, including preparation for the General
Education Development (GED) exam.
Job placement: Assistance in not only searching for a job but also helping the recipient secure the job.
Transportation: Assistance in finding transportation to and from work.
Job development: Generation of jobs for which welfare recipient can apply by collaborating with
employers in the community.
Work experience: Opportunity to practice skills in a work environment within the security of the program.
Health care: Direct health care provided for recipients and their families, or financial assistance that is
intended for health care.
Apprenticeship: Work experience that is supported by an individual co-worker or supervisor who trains
the recipient in the skills needed for the job for a certain period of time.
Financial assistance: Direct financial benefits for the recipient during the time he or she is in the program,
including tax credits, financial crisis assistance, clothing, payment for legal expenses, and
opportunities for investment.
Data from: Wilson (2000). The role of occupational therapy in Welfare to Work. (Unpublished master’s thesis). Ithaca College,
Ithaca, NY.
seeking, life skills, community mobility, and parenting. health impairments or other hidden barriers to em-
Based on a frequency analysis to determine how often ployment as discussed above. Others are helping to
the services are currently used in Welfare to Work educate employers and staff on the needs of em-
programs, it was determined that 55.6% of the ser- ployees with learning disabilities or limited previous
vices provided by these programs were considered to work experience. Recently, some programs have
be occupational therapy–related and 44.4% were discovered the benefits of hiring an occupational
considered to be not occupational therapy–related therapist full-time to cover a wide variety of needs
(Wilson, 2000). Occupational therapy practitioners in the program.
could provide many of the services offered by Welfare There are several roles that an occupational
to Work programs. Therefore, it seems appropriate therapist could potentially fulfill in Welfare to
to utilize occupational therapists and occupational Work programs. These include direct care provider,
therapy assistants to develop effective services for the consultant-educator, and broker-advocate (Box 18-3).
Welfare to Work population (Wilson, 2000).
Direct Care Provider Role
As a direct care provider, the occupational therapist
Occupational Therapy Roles would work directly with participants in the Welfare
An increasing number of occupational therapists to Work program to develop performance skills in
have been attracted to this innovative setting. Some order to improve occupational performance in the
are working under federal grants to identify mental area of work. An occupational therapist may use
2580_Ch18_257-270 16/07/13 2:56 PM Page 262
Box 18-3 Potential Roles for Occupational education. The educator role could involve both
Therapists in Welfare to Work direct education of welfare recipients and staff edu-
cation. Some examples may include developing par-
• Direct care provider: create and carry out an inter- enting groups to teach welfare recipients about child
vention plan in order to improve client’s ability to care and child development, or implementing sup-
transition from welfare to successful employment. port groups to increase self-esteem and coping skills
• Consultant-educator: consult on individual client dys-
in newly working welfare recipients so that they may
function or on program development. Also directly
educate welfare recipients and program staff.
better meet the challenges of the worker role. This
• Broker-advocate: act as liaison between client and may also include helping a welfare recipient develop
employer or case manager to advocate for the short-term and long-term goals, a career develop-
client’s needs in the workplace. ment strategy, and techniques to successfully com-
plete the plan.
Data from: Wilson (2000). The role of occupational therapy in In the consultant role, the occupational therapist
Welfare to Work. (Unpublished master’s thesis). Ithaca College, can assist with program development. Staff persons
Ithaca, NY.
could identify workers’ training adjustment difficul-
ties and refer to an occupational therapist for evalu-
therapeutic occupations and activities to develop a ation. The occupational therapist may perform an
welfare recipient’s job skills, such as organizing work evaluation, determine appropriate goals and inter-
space in order to efficiently complete tasks. Other ventions for the client, and make recommendations
strategies to manage work stress may include having to the client’s case manager.
the client practice appropriate interactions with a
supervisor or work colleagues through role-playing Broker-Advocate Role
and learning stress management and coping skills. In the broker-advocate role, the occupational ther-
Occupational therapists could also develop a client’s apist acts as an advocate for the recipient’s needs.
life skills, such as family planning, budgeting, or job For example, a client in a work apprenticeship pro-
seeking skills, which can include searching classified gram may have difficulty completing work because
ads for potential jobs, and may serve as a job coach, the supervisor refuses to make accommodations for
assessing job sites for potential challenges and mod- a learning disability. The occupational therapist may
ifying environments for competent occupational communicate with the supervisor to assist in devel-
performance. oping proper modifications to the environment to
The role of direct care provider also includes the compensate for the client’s impairment. The occu-
occupational therapist assessing the welfare recipi- pational therapist may also act as a case manager for
ent’s skills, abilities, priorities, interests, and limita- a client. If a client needed to find reliable child-care
tions and developing an occupational profile. Some service in order to participate in the work program,
of the client’s limitations may be due to past expe- the occupational therapist could give the client a list
riences or lack of opportunities, for which occupa- of child-care resources and instruction on how to
tional therapists could identify appropriate training set up an interview with the child-care providers.
needs. However, the occupational therapist may
discover an underlying cause of work difficulty, such Barriers to Occupational Therapy
as a mental health disorder, past or present history
of domestic abuse, or a learning disability. In this
Practice in Welfare to Work
case, the occupational therapist would consider Programs
these underlying client factors and implement inter- One of the most prominent barriers to developing
ventions for successful Welfare to Work transition. occupational therapy in Welfare to Work programs is
the lack of awareness of occupational therapy services
Consultant-Educator Role by Welfare to Work staff persons. Active marketing
The consultant-educator role encompasses both an of the benefits of occupational therapy interventions
indirect model of intervention through consultation to the directors of Welfare to Work programs can in-
and a more direct form of intervention through crease occupational therapy’s visibility and promote
2580_Ch18_257-270 16/07/13 2:56 PM Page 263
awareness. This increased awareness comes when oc- health problems (East, 1999). Occupational thera-
cupational therapy practitioners publish their research, pists focus on positive occupational engagement and
market their services, increase their visibility, and get implement interventions to develop appropriate
involved in government issues and policy. Occupa- skills and coping strategies related to employment
tional therapists may need to offer consultative inter- and socialization. These skills can be used to transi-
ventions because many programs will not be able to tion from reliance on welfare to self-sufficiency
afford a full-time occupational therapist on staff. through work.
Another obstacle to occupational therapists Occupational therapy practitioners can also
working with Welfare to Work programs is funding. provide services to the children of mothers on wel-
Many programs are on a tight state budget, often fare. As Page (2002) found, daughters of welfare-
operating under a federal grant. They may not be dependent parents were three times more likely
able to afford occupational therapy interventions. than other daughters to become welfare recipients
Occupational therapists may need to create ways to themselves. Occupational therapy practitioners
decrease the cost of their services, such as leading can develop intervention programs for children of
groups instead of seeing participants individually, welfare recipients to prepare them for a working
or hiring occupational therapy assistants to provide role in the future and prevent them from becom-
direct intervention. ing welfare dependent themselves. Research has
Finally, it is important to consider the barriers that also demonstrated that children raised in condi-
occupational therapists may have in adjusting to the tions of poverty are at higher risk for health prob-
Welfare to Work setting. First, occupational thera- lems, poor school performance, abuse and neglect,
pists in many settings focus on persons with disabili- emotional distress, and victimization of violent
ties and may need to adjust skills appropriately to crime (Duncan & Gunn, 2000). Many factors
work with individuals who are not labeled “sick” or contribute to these negative outcomes, including
“disabled.” Also, occupational therapists may need to the quality of the child’s home environment, the
increase professional knowledge on the public welfare quality of care children receive outside of the
system since this is a different setting from traditional home, family economic pressure that leads to con-
occupational therapy practice. As with every new flict, parental health and parent-child interactions,
setting, a different set of assessment and intervention and the neighborhoods in which these children
approaches would be used with this population. reside (Duncan & Gunn, 2000). Occupational
therapists may address some of these risk factors
by providing parent education and training, home
The Future of Occupational Therapy and educational enrichment services, and mental
in Welfare to Work Programs health support for parents and children. In addi-
Research has shown that welfare recipients will be tion, occupational therapists may empower recip-
most successful in the transition to work if skill ients to locate and use child-care resources that are
training is specific to their employment and is com- more dependable so that the client can then
bined with a quick employment strategy (Trutko develop occupational routines and habits that
et al., 1999). This is consistent with the occupa- support the worker role.
tional therapy philosophy that clients learn most
effectively in their own natural environments.
Rangarajan and Novak (1999) noted that case man- Ticket to Work Programs
agement services are most effective when they are
individualized, recognizing that each person needs Providing opportunities for employment for persons
a different combination of services. This is consistent with disabilities has long been a priority in U.S.
with occupational therapy’s client-centered and federal policies. Examples of policy initiatives pro-
context-specific approach. moting work include the Americans with Disabili-
Occupational therapists are well trained to ties Act of 1990, vocational rehabilitation services,
work with individuals with hidden barriers, such the Work Incentive Tax Credit, and the Ticket to
as domestic violence, substance abuse, and mental Work Program (Barnow, 2008).
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Background (Hernandez et al., 2007). The implementation and

participation of ENs has greatly altered the ways in
Individuals with disabilities have a much lower em-
which Social Security Administration beneficiaries
ployment rate than individuals without disabilities of
receive vocational rehabilitation services (VRS).
the same age. According to the Bureau of Labor Sta-
Prior to the implementation of ENs, each state had
tistics (BLS) (2009), 29.7% of non-institutionalized
a Disability Determination Service that identified
individuals with disabilities who were classified as
persons who were eligible to receive VRS. The eli-
working age were employed either part-time or full-
gible beneficiaries were then referred to SVRAs and
time as compared to 70.7% of individuals of working
mandated to participate or potentially lose all cur-
age without disabilities. For individuals diagnosed
rent benefits. In addition, SVRAs were the only
with mental disorders, the unemployment rate is
source of VRS for the beneficiaries.
60%–80%, whereas the general population experi-
The implementation of TTW and the partici-
ences a rate of 9% (BLS, 2009; National Alliance on
pation of ENs have provided beneficiaries with an
Mental Illness, 2010). In addition, the poverty rates
alternative to SVRAs and ended the Disability
for individuals with disabilities are twice as high as
Determination Services (Silva, 2007). The TTW
those for individuals without disabilities. Over the
Program allows almost any public or private associ-
past 30 years, legislation and incentives have com-
ation to sign up as an EN, which essentially gives ben-
bined to increase the employment rates of individuals
eficiaries endless options when selecting a provider of
with disabilities. One of the most significant is the
VRS (Silva, 2007).
1999 Ticket to Work and Work Incentives Improve-
Employment networks assist beneficiaries with
ment Act (Hernandez, Cometa, Velcoff, Rosen,
problems affecting employment that are not directly
Schober, & Luna, 2007; Stapleton, O’Day, Livermore,
related to their disabilities. These problems may in-
& Imparato, 2006).
clude little or no work history, low education levels,
The Ticket to Work (TTW) and Work Incen-
older age, English as a second language, and the
tives Improvement Act of 1999 was originally im-
need for child care. In addition, beneficiaries who
plemented in February of 2002 in 13 states, and
participated in tickets to ENs rather than SVRAs
the program was in full operation in all states by
worked more hours, had higher hourly wages, and
September of 2004. The five main focus areas of the
earned more each month (Stapleton, Livermore, &
TTW Program are to provide beneficiaries with:
Gregory, 2007).
1. Access to more rehabilitation service
provider options,
2. Better quality of rehabilitation services,
Implementation Process
3. Paid employment, The TTW Program consists of a process that the
4. Access to services for an extended period of beneficiaries must follow in order to receive services
time in order to maintain paid employment, under the program. Eligible beneficiaries with dis-
and abilities who are receiving social security disability
5. Support from Employment Networks (ENs) insurance (SSDI) payments or supplemental security
and State Vocational Rehabilitation income (SSI) payments receive a ticket by mail that
Agencies (SVRAs) (Ticket to Work and can be redeemed with an EN or SVRA for vocational
Work Incentives Advisory Panel, 2004). rehabilitation services (Capella-McDonnall, 2008;
Hernandez et al., 2007). The ticket is a document
that shows the EN or SVRA that the Commissioner
Employment Networks of the Social Security Administration has agreed to
Employment Networks (ENs) are “public or pri- pay for services provided. Eligibility for this program
vate organizations that provide ticket holders with is based on many factors, including age (18–64 years)
vocational training, job placement, and employ- and the receipt of payments under a Title II or Title
ment support/retention services” (Hernandez et al., XVI disability (Social Security Administration, 2008).
2007, p. 192). Ticket holders are beneficiaries who Once the ticket is submitted, the agency must set
are eligible to participate in the TTW Program goals that focus on the individual’s return to work.
2580_Ch18_257-270 16/07/13 2:56 PM Page 265
Together, the beneficiary and EN or SVRA form an Box 18-4 Benefits for Beneficiaries
Individual Work Plan (IWP) that states the goals
for the beneficiary and the services to be provided by Five major benefits for TTW beneficiaries include:
the EN or SVRA. In addition to the goal of returning • Beneficiaries are no longer subject to continuing
to work, the TTW Program also focuses on decreas- disability reviews
ing barriers to employment (Hernandez et al., 2007). • New, faster reinstatement policy
• Addition of Work Incentives Planning Assistance
(WIPA) providers
Payment Systems • Extension of Medicare coverage from 39 months
to 93 months for beneficiaries who maintain
The TTW Program allows ENs and SVRAs to receive employment and are forced to leave the rolls due
compensation for their services through one of two to SGA
payment methods: Outcomes-Only or Milestones- • Permission of beneficiaries to purchase Medicaid
Outcomes. The Outcomes-Only payment system insurance coverage on an income-based scale
“allows for up to 60 monthly payments, to begin only
after the beneficiary has left the disability program Data from: Thornton & O’Leary (2007). Slow change in the
employment services market: The early years of Ticket to
rolls due to earnings” (Silva, 2007, p. 118). In addi- Work. Journal of Vocational Rehabilitation, 27, 73–83.
tion, providers receive 40% of the nationwide average
monthly SSI or SSDI payments every month that a
beneficiary receives no SSA benefits due to earnings The first benefit is that beneficiaries who are
above the substantial gainful activity (SGA) level actively using their tickets to attain or maintain
(Cook et al., 2006; Silva, 2007). Substantial Gainful employment are no longer subject to continuing
Activity (SGA) level refers to a set earnings level at disability reviews (CDRs). Continuing Disability
which SSA benefits stop entirely once the beneficiary Reviews (CDRs) are reviews that decide if an indi-
has earned more than this set amount for 9 months. vidual is unable to work due to a medical disability
The SGA for 2011 was set at $1,000 per month (Capella-McDonnall, 2008; Thornton & O’Leary,
(Social Security Administration, 2011). 2007). This means that beneficiaries can work with-
Under the Milestones-Outcomes payment sys- out worrying about losing their current disability
tem, providers receive payments for the first, third, status due to a CDR.
seventh, and twelfth month that the beneficiary The second benefit is that the TTW Program set
earnings exceed the SGA level. Once these mile- up a new, faster reinstatement policy for beneficiar-
stones have passed, the providers receive smaller ies. If a beneficiary needs to return to SSI or SSDI
payments for up to the next 60 months (Cook et al., benefits within 5 years of beginning the TTW
2006; Silva, 2007). The smaller payments, referred Program, he or she no longer has to complete a new
to as outcome payments, are set to equal 34% of the application process (Thornton & O’Leary, 2007).
nationwide average monthly SSI or SSDI payments This gives beneficiaries who leave the SSA rolls while
(Silva, 2007). employed the assurance that they can easily regain
benefits if they are unable to continue working.
Benefits and Limitations The third benefit is the addition of Work In-
of the Ticket to Work Program centives Planning Assistance (WIPA) providers.
These providers explain the process of the TTW
Benefits of the TTW Program Program to beneficiaries to ensure that they have
The TTW Program has many positive aspects and a full understanding of the incentives offered. In
implications for individuals with disabilities related addition, groups of advocacy and protection
to attaining and maintaining employment. Many of providers were created to assist beneficiaries with
the benefits that came from the TTW Program stem any negotiations related to the program (Thornton
from the changing of SSI and SSDI programs so & O’Leary, 2007). The beneficiaries can now use
that there are fewer disincentives and more incen- WIPA providers to ensure that beneficiaries are
tives for employment. The five major benefits are knowledgeable about the process and employers
listed in Box 18-4. are treating them fairly.
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The fourth benefit is the extension of Medicare the majority of the tickets assigned were still being
coverage from 39 months to 93 months for benefi- assigned to SVRAs under the traditional payment
ciaries who maintain employment and are forced to system (Hernandez et al., 2007).
leave the SSA rolls due to SGA. In addition, the These low numbers have been attributed to a lack
TTW Program made it simpler for state agencies to of knowledge among beneficiaries, misperceptions,
create programs or services that permit beneficiaries and a lack of understanding of the program as a
to purchase Medicaid insurance coverage on an whole. A study based on beneficiaries’ perceptions
income-based scale. This is beneficial, because ben- of the TTW Program found that “some participants
eficiaries are able to purchase Medicaid insurance thought the program was a job bank because of its
even if they are no longer covered under Medicare name” (Hernandez et al., 2007 p. 197). Many ben-
(Thornton & O’Leary, 2007). This ensures benefi- eficiaries perceived the tickets as junk mail and
ciaries will be able to retain insurance even if their threw them away without opening the package. This
employers do not offer health-care benefits. same study found that beneficiaries also had the mis-
In addition to the changes listed above, other as- perception that any medical benefits would cease
pects and policies of the TTW Program offer bene- once they opted to participate in the program and
fits to the beneficiaries. With the addition of ENs, that it would take a long time to reinstate the ben-
TTW increased the options that beneficiaries have efits if they were to lose their jobs while participating
when choosing a VR provider. The creation of IWPs in the program (Hernandez et al., 2007).
gives the beneficiary a wide array of choices in the In addition to low participation rates from ben-
services that he or she will receive. It also gives the eficiaries, ENs and SVRAs have been skeptical about
beneficiaries control over their individual programs the TTW Program. Several studies have found that
and allows them to choose the options that are most ENs and SVRAs have been reluctant to participate
significant to them. This, and the fact that benefici- in the TTW Program due to:
aries have the ultimate choice of whether or not to
• increased perceived financial risk,
use their tickets, ensures a consumer-driven program
• burdensome paperwork and managerial
(Thornton & O’Leary, 2007).
procedures and costs, and
All of these factors combined contribute to the
• low volume of ticket assignments among
fact that beneficiaries in the TTW Program are three
beneficiaries (O’Day & Revell, 2007; Silva,
times more likely to be employed than other bene-
2007; Thornton & O’Leary, 2007; Wehman
ficiaries are. TTW participants also had higher mean
& Revell, 2006).
wages, higher monthly wages, and worked more
hours per week than beneficiaries who were em- ENs and SVRAs that elect to participate in the
ployed but were not TTW participants (Stapleton TTW Program must use their own money to buy
et al., 2007). Thus, the TTW Program gives states equipment and tools needed for training to ensure
flexibility in the resources that they use to serve the that the beneficiaries are employable (Stapleton et
beneficiaries, and it provides beneficiaries with bet- al., 2006). SVRAs have reported that monies are al-
ter outcomes related to attaining and maintaining ready limited, and this has forced these providers to
employment (Thornton & O’Leary, 2007). place some beneficiaries on waiting lists even though
they could potentially receive reimbursement
Limitations of the TTW Program through the TTW Program (Thornton & O’Leary,
Even though the TTW Program has many benefits 2007). One study found that ENs were spending
for the beneficiaries and the providers, participation two to three times more on program implementa-
rates have been low. While many beneficiaries state tion than they were receiving from the program
that they want to work, few participate in the TTW (Silva, 2007). These factors have contributed to the
Program. As of March 2007, only 2% of benefici- view among ENs and SVRAs that the TTW Pro-
aries who received tickets had assigned them to an gram is more economically burdensome than bene-
EN or SVRA (Thornton & O’Leary, 2007). Specifi- ficial; therefore, these providers have been very
cally, 12 million tickets were mailed by February selective of beneficiaries to whom they provide ser-
2007 but only 159,411 had ever been assigned, and vices (Silva, 2007).
2580_Ch18_257-270 16/07/13 2:56 PM Page 267
In addition to the perceived economic burden of participate, and those who obtained a disabled
the TTW Program, the extended waiting periods status after age 55 were the least likely to participate
and extensive paperwork associated with funding (Capella-McDonnall, 2008; Stapleton et al., 2007).
decrease the likelihood of participation among Younger individuals have less experience in per-
providers. The first major issue is the fact that forming tasks and routines in a set method than
providers must submit beneficiaries’ check stubs as older individuals do; therefore, the younger indi-
a form of documentation. This is extremely difficult viduals are better able to adapt to a change in con-
due to the limited compliance of beneficiaries. The ditions. Occupational therapists could help older
second major managerial burden faced by ENs is the individuals with recently acquired disabilities adapt
fact that they must wait for extended periods, as to different circumstances and engage in occupa-
long as 6 to 8 months, to receive payments under tions within the limitations of their disability. This
this program. Moreover, many ENs complained could potentially lead to greater participation not
that the time they spent waiting to get accurate in- only in the TTW Program but also in other areas
formation from Program Managers was excessive of occupation.
(Silva, 2007). Research has found that eligible beneficiaries are
The low volume of ticket assignments among often uninterested in TTW and unmotivated to
beneficiaries results in a decreased need or demand learn more about the program because they do not
for ENs. In August of 2005, 98,000 tickets had been understand how it is different from previous pro-
assigned to ENs, but only 7,800 of these ENs were grams that emphasized return to work (Hernandez
not SVRAs. As a result, ENs are reluctant to partic- et al., 2007). Occupational therapists working with
ipate in the program (Wehman & Revell, 2006). eligible beneficiaries should be knowledgeable about
Since SVRAs are receiving most of the tickets, and the TTW Program in order to appropriately refer
most SVRAs assign the tickets under the traditional individuals with disabilities who want to begin
payment system, nothing has changed significantly working or return to work. If occupational thera-
for the beneficiaries participating in this program pists build rapport and earn the trust of these bene-
(O’Day & Revell, 2007). ficiaries, they can offer a reliable and trustworthy
source of knowledge about the TTW Program.
Moreover, if occupational therapists become knowl-
Implications for Occupational edgeable and are able to explain the program effec-
Therapy tively to the beneficiaries, they could become an
The implementation of the TTW Program has invaluable member of the TTW process.
several implications for occupational therapists, The overall goal of the TTW Program, to enable
particularly those working in community-based eligible beneficiaries to become employed by reduc-
practice. One study found that beneficiaries who ing barriers and disincentives associated with em-
have limitations in activities of daily living (ADL) ployment, is perfectly compatible with occupational
and instrumental activities of daily living (IADL) therapy philosophy. Occupational therapists can
performance were 50% less likely to participate play a vital role in the community by training
in the TTW program compared with those who beneficiaries to become employable.
displayed independence in these areas (Stapleton
et al., 2007). Occupational therapists could play a
crucial role in helping beneficiaries gain indepen- Conclusion
dence and improve their ADL and IADL perfor-
mance. These occupational therapy interventions Changes in welfare legislation in recent years have
have the potential to increase overall participation led thousands of people in the United States to tran-
in the program. sition from welfare to work. This trend provides a
Another characteristic that was found to greatly new opportunity to explore potential roles for oc-
affect participation in the TTW Program was the cupational therapists and occupational therapy as-
age of disability onset. Beneficiaries who obtained sistants in Welfare to Work and Ticket to Work
a disabled status before age 18 were most likely to programs. Literature suggests many potential reasons
2580_Ch18_257-270 16/07/13 2:56 PM Page 268
why some individuals have difficulty attaining and Work programs have already experienced the ben-
maintaining employment. Barriers to success, such efits of hiring an occupational therapist, particu-
as low skill level, lack of support for work, or larly for the participants considered “hardest to
mental health impairments, have been identified. employ.” Moreover, occupational therapy is one of
Many of the services already provided by Welfare the most utilized services by TTW participants.
to Work and TTW programs fit within the occu- Occupational therapy practitioners have a unique
pational therapy domain. Occupational therapy set of skills that are useful to both populations.
practitioners could provide services in three roles Further research, increased awareness, and
to improve success in the workplace for these demonstration of efficacy are needed in order to
individuals, as direct care provider, consultant- maximize occupational therapy participation in
educator, or broker-advocate. Some Welfare to these programs.
CASE STUDIES
CASE STUDY 18•1 Aundria
Aundria is a single 30-year-old Caucasian female with two children, ages 4 and 6. She has been unem-
ployed since her first child was born, and she receives welfare benefits monthly. Her work history includes
working as a cashier at a convenience store for 6 months and as a cashier at a doughnut shop for 2 weeks.
Aundria also worked as a customer service representative for 1 year before her first child was born. Aundria
completed 10 years of school before quitting due to heavy drug and alcohol use. Aundria is interested in
attaining employment but is concerned about leaving her children when she goes to work.
Aundria enrolled in the Welfare to Work program and as a result was assigned a case manager who
referred her to the occupational therapist on staff. The therapist completed an initial evaluation and
developed an occupational profile on Aundria. As a result of this assessment and profile, the therapist
implemented a plan for Aundria that included:
• therapeutic activities to increase specific job skills (i.e., role-play scenarios);
• connecting Aundria with community resources to assist with child care;
• identifying community resources to help Aundria work toward obtaining her GED;
• guiding Aundria through the process of searching for employment opportunities and applying for
these opportunities; and
• meeting with potential employers to assess potential barriers to employment.
Aundria was compliant with the occupational therapy plan, and she had several positive outcomes as
a result. She was attending GED classes and was planning to graduate in the next 2 months. Moreover,
she had attained employment as a part-time customer service representative at a local retail store.
Aundria found a babysitter with a flexible schedule to attend to her children while she is at work or in
classes. Aundria had the ultimate goals of obtaining her GED, becoming a full-time employee, and
possibly attending college to obtain a degree that would make her eligible for a management position
with her current employer.

1. What are two methods of evaluation that would be appropriate for this case?
2. Identify three appropriate community resources for Aundria to help address her specific needs.
3. What are three specific interventions that can help Aundria meet her goals?
4. Use your available resources (i.e., Internet, journals, etc.) to find evidence to support the interventions
chosen in question #3.
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CASE STUDY 18•2 Austin
Austin is a 23-year-old male who suffered a T12 spinal cord injury 4 years ago as a result of a car crash.
The injury resulted in paraplegia. Austin began receiving SSDI benefits 2 years ago and was classified as an
eligible beneficiary for the Ticket to Work Program. He received his ticket in the mail 2 months ago, but
he had some concerns. Austin had limited work skills and did not understand the program. After contact-
ing an employment network in his area, the coordinator gave him the contact information for an occupa-
tional therapist who was contracted as a consultant for the program. After contacting the consultant,
Austin decided to meet with the therapist. During the consultation session, the occupational therapist:
• explained the TTW Program so that Austin had the knowledge to make informed decisions regarding
his rights and employment opportunities;
• contacted the employment network to discuss potential modifications and adaptations that could be
made to allow Austin to be successful as an employee; and
• initiated the process to offer Austin occupational therapy services to increase work skills and
employment training.
Austin began receiving occupational therapy services, and, after a workplace evaluation, his
prospective employer agreed to make some simple adaptations to allow Austin to be successful on the
job. Austin’s work skills increased dramatically, and he was successfully employed part-time after 4 weeks
of therapy. Austin maintained employment throughout the next 6 weeks of therapy, and he had the
ultimate goal of increasing his employment status to full-time.

1. Create an explanation of the TTW Program that would be appropriate for and understandable by
Austin.
2. Identify three intervention strategies that the occupational therapist can implement to address
Austin’s primary areas of need.
3. Identify three appropriate community resources for Austin to help address his specific needs.
4. Identify five potential modifications that could be made to the workplace to help Austin to be successful.
Learning Activities roles and responsibilities, and discuss how

occupational therapy services might be
1. Use the Internet to find the current welfare par- integrated into this program.
ticipant statistics related to employment for your 4. Write a summary that describes the Ticket to
state. Create a proposal to present to administra- Work Program as if you were describing the
tors at your local Welfare to Work program program to clients. Make sure that the word-
recommending the integration of occupational ing used describes the program effectively
therapy services into the existing program. enough for the clients to make informed
2. Identify one Employment Network (EN) in decisions regarding their potential participa-
your geographic area. Contact the EN and tion. Create an attractive information sheet or
gather information regarding the process brochure about the program.
of placing Ticket to Work participants into
employment positions.
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3. Contact one SVRA in your geographic area.
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Bishaw, A., & Macartney, S. (2010). Poverty: 2008 and 2009.
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Work Program. Write a summary of these acsbr09-1.pdf
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Blank, S. W., & Blum, B. B. (1997). A brief history of work Rangarajan, A. (1996). Taking the first steps: Helping
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mental illness in the Ticket to Work program. Psychiatric whatsnew.htm#1
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Compromise. Community College Week, 15(5), 5–6. Thornton, C., & O’Leary, P. (2007). Slow change in the
Gittleman, M. (1999). Time limits on welfare receipt. employment services market: The early years of Ticket to
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Hamilton, G. (2002, July). Moving people from Welfare to Ticket to Work and Work Incentives Advisory Panel. (2004).
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Hernandez, B., Cometa, M. J., Velcoff, J., Rosen, J., Schober, Trutko, J., Nightingale, D., & Barnow, B. (1999). Post-
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low-skilled women. Washington, DC: Urban Institute. Ithaca, NY.
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SECTION VI
Mental Health
Chapter 19
Community Mental
Health Programs*
Ruth Ramsey, EdD, OTR/L
Recovery is a process, a way of life, an attitude, and a way of approaching the day’s
challenges.... The need is to meet the challenge of the disability and to re-establish a
new and valued sense of integrity and purpose within and beyond the limits of the
disability; the aspiration is to live, work, and love in a community in which one
makes a significant contribution.
—P. E. Deegan (1988)
SECTION VI
Learning Objectives
• Describe the evolution of community-based mental health services.
• Discuss the relevance of various psychological and occupational therapy theories to community mental health
practice.
• Describe different types of community mental health programs.
• Discuss the role of occupational therapists in community-based mental health settings.
• Understand the supports and services needed for successful community integration of persons with serious men-
tal illness.
• Identify and describe major evidence-based mental health community interventions.
*Acknowledgments: Many thanks to Marian Scheinholtz, MS, OT, for her input and feedback on
this chapter.
271
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272 SECTION VI | Mental Health
Key Terms
Assertive Community Treatment (ACT) Reasonable accommodation
Community integration Recovery
Partial hospitalization program Supported education programs
Peer support/peer-run programs Supported employment
Permanent supportive housing WRAP (Wellness Recovery Action Plan)
Psychiatric rehabilitation
Introduction and are homeless, imprisoned, and/or marginalized

by society.
Occupational therapy has had a long and meaning- In the late 1970s, the National Institute of Mental
ful history of providing services for persons with Health introduced Community Support Programs
serious mental illness (SMI) since the inception of (CSPs), which were designed to create a framework
the profession in 1917. Early occupational therapists that would support people with SMI to live success-
promoted habits of healthy living and meaningful fully outside of institutions. Elements of these pro-
occupations for their patients using modalities such grams included 24-hour crisis assistance, psychosocial
as crafts, woodworking, basketry, gardening, and rehabilitation, long-term supportive services, case
work activities. They were influenced by the work management, and employment services. As funding
of social worker and reformer Jane Addams and the for community supports is often inadequate, people
settlement house movement, which sought to teach with SMI have higher rates of homelessness, poverty,
recent immigrants how to adapt to life in a new and incarceration, and lower rates of employment
country through the use of occupations. Their work and stable housing than the general population.
was community-based and would today be consid- Action was taken to reverse these trends in 2001
ered primary prevention. It focused on creating safe, when President George W. Bush signed the Presi-
clean communities; promoting child health and wel- dent’s New Freedom Initiative for Mental Health, a pol-
fare; and providing educational courses on topics icy statement affirming the nation’s commitment
such as nutrition, adult literacy, and sewing at the to help people with mental illness live and work in
settlement houses (Addams, 1910). integrated community settings (U.S. Department of
In the 1960s, as abuses in mental health hospi- Health and Human Services, 2003).
tals were exposed and new psychotropic medica- In California, the passage of Proposition 63,
tions more effectively controlled symptoms of SMI, known as the Mental Health Services Act (MHSA),
mental health advocates and experts demanded in November 2004 provided the first opportunity in
treatment focused on recovery, not maintenance or many years for increased funding, personnel, and
custodial care. During the deinstitutionalization other resources to support new public mental health
movement, state hospitals downsized and many programs and monitor progress toward statewide
patients were discharged to non-existent or ill- mental health service and outcome goals for children,
prepared community treatment services and pro- transition-age youth, adults, older adults, and fami-
grams. The Community Mental Health Act of lies. The Act addresses a broad continuum of preven-
1963 greatly influenced the shift of treatment of tion, early intervention, and service needs, and the
persons with SMI from the hospital to the commu- necessary infrastructure, technology, and training
nity. However, funding for the legislation was elements that effectively support this system. This Act
inadequate and the infrastructure for a system of is funded by a 1% income tax on personal income in
integrated medical, rehabilitative, and supportive excess of $1 million, and so far has generated over
services never materialized (President’s New Free- $900 million dollars (California State Department
dom Commission, 2003). This resulted in a nearly of Mental Health, 2011). Similar legislation enacted
complete failure of deinstitutionalization and led to in other states focused on the need to develop
the present situation where many individuals with community-based programs may create new career
SMI receive little to no community support services opportunities for occupational therapy practitioners.
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Chapter 19 | Community Mental Health Programs 273
More recently, community mental health pro- disorder (U.S. Department of Health and Human
grams focused on rehabilitation and recovery have Services, 2010).
been developed. These programs, staffed by multi- Mental health disorders co-occur at a significant
disciplinary teams of health professionals, provide rate with physical medical conditions such as trau-
individuals with SMI the practical skills they need matic brain injury, rheumatoid arthritis, diabetes,
for working and living in the community and avoid- and chronic pain. Individuals with mental health
ing cycles of re-hospitalizations (Anthony, 1993). disorders have shorter life spans and worse overall
As treatment programs and services moved into the health than non-disabled individuals, possibly due
community, goals shifted to enhancing wellness, pro- to poor self-care, self-injury, lower socioeconomic
moting independent living, facilitating employment, status, and significantly higher rates of smoking than
and community integration. Community integra- the overall population. According to the Parks
tion refers to the ability of persons with disabilities Report, persons with SMI are dying 25 years earlier
to live in housing of their choice and participate in than the general population (Parks, Svendsen,
home, family, school, work, and community settings Singer, Foti, & Mauer, 2006). This increased mor-
with or without supports and services (Bond, Salyers bidity and mortality is due in part to treatable med-
Rollins, Rapp, & Zipple, 2004). ical conditions that are caused by modifiable risk
While some occupational therapists moved with factors such as smoking, obesity, substance abuse,
these programs into the community, the profession and inadequate access to medical care (Hyman,
as a whole did not respond effectively or dynamically 2000; Hyman & Rudorfer, 2000). Many individu-
to this new practice paradigm (Kielhofner, 2009). As als with a primary mental health disorder carry two
a result, the numbers of occupational therapists prac- or more additional diagnoses that may complicate
ticing in mental health fell dramatically. In 2010, their ongoing care and functional capacity.
fewer than 3% of all occupational therapists described The primary focus of this chapter is on adults with
themselves as practicing in primary mental health serious mental illness or serious and persistent mental
settings (American Occupational Therapy Association illness (SPMI). As a result of cognitive limitations
[AOTA], 2010). Most of those are working in insti- associated with these disorders, persons with SMI
tutional settings such as hospitals, providing treat- often have impairments in one or more areas of daily
ment that is based on a medical model of practice living, and need assistance to achieve and maintain
rather than on a recovery model of practice. However, community function. Services for children, youth,
the shift toward strengths-based approaches, such as seniors, and persons with substance abuse disorders
psychiatric rehabilitation, provides an excellent fit are covered elsewhere in the text (see Chapter 20).
with the theoretical knowledge and skills of occupa- The chapter begins with a review of theoretical
tional therapists, provided they are educated and and conceptual models of community-based mental
trained in the use of recovery-based models of practice. health, describes programs and services offered in
In this chapter, the role of occupational therapists community settings, and discusses roles for occupa-
in community-based programs for persons with SMI tional therapists in those settings. A brief discussion
will be described, focusing on how occupational ther- of payment, reimbursement, and advocacy is also
apy practitioners can function within established or presented. The chapter concludes with a case exam-
emerging service systems. Mental disorders addressed ple and a discussion of challenges and opportunities
are those illnesses and disorders, other than substance for occupational therapists working in community
abuse and addictive disorders, defined in the Diag- mental health settings.
nostic and Statistical Manual of Mental Disorders,
Fourth Edition-TR (American Psychiatric Association
[APA], 2000). Epidemiological studies indicate that Theoretical and
approximately one out of four persons in the United
States experiences a mental health disorder in his
Conceptual Models
or her lifetime. Nearly 5% of the U.S. population, or Several theoretical and conceptual models used
11 million adults, live with serious mental illnesses in community-based mental health practice are
such as schizophrenia, major depression, or bipolar presented here, including the stress-vulnerability
2580_Ch19_271-291 16/07/13 2:57 PM Page 274
theoretical model, the psychiatric/psychosocial factors that prevent or diminish the intensity of
rehabilitation models, the recovery model, and an symptom recurrence (Birchwood et al., 1989).
occupation-based approach to the provision of Community-based programs for people with SMI
services to people with SMI in community settings. are designed to teach individuals how to cope with
life stressors, develop increased resilience in the face
of adversity, and reverse the negative cycle of symp-
Stress-Vulnerability Model tom recurrence and re-hospitalization. In this con-
The stress-vulnerability model was originally pro- text, “resilience” is defined as the ability to recover
posed to explain the occurrence of the symptoms from adversity through the development of a posi-
of SMI through an understanding of the interaction tive mind-set and the support of social networks
of environmental “stressors” and personal “vulnera- (Edward, Welch, & Chater, 2009).
bilities” inherent in individuals diagnosed with
this disorder (Birchwood, Hallet, & Preston, 1989;
Neuchterlein, 1987). While originally conceptual-
Psychiatric/Psychosocial
ized to explain schizophrenia, this model is particu- Rehabilitation Models
larly helpful in understanding the exacerbation and Psychiatric/psychosocial rehabilitation models were
remission of symptoms in individuals with mental developed to help persons in recovery gain the skills
health disorders living in a community setting. they need to function at their highest level, despite
Episodes of symptom exacerbation are usually their mental illness, and were based on the rehabilita-
accompanied by a decrease in the individual’s ability tion of persons with physical disabilities. Psychiatric
to perform in functional tasks and occupational Rehabilitation “promotes recovery, full community
roles. According to the stress-vulnerability model, integration, and improved quality of life for persons
these episodes can be prompted by environmental who have been diagnosed with any mental health con-
stress in vulnerable individuals (Neuchterlein, 1987). dition that seriously impairs their ability to lead mean-
Individual vulnerabilities may result from abnormal ingful lives. Psychiatric rehabilitation services are
brain functioning, physical illnesses, or disorders collaborative, person directed, and individualized.
such as addiction or developmental disability. The These services are an essential element of the health
degree of intrinsic vulnerability is inversely related to care and human services spectrum, and should be
the level of stress that provokes acute episodes of evidence-based. They focus on helping individuals de-
mental disorder (Birchwood et al., 1989). velop skills and access resources needed to increase their
As an individual becomes more stressed, the con- capacity to be successful and satisfied in the living, work-
dition is further impacted, resulting in deterioration ing, learning, and social environments of their choice”
of skills, narrowing of environmental parameters (emphasis added) (Anthony & Farkas, 2009, p. 9).
where the individual is able to function, and decrease The focus of psychiatric rehabilitation programs
the ability to perform responsibilities associated with is on the development of community living, employ-
his or her occupational roles. Each relapse directly ment, and social interaction skills. This includes
increases vulnerability and the likelihood of future housing in the least restrictive environment, compet-
relapse and is associated with progression of the illness. itive employment with supports as needed, and any
Subsequent entry into institutions such as hospitals other resources that are required. Individuals receiv-
further isolates the individual and reinforces the life ing services are referred to as clients or consumers,
role of patient, increasing dependency, negativity, and and interventions are individualized, client-centered,
hopelessness. and focused on functional outcomes.
Some believe the stress-vulnerability model con- Psychiatric rehabilitation programs start with an
tains some inherently flawed assumptions about the extensive evaluation of client strengths and weak-
amount of stress that persons with mental illness can nesses determined from detailed history taking and
handle, especially related to employment (Marrone, personal review. Then the individual is assisted in
Gandolfo, Gold, & Hoff, 1998). Rather than avoid setting personal goals for optimal community func-
stressful situations, the focus should be on helping the tion. Community supports are identified, and the
client develop personal and environmental protective need for environmental modification is determined.
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Restoration or development of skills is desired and even though symptoms reoccur, and does not usually
can be set as a goal. If skills cannot be acquired or follow a linear path. According to proponents of the
improved, goals are modified and/or environmental model, recovery has four stages: hope, empowerment,
supports are utilized. Practical techniques are used self-responsibility, and finding a meaningful role in
to directly address vocational, social, housing, and life. As the clients move through these stages, it is the
recreational needs. Every individual is perceived as job of the professional staff to support the process
having the ability and need to be productive through an emphasis on mutual respect, client choice,
through paid or unpaid employment or another and promoting quality of life (Ragins, n.d.b.).
productive social role, such as homemaker or vol- One process that has been widely used to assist
unteer (Anthony & Blanch, 1987). persons recovering from mental illness to manage
This model has much in common with the occu- their own health is the WRAP®, which stands for
pational therapy principles that contributed to its Wellness Recovery Action Plan. A WRAP “is a
development (Munich & Lang, 1993). The similar- structured system for monitoring uncomfortable
ities include a focus on function rather than in- and distressing symptoms and, through planned
trapsychic processes, the belief that health is responses, reducing, modifying or eliminating those
achieved through meaningful occupation, and the symptoms” (Copeland, 2001, p. 129). The focus of
understanding that change can be effected through a WRAP is to help the person develop a wellness
client choice and engaging in activities that promote plan that includes establishing and maintaining
skill building, exploration, education, and commu- healthy routines and habits. Occupational therapists
nity role development (Auerbach & Jeong, 2004). are well trained to support people in recovery by
helping them with this process. The WRAP is
designed to help people with SMI successfully inte-
Recovery Model grate into their communities and receive assistance
Recovery is viewed as a process, and it is recognized as needed. Persons with SMI need supported hous-
that symptoms may linger or last indefinitely and that ing, supported employment, active case/care man-
function may never be fully restored. Recovery is agement, and effective strategies for symptom
“a deeply personal, unique process of changing one’s management in order to achieve meaningful com-
attitudes, values, feelings, goals, skills, and/or roles. It munity integration (Carling, 1995; Provencher,
is a way of living a satisfying, hopeful, and contribut- Gregg, Mead, & Mueser, 2002).
ing life, even with limitations caused by illness”
(Anthony, 1993, p. 528). The key components of a
recovery-oriented program are listed in Box 19-1. Occupation-Based Approach
Ragins (2002) asserts that recovery is a process that Occupational therapists believe that intentional and
can occur without professional intervention, can occur supported engagement in occupation is necessary
for the health and well-being of all people, including
those with SMI (AOTA, 2008). Occupational ther-
Box 19-1 Components of Recovery apy models typically look at the interaction between
the person, the environment, and the occupation
• Individualized and Person-Centered (AOTA, 2008). Occupational therapists seek to
• Self-Direction minimize barriers to engagement through person-
• Hope focused interventions that increase self-awareness
• Responsibility and skill competence, occupation-focused interven-
• Empowerment tions that restructure or modify characteristics of the
• Respect
tasks themselves, and environment-focused inter-
• Peer Support
• Strengths-Based
ventions that modify or adapt the environment
• Non-Linear so the client can experience success. Recovery and
• Holistic psychiatric rehabilitation models of service are highly
compatible with core occupational therapy constructs
Retrieved from www.samhsa.gov/pubs/mhc/MHC_recovery.htm of meaningful occupation and engagement.
2580_Ch19_271-291 16/07/13 2:57 PM Page 276
Community-Based Services can serve in a variety of roles in these programs as

shown in Table 19-1.
for People With Serious
Mental Illness Partial Hospitalization/Intensive
A variety of program models are used when serving Outpatient Programs
people with SMI in community settings. These Partial hospitalization and intensive outpatient pro-
include partial hospitalization programs, intensive grams are forms of ambulatory behavioral health
outpatient programs, home health services, peer care services. These programs typically use a medical
support programs, supported education programs, model approach to the provision of services and are
transitional housing, and programs designed specifi- associated with a hospital or established health care
cally for military veterans. Occupational therapists center. Ambulatory services are designed for people
Table 19-1 Community-Based Services for People with Serious Mental Illness
Setting Model Role of Occupational Therapy
Partial Hospitalization Medical Individual assessment and intervention, group
development and leadership, case management,
community reintegration
Intensive Outpatient Medical Individual assessment and intervention, group
development and leadership, case management,
community reintegration
Home Health Medical Individual assessment and intervention for psychiatrically
homebound individuals
ACT/PACT Programs Social/Recovery WRAP development, skill building, case management,
group interventions as requested
Supported Housing Social/Recovery Helping clients secure and maintain permanent housing
through skill building, case management, assessment of
functional strengths and limitations, implementing of
environmental modifications as needed. Assessment
and development of community living skills, home
management skills, conflict management related to
living with roommates.
Peer Support / Social Social, educational, and/or recreational groups; staff/peer
Peer-Run Programs development and training; individual support and training
as requested by clients
Supported Employment Social/Recovery Assisting clients to identify job skills and interests, help
securing and keeping jobs, job development
Supported Education Social/Recovery Assisting clients to identify educational skills and interests,
help entering the educational setting, referral to additional
resources such as financial aid and tutoring as needed
Veterans Services Medical and/or All of the above, plus coping with re-entry to civilian life,
social symptoms of post-traumatic stress disorder (PTSD),
accessing services through the Veterans Administration
Transitional Housing Social Helping residents develop skills needed for employment,
independent living, money management, parenting.
Working with children and families on developmentally
appropriate play, normalizing routines of daily life.
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of all ages who do not require 24-hour care but do benefit for both physical and mental health disor-
need psychiatric care that is more intense than can ders and may be covered by third-party payers and
be provided by outpatient visits. Services include a managed-care companies. However, psychiatric
comprehensive evaluation of client needs and a home health services are less common, especially
coordinated array of active treatment components. those utilizing occupational therapy services. Psy-
Services are delivered in a manner that is least dis- chiatric home health services are provided to indi-
ruptive to and/or simulates daily functioning, and viduals with acute symptoms, who are unable to
community and family are involved in the treatment leave their homes except for short periods and/or
process. The nature of these services makes them must be accompanied by a caregiver. Diagnoses
cost effective because they are delivered in the least include, but are not limited to, major depressive
restrictive environment, with reliance on client episode, agoraphobia, obsessive-compulsive disorder,
strengths and the utilization of existing resources schizophrenia, and dementia.
and family/community support systems (Associa- Psychiatric nurses are most commonly the first
tion for Ambulatory Behavioral Healthcare, 2010). professionals involved with homebound clients
Partial hospitalization programs are intended diagnosed with mental illnesses. The nurse’s role is
to divert the person from hospitalization or serve as to assess mental status and home safety and to
an intermediary step toward community living after administer and monitor medications. Social work-
an acute inpatient course of treatment. As an alter- ers address legal and financial issues, family dynam-
native to the hospital, the goal is to reduce acute ics, and use of community resources (Earle-Grimes,
symptoms and provide crisis intervention. Persons 1996). The occupational therapy practitioner’s
at this level exhibit severe symptoms that cause sig- primary focus is rehabilitative, evaluating the func-
nificant functional disability, possibly resulting from tional impact of “severe anxiety, immobilizing
an acute illness/episode or the exacerbation of a depression, memory impairments, agoraphobia,
chronic illness. Services are usually provided on a impaired judgment, impaired safety awareness
full-time basis with attendance in a daylong program and paranoid delusions” on function (Azok &
at least four days per week. Occupational therapy is Tomlinson, 1994, p. 1).
specifically listed as a covered service by Medicare in Occupational therapy intervention focuses on
partial hospitalization programs. Occupational ther- how clients manage daily activities, meet social
apy practitioners play a significant role in partial hos- needs, cope with stress, and resolve problems in
pitalization programs due to the extremely short daily living (Earle-Grimes, 1996). The occupa-
lengths of stay in acute care hospital settings and the tional therapy practitioner identifies meaningful
need for intense aftercare services upon discharge. and purposeful activities, assesses cognitive func-
Occupational therapy practitioners in this setting tioning, instructs family and caregivers about cog-
focus on comprehensive and accurate assessment of nitive deficits, and teaches adaptive techniques for
function; preparation for community reintegration; enhancing self-care and home-care management
and teaching of coping, stress management, and com- (Earle-Grimes, 1996). Time management, com-
munity living skills. Intensive outpatient programs pensatory strategies for sensory-motor deficits, and
are designed as a step-down from partial hospitaliza- community re-entry skills may be other areas of
tion programs. Persons at this level may be function- therapeutic intervention.
ing adequately in one or more of their occupational Home health services allows the professional
roles but need more support or therapy than that to observe the actual environment in which con-
offered by traditional outpatient treatment. sumers perform their daily living activities and
make suggestions to improve safety and effective
performance. For example, living space may be
Home Health Services extremely chaotic and disorganized, leading to
Occupational therapy practitioners can provide frustration, lack of motivation, and increased risk
home health services to persons with psychiatric dis- for falls. In addition, home health services provide
orders following the same general guidelines direct access to family and caregivers who can
for services provided to persons with a physical significantly impact consumers’ ability to function.
illness. Home health care is a Medicare covered Therapeutic collaboration with families can result
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in problem solving and adaptation to make the them for competitive employment. Some of these
consumer more independent, and the occupational businesses are partnerships with private individuals
therapy practitioner can model more effective or corporations. Other peer-run programs use a
responses and interventions for the family (Azok social enterprise model to provide competitive
& Tomlinson, 1994). employment apart from agency-sponsored work
programs (Herron, Gioia, & Dohrn, 2009). In this
model, the goal of the business is to generate earned
Peer Support and Peer-Run Programs income while employing people with and without
Peer support or peer-run programs are developed psychiatric disabilities, thus accomplishing its social
and run by clients as drop-in centers or day mission. Employees are permanent, receive benefits,
programs, and were originally modeled after the and are allowed to continue as employees through
Fountain House program. Participants are called difficulties and relapses. One such program offers a
members or consumers, and everyone is expected to daily morning meeting with a brief check-in that
participate fully in the day-to-day operations of the creates an opportunity to offer support to employees
program. Roles for occupational therapists vary in as needed and monitor individuals who may be
these programs and typically focus on vocational displaying early signs of relapse (Herron, Gioia, &
and prevocational services, as well as providing Dohrn, 2009).
opportunities for socialization and peer support Volunteer work can be used for work adjustment
(Kavanagh, 1990; Urbaniak, 1995). or as a final outcome by establishing a productive
In peer-run programs, occupational therapy roles life role for a person living with a mental illness.
range from direct care to administrative. Direct care A successful group volunteer project in one peer-
roles include member evaluation, usually done using run program involved having members take ani-
naturalistic observation and interview techniques; mals to a local nursing home for regular visits and
interaction using modeling and coaching with pet therapy. Members participated in other activi-
members in work units or social programs; clinical ties with the elders, including helping with simple
case management; and the development, monitor- craft activities and holiday events (Tryssenar,
ing, and revision of members’ individual service 1998). Volunteer work is a way for consumers who
plans. Administrative roles include managing the are unable or unwilling to seek paid employment
program, supervising staff in the implementation of to be altruistic and contribute to society. Further,
the service plan, and managing and developing consumers can choose their own hours and type of
vocational programs. The transitional employment activity. Volunteer job matching, education of the
concept that originated with Fountain House con- volunteer agency/workplace, and volunteer job
tinues to be used in many peer-run programs. accommodations improve the effectiveness of place-
Job coaching and other types of supported employment. Volunteer work placements throughout the
ment models are also used to expand the range Clinical Center at the National Institutes of Health
of employment opportunities for consumers. (NIH) have been utilized by occupational therapists
Consumer-run businesses are part of many pro- for many years as work therapy for persons with
grams and allow members to earn salaries of varying affective disorders, schizophrenia, and Alzheimer’s
amounts. Staff facilitates the business by assisting disease (NIH Clinical Center, 2011).
members with community contacts, preparing for
work assignments, and supporting clients to be
successful on the job. Examples of these types of Supported Education Programs
businesses include food carts, gardening services, Supported education programs help individuals
newspaper delivery services, thrift shops, recycling with psychiatric disabilities start, continue, or com-
operations, and courier services. Some businesses are plete post-secondary education (Chandler, 2008).
run solely by consumers, subsidized by grants and The purpose of supported education programs is
contracts with state departments of vocational reha- to address barriers to education, develop strategies
bilitation. Others are run by professional staff that for success, and provide resources and accommoda-
trains and supervise consumers while also preparing tions as needed. Post-secondary education is seen by
2580_Ch19_271-291 16/07/13 2:57 PM Page 279
many as a developmentally appropriate activity that supports veterans who have mental illnesses in
enables individuals to gain access to meaningful developing skills, support systems, and wellness
employment, achieve community integration, and strategies to help improve their quality of life.
fulfill life goals. Supported education programs have Veterans participate in classes aimed at promoting
been developed in community colleges, adult edu- community integration through effective symptom
cation programs, and universities throughout the management, communication, coping, and com-
country. Supports offered in these programs include puter skills (San Francisco VA Medical Center,
educational and vocational exploration, educational 2010). Classes also are held on topics such as anger
assessment, educational goal planning, assistance management, stress management, health and well-
in securing financial aid, stress and time manage- ness, maximizing cognitive function, and social skills.
ment skills, talking through performance problems Clients also participate in community outings
and developing solutions, and collaborating with designed to facilitate community reintegration and
campus and community resources. receive intensive case management services. The VA
Occupational therapists have been involved in has long recognized and valued the contributions
many supported education programs. In one such of occupational therapy in mental health practice.
program, occupational therapy students and faculty
work with clients over a 6-week period, meeting with
them twice weekly to help them with study skills, Transitional Housing
time management skills, reading and writing skills, Persons who are experiencing homelessness often
and basic computer and Internet skills, among other need to spend time living in temporary housing
skills. Participants also are partnered with an educa- or homeless shelters before securing permanent
tional mentor/occupational therapy student who housing. These individuals can benefit from the spe-
helps them find educational and job-training pro- cialized knowledge and skills of occupational thera-
grams, complete application forms for specific pro- pists. Facilitating the development of skills such as
grams, and use compensatory strategies as needed managing money and time, developing leisure skills,
(Gutman, 2008). finding affordable housing, and gaining employ-
ment are all important areas of need. Occupational
therapists lead individual and group sessions on
Veterans Support Services topics such as assertive communication, cognition,
The U.S. Department of Veterans Affairs (USDVA) independent living skills, stress management, and
is becoming a leader in psychosocial rehabilitation wellness (Griner, 2006).
and implementation of evidence-based practices for Many people experiencing homelessness are
persons with SMI (Goldberg & Resnick, 2010). mothers with children. Schultz-Krohn (2004)
Due to the wars in Iraq and Afghanistan, more vet- found that lack of daily routines and decreased
erans than ever before are returning from combat parental authority are often issues for these families.
situations with a variety of psychiatric and mental Occupational therapists can help children through
health needs. In response to this, the Veterans the facilitation of developmentally appropriate play.
Administration has developed programs such as the Teaching appropriate parenting skills such as estab-
Federal Recovery Coordination Program. In these lishing healthy routines, helping with homework,
programs, a Local Recovery Coordinator (LRC) managing challenging behaviors, and supporting
develops a Federal Individualized Recovery Plan healthy eating habits is also an area that occupa-
with input from the service member or veteran’s tional therapists can address in these settings.
multidisciplinary heath care team, the service member Helfrich, Chan, and Sabol (2011) investigated the
or veteran, and his or her family or caregiver. The effectiveness of an occupational therapy life skills
LRC tracks the care, management, and transition intervention program for people with mental illness
of a service member or veteran through recovery, who have been homeless. They found that partici-
rehabilitation, and reintegration. pants in the program made gains in the areas of
The Psychosocial Rehabilitation and Recovery food management, money management, and safe
Center (PRRC) at the San Francisco VA Hospital community participation.
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Evidence-Based Practices “fixed point of responsibility” for the client. Based

on a comprehensive evaluation, services are highly
Research on the relative effectiveness of interventions individualized. The manner of delivery is based on
for people with SMI has been designed to establish the individual client’s current needs and preferences.
evidence in support of these interventions through ACT services are delivered continuously and over
well-designed clinical trials. Although much of the a long term. The occupational therapist contributes
research is focused on medications, research has also to the initial comprehensive evaluation in the areas
been done on the relative effectiveness of interven- of occupational and social functioning and to the
tions used by occupational therapists and other men- ongoing assessment of effectiveness of interventions
tal health professionals. Third-party payers and on impaired areas of functioning. As members of
consumers are increasingly demanding evidence that the team, occupational therapy practitioners provide
interventions work. Several systematic review articles rehabilitation services to clients and rehabilitative
are available that examine the effectiveness of occu- expertise to the team (Scheinholtz, 2001).
pational therapy interventions for employment and The ACT team assists clients in structuring their
education of persons with SMI (Arbesman & Logs- time on a day-to-day basis in normal daily activities,
don, 2011), community re-integration (Gibson, rather than referring them to other day-treatment
D’Amico, Jaffe, & Arbesman, 2011), and activity- programs or sheltered workshops. Clients are helped
based work groups (Bullock & Bannigan, 2011). to establish a daily plan of what needs to be accom-
In the following section, several evidence-based plished and how it is to be done. The ACT team
practices used by occupational therapists and other provides support to varying degrees and at varying
mental health professionals in community-based levels, based on the client’s needs and goals. This
mental health are reviewed, including: assertive includes assistance with employment, personal and
community treatment, supported employment, per- instrumental daily living activities (IADLs), social
manent supportive housing, illness management, participation, and use of leisure time.
and family psychoeducation. Helping clients find and keep a job is central
to the ACT model. All clients are involved in
the vocational rehabilitation process. Employment-
Assertive Community related services are delivered in a community-based
Treatment (ACT) setting, emphasizing real jobs. Once employment is
attained, the team provides support and assistance
Programs for assertive community treatment (PACT), to clients and their employers. Rather than disin-
also known as assertive community treatment centives, entitlements are viewed as financial sup-
(ACT) programs, are comprehensive community- port while the client is preparing for competitive
based intervention models for persons with severe employment. The methods used by the ACT team
mental illness. ACT programs began in 1972 in Madi- in providing rehabilitation services are congruent
son, Wisconsin, during the closing of some state with occupational therapy theory and values and
psychiatric hospital units and provide intensive treat- have been proven to be effective in accomplishing
ment, rehabilitation, and support services to clients client goals. This approach can be applied in many
in their homes, at their jobs, and in social settings of the community settings and programs where
(Allness & Knoedler, 1998). occupational therapy practitioners work (Scheinholtz,
In this approach, a multidisciplinary mental 2001). For examples of how occupational therapists
health team is organized as a type of mobile mental can use PACT methods, see Box 19-2.
health agency. The members function as a transdis- Research on ACT programs has demonstrated
ciplinary team, each fulfilling his or her unique role effectiveness in producing successful outcomes (San-
(e.g., physician, psychiatric nurse, psychologist, tos, Henggeler, Burns, Arana, & Meisler, 1995).
occupational therapist, social worker, counselor, These positive outcomes include:
vocational specialist) and also taking on other roles
to provide seamless, uninterrupted services that are • significantly fewer hospitalizations and
available when and where clients need them. The significantly shorter stays for those who are
team is the primary provider of services and the hospitalized,
2580_Ch19_271-291 16/07/13 2:57 PM Page 281
Box 19-2 Occupational Therapy Use of PACT Methods
• Helping clients establish and maintain normal daily routines. Clients are assisted in scheduling activities of daily
living, employment, and social leisure time activities. The team schedules are developed after the client’s sched-
ule is established, based on the client’s need for assistance to engage in the activities. Clients are then informed
as to when to expect to see team members.
• Lending side-by-side assistance to establish or re-establish adult role activities. Team members actively partici-
pate with the client in planning and carrying out living, working, and social activities. The team member may
initially do the bulk of the activity, but service intensity decreases when routines are established and client
stamina and ability to concentrate are increased. This is especially important with home maintenance, money
management, dealing with social service providers such as public welfare or social security, and structuring
leisure time.
• Modeling (demonstration), rehearsal (practice), coaching (prompts), and feedback. Strategies are provided
individually or in groups with clients and in real-life situations in the community. Feedback from families,
roommates, employers, landlords, and others is regularly scheduled with team members to provide valuable
information to both the client and the team.
• Providing environmental adaptations to meet client needs. Environmental adaptations are based on assessment
of clients and their surroundings to determine when the environment is creating an obstacle to clients’ success-
ful performance of life activities. These adaptations may include limiting the length of holiday visits with family
when a full-day visit is too long, scheduling frequent breaks during work hours for a client with a short attention
span, and helping a client who is experiencing paranoia while riding a bus to work to find housing within
walking distance.
• more time employed and more earnings from Healthcare, 2009). According to Iannelli and Wilding
competitive employment, (2007), work provides a sense of responsibility,
• overall greater time in independent living self-worth, and identity. Work helps participants build
situations, a positive sense of their own future (Leufstadius,
• fewer symptoms, Erlandsson, & Eklund, 2006) and has a stabilizing
• greater satisfaction with life, and effect, reducing the chance of relapse and promoting
• modestly increased social functioning. improved health and well-being (Marrone, Gandolfo,
Gold, & Hoff, 1998).
However, studies indicate that when clients are
Supported employment was initially developed
discharged from the program, their gains are not
to assist persons with developmental disabilities to
always sustained. This indicates a need for ongoing
work in places of competitive employment instead
support services for persons with SMI (Allness &
of sheltered workshops. Currently, supported em-
Knoedler, 1998). Recent funding challenges have
ployment is used extensively in the field of psy-
led to a decrease in the number of ACT programs
chosocial rehabilitation, in peer-run programs, and
nationally. While successful, ACT programs are
in programs providing primarily vocational services
extremely expensive to staff and maintain. Many
(Cook & O’Day, 2006).
communities have significantly altered their pro-
According to Arbesman and Logsdon (2011),
grams from the original model, reduced the number
there is strong evidence of the effectiveness of sup-
of persons eligible for ACT services, or shifted to
ported employment using individual placement and
less-intensive programs.
support (IPS) to result in competitive employment.
These two occupational therapists conducted a sys-
tematic review of 46 articles describing work-related
Supported Employment interventions within the scope of occupational ther-
Persons with mental disorders have identified apy practice. The evidence supported a role for
that work is extremely important in the process of occupational therapists in supported employment
recovery and the ability to live a normal, satisfying life and education programs, providing goal setting, skill
(National Council for Community Behavioral development, and cognitive training. Using IPS
2580_Ch19_271-291 16/07/13 2:57 PM Page 282
models, which focus on first placing a client in a job understand the appropriate types of accommoda-
and then providing needed supports to maintain tions and the standards with which they must comply.
employment, occupational therapists and other Occupational therapy practitioners have worked
mental health professionals can help facilitate positive with employers prior to and since the passage of the
work outcomes for their clients. ADA to address accommodations for persons with
Interventions in supported employment programs physical disabilities. The same opportunity exists to
start with an initial evaluation, after which the person recommend accommodations for persons with psy-
is matched to a job. The job coach works with the chiatric disabilities. Advocacy is an integral part of
employer to train the individual to perform the job this work, initially to educate employers about the
and makes recommendations for appropriate accom- causes and treatment of mental illness, then to help
modations. The job coach or agency provides edu- dispel the stigma of mental illness, and finally to
cation to employers about mental illness, focusing support employee success.
on the abilities and reliability of workers. The job Some specific accommodations include structur-
coach is available to help the employee with difficul- ing the work environment to eliminate distraction;
ties encountered on the job or by supporting daily providing frequent supervision, flexible work hours,
living functions. The job coach works in conjunction and breaks; job coaching; and time off for doctor or
with a case manager to assist the consumer with therapy appointments. Assessing the work environ-
recurring symptoms, medication changes, or other ment prior to the client beginning work may be
issues that might interfere with successful job per- helpful to determine whether the job is a good
formance. Occupational therapy practitioners can match and if accommodations can be made. For
play a role in supported employment during the accommodations to occur, the employee must dis-
initial evaluation of the consumer, during the job close that he or she has a psychiatric disability some-
matching process, and in the development of neces- time after being hired. Occupational therapists can
sary accommodations. Because salaries for job coaches help consumers determine the positive and negative
are generally modest, this might be an appropriate aspects of disclosure and educate them regarding
role for an occupational therapy assistant who would their rights under the ADA.
be supervised by an occupational therapist. The
evidence-based toolkit on supported employment
available from the Substance Abuse and Mental Permanent Supportive Housing
Health Services Administration (SAMHSA) is an When people with SMI were discharged from large
excellent resource (SAMHSA, 2010a). institutional settings in the 1960s, they were often
placed in board-and-care facilities. Often these
Reasonable Accommodations facilities were located in economically disadvan-
The Americans with Disabilities Act (ADA) (1990) taged and/or undesirable urban centers, creating
guarantees workers the right to reasonable accom- new problems as the clients were victimized or
modations on the job, provided they can perform shunned by society. In time, it was recognized that
its essential functions. Essential job functions are a better long-term solution was to help the clients
those tasks that an individual who holds the job develop independent living skills, place them into
would be required to perform on a regular basis. subsidized housing units, and provide ongoing
Reasonable accommodations are modifications or support as needed to help them remain housed.
adjustments made in a system to enable a person Because people with psychiatric disabilities are
with a disability to successfully perform the duties often unable to work full-time, their primary
required of a specific job (U.S. Office of Personnel source of income is supplemental security income
Management, n.d.). (SSI). This low level of income typically makes
The business community is required to comply it impossible for them to afford market rate hous-
with the ADA for workers with physical and psy- ing. In response to this situation, a variety of fed-
chiatric impairments. While the interpretation of erally funded programs have been created,
the law for persons with psychiatric impairments including public housing units, Section 8 housing
is extensive, employers still need assistance to vouchers that enable people to obtain private rental
2580_Ch19_271-291 16/07/13 2:57 PM Page 283
apartments, and housing units maintained by of client-centered and intensive training; and
community programs serving persons with SMI inconclusive support for providing interventions
(SAMHSA, 2005). in natural contexts. Their findings can be used
Permanent supportive housing refers to a pri- to guide occupational therapists in developing
vate and secure place for persons with mental disor- interventions and also indicate a need for more
ders to live, with the same rights and responsibilities research in this area.
as other tenants, and access to support services
as needed (SAMHSA, 2010b). Evidence has shown
the overwhelming majority of people with SMI Illness Management and Recovery
desire to and are able to live independently in their Illness Management and Recovery (IMR) is a cur-
own homes, without 24-hour supervision (SAMHSA, riculum that a mental health professional, such as
2005). However, some supports have been shown an occupational therapist, can implement to help
to increase success in community housing programs. people develop personal strategies for managing
These include assistance in learning household man- their mental illness and moving forward with their
agement skills such as budgeting, meal preparation, recovery (SAMHSA, 2010c). IMR practitioners use
and basic home care. Case managers also assist with a combination of motivational, educational, and
resolving conflicts that may arise between roommates cognitive-behavioral techniques. IMR includes
and can be helpful in teaching and modeling education about mental illness but emphasizes help-
effective communication skills. ing people set and pursue personal goals, select
Occupational therapists in these settings may pro- strategies, and implement them in their everyday
vide care management or case management services. lives. This action-oriented approach to recovery is a
A care manager is described as “a broker of service, good fit with the knowledge, skills, and philosophy
skill instructor, conflict mediator, and cheerleader” of occupational therapy practitioners.
for the person with mental illness (Gray, 2010, The IMR program can be provided in an indi-
p. 293). Occupational therapists have a strong skill vidual or group format. IMR participants are asked
set to bring to care management work, including to do home practice/homework, and families and
an understanding of both person and environment other supportive people are included if desired. The
issues that may be impacting occupational perfor- following subjects are typically covered in educa-
mance, the ability to administer functional assess- tional handouts: recovery strategies, practical facts
ments to determine the strengths and needs of the about mental illness, the stress vulnerability model
client, and the ability to analyze and grade tasks. and treatment strategies, building social support,
SAMHSA (2010b) has published an evidence- reducing relapses, using medication effectively, cop-
based toolkit for the development of permanent ing with stress, coping with problems and symp-
supportive housing for people with serious mental toms, and getting their needs met in the mental
illness. This resource is intended to serve as a guide health system (SAMHSA, 2010c).
for consumers, policy makers, practitioners, fun-
ders, and government agencies in developing and
implementing supportive housing programs in Family Support and Education
their communities. Included is an extensive bibli- Families of people with mental illness often strug-
ography of research articles that identify character- gle with a variety of issues. They need help to cope
istics and outcomes of effective supportive housing with their complex emotional responses to their
programs. family member, which often include sadness,
Gibson, D’Amico, Jaffe, and Arbesman (2011) anger, loss, frustration, embarrassment, shame,
have conducted a systematic review of research and bewilderment. Urish and Jacobs (2011)
on occupational therapy interventions for recovery suggest that occupational therapists can offer sup-
in community reintegration and normative life port to families of people with SMI in a variety
roles. They found moderate support for the effec- of ways, including leading family support groups
tiveness of life skills, IADL, and neurocognitive and offering family psychoeducation groups on
training; limited but positive evidence in support topics such as symptom management, medication
2580_Ch19_271-291 16/07/13 2:57 PM Page 284
management, and living with a mentally ill family in a community mental health setting, defining the
member. It is important to help family members relationship with clients as a partnership that in-
understand the reality of mental illness, the need volves accompanying the client on the recovery
to support their family member to stay on pre- journey. Teaching skills, modifying the environ-
scribed medications, and the fact that their men- ment, and adapting tasks to the skill level of the
tally ill family member can still achieve many client are examples of ways in which occupational
standard and desired life goals, including inde- therapists can be effective. Clients with physical
pendent living, meaningful adult relationships, disabilities or conditions are also referred to the
and meaningful employment. occupational therapist as the team member with the
SAMHSA (2010d) offers a free evidence-based most expertise in that area.
toolkit on family psychoeducation, available on its As Wollenberg described, occupational therapists
Web site. Occupational therapists can also help plan can be important members of the team in commu-
and implement programs that bring together clients nity mental health settings. Typically, occupational
and families for enjoyable activities such as picnics, therapists work with other mental health profession-
hikes, and community outings. als, including counselors, social workers, psycholo-
gists, and nurses. Psychiatrists often work on a
consultation basis with community mental health
Occupational Therapy in programs, and many teams also include unlicensed
paraprofessionals who serve in case management or
Community Mental Health community support positions.
Settings The occupational therapy practitioner may
work as a direct general service provider or serve in
For occupational therapists to be successful in a variety of specialized roles (Table 19-2). The
community mental health settings, they should occupational therapist may also provide evaluation
embrace the basic values of recovery and wellness; and intervention with consumers, serve as a pro-
be skilled in functional assessment, intervention gram or project manager, be a consultant to a pro-
planning, and implementing group and individual gram or system of care, and train and supervise
interventions that are designed to remediate areas paraprofessional and professional staff. While some
of functional deficit; have or develop case manage- occupational therapists have expressed a preference
ment skills; be aware of neurocognitive and senso- for more of a rehabilitation specialist role on
rimotor impairments that often affect people with the team (Lloyd, King, & Bassett, 2002), most
SMI; and be able to design and offer a variety of value working as part of an interdisciplinary team
groups and programs that help people with SMI (Eklund & Rahm, 2000).
improve and maintain basic health, such as nutri-
tion, smoking cessation, exercise, and sleep hygiene
(Pitts & Ingersoll, 2009). Consumers of mental Occupational Therapy
health services also want care providers who are Evaluation and Interventions
committed, hold positive attitudes toward clients, Evaluation
work well in teams, adjust well to change, and are
A variety of standardized functional assessments are
able to act independently (Aubry, Flynn, Gerber,
used by occupational therapists when working with
& Dostaler, 2005) as well as interact positively
clients with SMI in community settings (Brown,
with family members.
2011). ADL and IADL evaluations include the:
• Katz Index of Independence in Activities of
Role of Occupational Therapists Daily Living Scale (Katz, 1983),
Limited research has been conducted on the role of • Independent Living Skills Survey (Wallace,
occupational therapists in community mental Liberman, Tauber, & Wallace, 2000),
health settings. Wollenberg (2001) described a • Kohlman Evaluation of Daily Living Skills
process of creating an occupational therapy program (Thompson, 1992),
2580_Ch19_271-291 16/07/13 2:57 PM Page 285
Table 19-2 Occupational Therapy Roles in Community Mental Health

Roles Functions
Direct Service Provider • Functional evaluation of client
• Home and job site analysis to determine environmental supports and
barriers to success
• Work with client, employer, and housing staff to facilitate function and
optimal occupational engagement
Employment Specialist • Work with clients to identify vocational interests, abilities, and limitations
• Develop employment plan and supports
• Seek employment opportunities for clients
• Consult with employers on job site modifications for people with
serious mental illness
Consultant • Conduct needs assessments of individuals and/or systems of care
• Develop and deliver services for individual
• Plan and implement program changes
• Train staff, develop resource materials
Supervisor • Train and evaluate multidisciplinary staff and students
• Develop and review treatment plans and progress updates
• Solve problems as needed
• Contribute to budget and program development
Program Director • Provide day-to-day program direction
• Assume overall budget responsibility
• Supervise midlevel staff
• Participate in grant development
• Participate in program development
• Perform public relations
Case Manager • Coordinate client service delivery
• Collaborate with community providers
• Manage entitlements and finances as needed
• Interact with families and significant others regarding client’s services
Community Integration Specialist • Work with clients to achieve independent living
• Develop skills for successful community integration
• Community mobility; management of daily living; identification
and utilization of community resources for leisure, education, social
engagement, and employment
• Milwaukee Evaluation of Daily Living Skills It is beyond the scope of this book to fully explore
(Leonardelli, 1988), and all these assessments; the reader is referred to the
• Test of Grocery Shopping Skills (Hamera, references for a full explanation of their uses.
Brown, Rempfer, & Davis, 2002; Hamera &
Brown, 2000). Interventions
Work assessments include the Occupational Per- Because the focus of community-based programs for
formance History Interview (Kielhofner et al., people with SMI is on work, housing, and commu-
2004), the Work Environment Impact Scale nity integration, occupational therapy interventions
(Moore-Corner, Kielhofner, & Olsen, 1998), and should also be focused in these areas. The use of
the Occupational Self-Assessment (Baron, Kiel- WRAPs is common, so occupational therapists
hofner, Iyenger, Goldhammer, & Wolenski, 2002). should be knowledgeable about how to develop
2580_Ch19_271-291 16/07/13 2:57 PM Page 286
these plans in collaboration with their clients. community mental health settings are listed in
Clients often need help learning or relearning Table 19-3.
basic IADLs to maintain independent living, in-
cluding meal preparation, household manage-
ment, budgeting, and clothing care. Clients who Funding for Community-
wish to work may need assistance in seeking and
maintaining employment, managing psychiatric
Based Mental Health
symptoms at work, developing positive working Several sources of funding for community mental
relationships, and managing workplace stress. health programs incorporating occupational therapy
With an increased focus on health and wellness services are available. These include the federal enti-
for people with SMI, occupational therapists can tlements, Medicare and Medicaid, state funds for
help clients with nutrition, exercise, weight loss, persons with SMI, private insurance, grant funding,
symptom management, smoking cessation, sleep and state block grants. Partial hospitalization pro-
hygiene, and avoidance of drugs and alcohol grams (PHPs) and intensive outpatient programs are
(Swarbrick, 2011). based in hospitals as outpatient services or in com-
Clients living in the community also desire to munity mental health programs. Medicare and pri-
have meaningful leisure occupations and social vate insurers pay for these programs. Occupational
relationships, so occupational therapists can be of therapy is specified as an included, but not mandated,
assistance in these areas. One important difference service in the Medicare partial hospitalization benefit.
between community-based and hospital-based oc- In 2000, PHPs came under a prospective payment
cupational therapy interventions is that community- system. Unlike the prospective payment system for
based programs typically use more individual skilled nursing facilities, there are no categories that
interventions in naturalistic settings rather than account for patient severity. The daily rate is an
group interventions. For example, rather than average of all patients, and occupational therapy is
having a cooking group on an in-patient unit, a bundled into the daily rate for PHPs (Centers for
community-based occupational therapy practitioner Medicare and Medicaid Services, 2012).
might help a client plan a week’s work of menus, Community rehabilitation programs usually
develop a shopping list, take public transportation receive funds from a variety of sources. These can
to the grocery store, make healthy choices at the include Medicaid, state block grants, and other grant
store, and safely transport and store the groceries. funding. In addition, some receive funds from
Teaching basic cooking and kitchen safety skills departments of vocational rehabilitation if they have
might be the focus of a second visit. Examples of an approved work adjustment and placement pro-
potential occupational therapy interventions in gram. Medicaid definitions as to what constitutes
Table 19-3 Occupational Therapy Interventions in Community Mental Health

Intervention Examples
Activities of daily living Grooming, bathing, oral hygiene, medication management
Instrumental activities of daily living Money management, meal preparation, community mobility,
household management
Work-related skill building Seeking and maintaining employment, managing workplace stress,
work relationships
Social interaction/leisure Leisure time management, community resources, relationship skill
building
Health and wellness Diet, smoking cessation, exercise, weight loss, symptom
management, stress management, sleep management
Environmental modification Workplace adjustments, supported housing
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required and optional benefits vary from state to occupational therapy. The Mental Health Parity
state. For example, in California, occupational ther- and Addiction Equity Act of 2008 is a federal law
apists are eligible providers under the Medicaid that provides participants who already have bene-
Mental Health Rehabilitation option and can profits under mental health and substance use disorder
vide case management and mental health rehabilita- coverage parity with benefits limitations under
tion services (Pitts & Ingersoll, 2009). Many states their medical/surgical coverage (U.S. Department
contract with managed-care companies to manage of Labor, n.d.). Through demonstrating the cost
the Medicaid benefit program, and mental health effectiveness of occupational therapy interventions,
benefits may be “carved out” and managed by be- occupational therapists may be able to secure a
havioral health care companies. Third-party payers place among other mental health professionals as
may cover occupational therapy services for “parity” mandated service providers.
diagnoses, most often through the beneficiary’s med-
ical benefit rather than his or her mental health ben-
efit. Occupational therapists have had some success Conclusion
in obtaining reimbursement for outpatient services
provided to persons with psychiatric disorders (Pitts People with SMI want and deserve to live in commu-
& Ingersoll, 2009). Veterans Administration pro- nities of their choice and be provided with the neces-
grams are funded through the federal government. sary supports for them to flourish. Community-based
Each state receives about 10% of its state men- programs for people with psychiatric disabilities focus
tal health budget from the federal government on recovery; rehabilitation; wellness; and the provi-
through the SAMHSA. A requirement of this sion of jobs, housing, and support. Occupational
funding is that each state has a mental health therapists use their understanding about the value of
advisory planning council that provides input on meaningful occupation and skills in functional assess-
how the money is spent. The membership of ment, planning, and intervention to help persons in
these councils must be composed of at least 50% their process of recovery and rehabilitation. Occupa-
consumers and their families, with the remainder tional therapists also serve as team members, focusing
consisting of other stakeholders. Occupational on promoting overall physical health and wellness in
therapy practitioners can volunteer to serve on persons with SMI, in a variety of roles, including case
these planning councils, and advocate for the manager, specialist, and program director. With the
inclusion of occupational therapy in community advent of health care reform, more opportunities than
programs for persons with SMI. ever before are available for occupational therapists
Recent federal and state health care reform legis- to make meaningful contributions to the lives of
lation creates challenges and opportunities for people with serious mental illness.
CASE STUDIES
CASE STUDY 19•1 Antonio
Contributed by Karen Leigh, MS, OTR/L, San Francisco Veterans Administration Homeless Mentally Ill
Outreach Program
Antonio is a 63-year-old male who emigrated from Nicaragua at the age of 11 with both parents and an
older brother. He reports he developed symptoms of schizophrenia following an automobile accident
shortly after high school graduation, and that his symptoms were exacerbated by his service in the U.S.
Navy and worsened following a breakup with his girlfriend. Antonio had been hospitalized five times
prior to seeking treatment at the Veterans Administration (VA) hospital and was primarily living on
the street, in shelters, or in single-room-occupancy hotels. He self-medicated with cocaine, ampheta-
mines, marijuana, and alcohol, and initially presented to the VA for substance abuse treatment in 2001.
Following an acute hospitalization and a 3-year stay in a locked facility, Antonio has been living in a
Continued
2580_Ch19_271-291 16/07/13 2:57 PM Page 288
CASE STUDY 19•1 Antonio cont’d
board-and-care home and receiving intensive case management services at an out patient VA clinic for
the past 2 years, where he has remained abstinent from all substances and regularly attends AA meetings.
Antonio began attending an outpatient Psychosocial Rehabilitation program where he completed an
initial evaluation with the occupational therapist. The evaluation revealed that Antonio’s most important
goal was “to shave more often,” and together he and the occupational therapist determined this would be
every other day. He was currently shaving about once a week and typically only when reminded by
board-and-care staff. Further evaluation using the Allen Cognitive Level Assessment demonstrated that
Antonio’s cognitive level of functioning was consistent with the need for striking visual cues to initiate
ADLs. An evaluation of his living environment revealed that some shaving supplies were kept in a closed
cabinet in his room and others were kept locked up by the board-and-care operator and provided upon
request.
Antonio’s intervention plan included the purchase of an electric razor that he would be allowed to
keep in his room. The occupational therapist and client reviewed use and proper care of the razor, and
together determined a place near the sink where the razor would be visible to maximize the likelihood of
its use. A can of shaving cream was also placed with the razor. The occupational therapist educated the
board-and-care operator on the need for these items to be left where they had been placed in order to
maximize their use.

1. What other types of functional difficulty might Antonio be having?
2. What other interventions might the occupational therapist provide?
3. Which community supports might the occupational therapist refer Antonio to?
Learning Activities www.ottp.org: Occupational Therapy

Training Program
1. Visit one of the following Web sites to obtain 2. Identify an occupational therapist in your
more information about community-based community who works with people with
mental health services: SMI. Interview this individual and explore
www.iapsrs.org: International Associ- what he or she does in the course of a typical
ation of Psychosocial workday.
Rehabilitation 3. Read a first-person account of a person recov-
www.nami.org: National Association ering from a SMI. Consider the challenges
for Mental Illness he or she experiences on a daily basis while
www.mha.org: National Mental engaging in valued occupations. What gives
Health Association meaning and purpose to this person’s life?
www.samhsa.org: Substance Abuse and How could you as an occupational therapist
Mental Health engage with this person in his or her recovery
Association process?
www.potac.org: Psychiatric Occupa-
tional Therapy
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Chapter 20
Community-Based Approaches
for Substance Use Disorders
Marjorie E. Scaffa, PhD, OTR/L, FAOTA, Lauren Ashley Riels, MS, OTR/L, Penelope A.
Moyers, EdD, OTR, FAOTA, and Virginia C. Stoffel, PhD, OT, BCMH, FAOTA
If you treat an individual as he is, he will stay as he is, but if you treat him as if he were
what he ought to be and could be, he will become what he ought to be and could be.
—Johann Wolfgang von Goethe
Learning Objectives
• Describe the impact of substance use disorders on the community.
• Discuss the effects of substance use disorders on occupational behavior.
• Describe a variety of types of community-based services for substance use disorders.
• Identify and describe evidence-based interventions for substance abuse treatment.
• Discuss the role of occupational therapy in community-based programs for substance use disorders.
Key Terms
Aftercare program Intensive outpatient program (IOP)
Behavioral rehearsal Motivational enhancement therapy (MET)
Brief intervention Motivational interviewing
CAGE Mutual support programs
Crisis intervention Substance use disorder
Employee assistance program (EAP)
FRAMES
Introduction and cardiovascular systems also may be affected

(Mertens, Weisner, Ray, Fireman, & Walsh, 2005).
Substance abuse is an escalating problem in the High rates of comorbidity of substance abuse with
United States that often results in increased risk of other psychiatric diagnoses complicate and increase
dysfunction at work, in marriages, in families, and the cost of treating schizophrenia and other mental
in the health of the user (O’Day, 2009). In addition disorders (Ziedonis, Smelson, Rosenthal, Batki,
to being a mental health problem, substance use et al., 2005).
disorders are a major factor in many medical, public As a community public health problem, substance
health, social, and safety issues within a commu- use disorders have been linked to AIDS, tuberculosis,
nity. As a medical problem, substance use, includ- and neonatal defects. Community social problems,
ing alcohol use, contributes to diseases of the such as unemployment and homelessness, are also
liver, pancreas, and digestive tract. Depending strongly associated with substance use disorders.
on the drug of choice, the respiratory, nervous, In terms of safety issues within a community, the
292
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Chapter 20 | Community-Based Approaches for Substance Use Disorders 293
relationships of substance use with crime, industrial similar across the various drug classes. However,
accidents, burns, spinal cord injury, and traumatic saliency of a symptom may vary, and some symp-
brain injury are well established (Levy, Mallonee, toms are not present in a given drug class. Some
Miller, Smith, Spicer, Romano, & Fisher, 2004; symptoms are more or less pronounced, depending
Weisner, 1995). on the drug involved. For example, withdrawal
The impact of substance use on the family cannot symptoms typically are not present for hallucino-
be underestimated. Persons with substance abuse gen dependence.
or dependence typically have extensive marital and The chief feature of substance use disorder is
family problems. Children of parents with substance continued use of a substance despite significant, per-
dependence are considered to be at high risk for sistent, and adverse substance-related consequences
experiencing a variety of difficulties, including cog- that usually results in tolerance, withdrawal, and
nitive, emotional, social, and academic problems. The compulsive drug-taking behavior (APA, 2013).
home environments for the children are characterized Compulsive substance use behavior typically in-
by more marital conflict, parent-child conflict, cludes the following:
and family violence when compared to the environ-
• Drinking or using the substance for a longer
ments of children with parents who do not use
time period or in greater quantity than
substances. In addition, negative consequences, such
originally planned,
as separation and divorce, are much more common
• Unsuccessful attempts to decrease or
in marriages containing an addicted partner in
discontinue use of the substance,
comparison with couples in the general population
• Spending an inordinate amount of time
(Saatcioglu, Erim, & Cakmak, 2006).
seeking, using, and recovering from
In this chapter, substance use terms are defined,
substance use, and
the influence of substance use disorders on occupa-
• Giving up or reducing important social,
tional performance is discussed, community-based
occupational, and recreational activities
treatment programs are described, evidence-based
(APA, 2013).
interventions that can be used by occupational
therapists are highlighted, and the relationship Substance use disorder is characterized by failure
between these interventions and the Stages of Change to fulfill major role obligations at work, school, or
model are illustrated. In addition, the potential con- home; repeated legal troubles related to substance
tributions of occupational therapy to these commu- use; and recurrent social and interpersonal problems
nity programs to better support recovery behaviors as a result of intoxication (APA, 2013). Other
are reviewed. primary features are tolerance, withdrawal, and a
pattern of compulsive use. Occupational therapists
are in an excellent position to evaluate occupational
Substance Use Terminology roles and to detect the impact that substance
abuse or dependence may have on an individual’s
The Diagnostic and Statistical Manual of Mental performance.
Disorders, Fifth Edition (DSM V) (American Psychiatric
Association [APA], 2013) defines various substance
use disorders according to groups of substances of Substance Use Disorders
10 classes of drugs. These include:
and Occupation
1. alcohol 6. inhalants
Occupations are the day-to-day activities or goal-
2. stimulants 7. tobacco
directed pursuits that typically extend over time, have
3. caffeine 8. opioids
meaning to the performer, and involve multiple tasks
4. cannabis 9. sedatives, and
(Christiansen, Clark, Kielhofner, & Rogers, 1995).
5. hallucinogens 10. other (or unknown)
Usually occupations are considered to be health
Substance abuse and dependence disorders can enhancing, positively valued by the culture, and nec-
be applied to nearly every class of substance. There- essary for daily survival. However, occupations that
fore, the characteristics of these two diagnoses are lead to negative consequences or are considered to be
2580_Ch20_292-308 17/07/13 4:18 PM Page 294
deviant from socially acceptable norms need to be from normal occupations and becomes deprived of
taken into account. Substance use can be thought of their healthy effects. Further engagement in non-
as an occupation because of its many associated tasks using occupations becomes devoid of usual mean-
and activities, which may include: ings, meaningful only to the extent that these
occupations serve as barriers or facilitators to drink-
• Raising money for the drugs
ing or using drugs, thus perpetuating the negative
• Purchasing or making the deal to obtain the
cycle of occupational alienation and deprivation.
drug supply
Occupational therapists should consider includ-
• Protecting the supply from others, or hiding
ing substance use questions in the initial interview
drug use
as a routine component of the development of
• Removing barriers to using, such as ignoring
an occupational profile regardless of the practice
family members who object to the person’s
setting. When this screening indicates a possible
behavior
alcohol or other drug use problem, the occupa-
• Creating situations for using
tional therapist attempts to ascertain the client’s
• Seeking persons with whom to use
readiness to change and uses motivational strate-
• Spending time using
gies to encourage the client to seek additional
• Recovering from the effects of using
evaluation and treatment as necessary (Stoffel &
• Resuming the drug use process all over again
Moyers, 2004). In addition, the occupational ther-
(Moyers, 1997).
apy evaluation can determine whether the person’s
As performance in occupations other than drink- activities of daily living, work, leisure, and other
ing or using substances progressively deteriorates, productive activities have been affected by substance
the individual becomes more and more alienated use (Fig. 20.1). The occupational therapist thus
Occupational Performance Performance Skills Performance Context
Are ADLs/IADLs affected? Cognitive Temporal
• Promiscuity • Rigid thinking • Temporary reaction to a major

• Poor eating habits • Uses familiar strategies life change?
• Drunk driving even though proven • Rite of passage in a young adult?
• Unsafe sexual practices ineffective • Experimental use in adolescence?
• Blackouts/memory lapses
Are work/education
Sensory, Motor and Praxis Physical
activities affected?
• Late for work/school • Peripheral neuropathy • Physical cues for drinking/using,

• Unexcused absences/ • Overall lack of such as places, objects, sounds,
too many sick days conditioning/fitness smells
• Argumentative behavior
• Not meeting deadlines
Are leisure activities Communication, Social, and

Social/Cultural
affected? Emotional Regulation
• Choosing only activities • Difficulty establishing and • Friends who drink/use

involving drinking/using maintaining close/intimate • Prevalence of alcohol at social/
• No time for leisure relationships recreational/sports events
• Uninhibited dangerous • Aggressive and hostile • Holiday celebrations
behavior during leisure • Copes with stress by • Family rituals
pursuits (boating, skiing, increasing use of
hunting while under the substances
influence)
Fig. 20•1 Analyzing the Impact of Substance Abuse on Occupational Performance and
Participation.
2580_Ch20_292-308 17/07/13 4:18 PM Page 295
evaluates the impact of substance use on occupa- Box 20-1 Substance Abuse and Addiction
tional performance and occupational participation. Service Delivery Sites
More specifically, impairments of a sensorimotor,
cognitive, or psychosocial/psychological nature Institutions
attributed to a substance use disorder are identified. • Addictions and dual-diagnoses inpatient units
• Detoxification units
• Partial hospitalization programs
Community-Based • Prisons
Outpatient
Substance Abuse Services • Intensive outpatient programs
Community-based substance abuse services include • Aftercare programs
outpatient and partial hospitalization programs, • Outpatient office visits
dual-diagnoses programs, and aftercare programs. Community
These programs equip the person with the skills • Community mental health centers
and strategies to stop drinking and using, and • Schools, colleges, universities
develop the behavioral flexibility necessary for • Halfway houses
maintaining abstinence. People who seek formal • Employee assistance programs
addiction intervention programs have often tried • Wellness centers and programs
other methods (e.g., personal contracting to reduce • Homeless shelters
• Community centers
or stop their alcohol/drug use or seeking support
• Sheltered workshops
through church or self-help groups) but have been • Battered women shelters
unsuccessful. The most effective intervention pro- • Mobile crisis units/crisis intervention programs
grams include a full continuum of services, which • Public health departments
typically include: programs for groups, individuals, • Church ministry programs
and families, and support and self-help groups.
Substance abuse and addiction intervention ser-
vices can occur in a variety of medical and com-
munity settings (Box 20-1). Crisis intervention, change as was once believed. Through the use of the
intensive outpatient, aftercare, and employee assis- Stages of Change model, “motivation is now under-
tance programs will be discussed here. stood to be the result of an interaction between the
drinker [or drug user] and those around him or her.
This means that there are things a therapist can
Crisis Intervention do to increase motivation for change” (Miller, 1995,
Crisis intervention refers to the management of p. 91). In crisis intervention, the goal is to address
alcohol or other drug emergencies due to overdose, the immediate psychological, criminal, or medical
adverse drug reactions, or catastrophic psychologi- dangers. Once out of danger, the goal changes to
cal responses. Similar to those services provided to treatment for the substance use disorder.
persons with other mental health diagnoses, such Intervention by the police may be necessary
as depression, crisis intervention often occurs as the when substance use produces violent and unpre-
result of suicide gestures made while the individual dictable behavior, particularly when overly high
is intoxicated or experiencing a severe withdrawal doses of the drug are ingested or when the content
syndrome. Persons in crisis are believed to be nega- of the drug is laced with some other unknown
tively acting out their desire to change. Thus, family mixture. For instance, amphetamine abuse and
members, community officials, and professionals dependence may lead to a psychosis with a close
must take advantage of this momentary opportu- resemblance to paranoid schizophrenia (Sadock &
nity for change by offering specific and structured Sadock, 2008).
forms of help. Medical crises may result when an individual
However, it is now recognized that a crisis or takes lethal mixtures of alcohol and barbiturates,
“hitting bottom” is not necessary for motivating when a person with alcohol dependence experiences
2580_Ch20_292-308 17/07/13 4:18 PM Page 296
delirium tremens as the result of an unsupervised Intensive outpatient programs have been found
withdrawal, or when an individual engages in self- to be effective in treating alcohol dependency, with
injurious behavior (Sadock & Sadock, 2008). The 64% of participants being sober 6 months after treat-
specific life-threatening conditions associated with ment ended (Bottlender & Soyka, 2005). Further-
the abuse of amphetamines, including cocaine and more, treatment of individuals with co-occurring
crack, include myocardial infarction, severe hyper- mental and substance abuse disorders at intensive
tension, cerebrovascular disease, and ischemic colitis. outpatient programs can reduce stays at inpatient
Inhalant use can lead to respiratory depression, car- treatment facilities (Wise, 2010).
diac arrhythmias, irreversible hepatic or renal dam- In order for an individual to be considered for an
age, seizures, and a decreased intelligence quotient intensive outpatient program, candidates must meet
along with other neurological signs and symptoms. all of the following criteria:
Crisis intervention thus involves evaluation
• not pose a threat of serious harm to self or
of the lethality of suicidal or homicidal gestures;
others;
the potential for violence or other negative and
• not be in active withdrawal, or the with-
unpredictable behaviors; the danger of medical
drawal symptoms can be managed in an
symptoms related to overdose, withdrawal, or com-
outpatient setting;
binations of multiple drugs and alcohol; and the
• any co-occurring medical or mental health
extent of injuries related to trauma sustained as the
conditions can be effectively managed in an
result of intoxication. This evaluation may initially
outpatient setting; and
occur over the telephone, with instructions to pro-
• be able to understand and abide by the
ceed to the nearest emergency room, mental health
rules set forth by the specific program
hospital or unit of a hospital, or an alcohol and
(United Behavioral Health, 2011).
drug rehabilitation hospital or unit. Paramedics
and police may also provide the initial evaluation The core services offered by intensive outpatient
and thus may arrest the individual as being dan- programs are listed in Box 20-2. Many IOPs, espe-
gerous to self or others. Emergency department cially in more urbanized areas, also offer specialized
personnel now routinely evaluate persons with
traumatic injuries for alcohol and drug problems,
once medical stability has been achieved (Rumpf, Box 20-2 Core Services Provided by
Hapke, Erfurth, & John, 1998). Arrests for drunk Intensive Outpatient Substance
and disorderly behavior, public intoxication, or Abuse Programs
driving while under the influence may initially
trigger involvement of the legal system. However, • Program orientation and intake
• Comprehensive medical and mental health
many courts later mandate intervention in place
assessment
of, or in conjunction with, incarceration. • Individual treatment planning
• Group and family counseling
Intensive Outpatient Programs • Psychoeducational interventions
Intensive outpatient programs (IOPs) are inde- • Case management
pendent or hospital-associated programs that serve • Integration of patients into the community
individuals with substance abuse disorders and in- • 24-hour crisis lines
clude partial hospitalization, or intensive treatment, • Drug and alcohol testing
• Vocational and educational services
for approximately 4 hours per day. Patients can be
• Psychiatric evaluation and psychotherapy
admitted into these programs at different stages of • Medication management
the treatment process. For example, these programs • Transition and/or discharge planning
can be used as initial treatment, as a more intensive
approach to regular outpatient services, or as a less Data from: Substance Abuse and Mental Health Services Admin-
intensive approach than acute inpatient treatment istration (1993). SAMHSA/CSAT Treatment Improvement
Protocols: Services in Intensive Outpatient Treatment
programs, residential programs, and day treatment Programs. Retrieved from http://www.ncbi.nlm.nih.gov/
programs (United Behavioral Health, 2011). books/NBK25875/ .
2580_Ch20_292-308 17/07/13 4:18 PM Page 297
services, such as HIV or AIDS counseling and edu- or drugs. Occupational therapists can provide
cation (Center for Behavioral Health Statistics and community reintegration and relapse prevention
Quality, 2011). activities that enhance physical and mental health
Occupational therapists can play a major role and increase the clients’ sense of well-being.
in many of the core services offered by IOPs. By
fulfilling many diverse roles, they are of value to Employee Assistance Programs
these programs. Case management is one service Since most adults with substance abuse problems
for which occupational therapists are well quali- are employed, the work site is an excellent place in
fied, because of their training in evaluation of which to identify persons needing intervention. Em-
individuals’ cognitive status, physical condition, ployee assistance programs (EAPs) are workplace-
communication or social skills, and environmental based programs designed to address problems that
factors (American Occupational Therapy Associa- negatively impact employee well-being and con-
tion [AOTA], 2008). Based on the results of the tribute to reduced productivity in the workplace,
assessments, occupational therapists can assist absenteeism, injuries, and work site disruptions
clients to identify the best resources to meet their (Merrick, Volpe-Vartanian, Horgan, & McCann,
needs. For example, community resources related to 2007). EAPs offer services such as crisis interven-
daily living skills and vocational rehabilitation may tion, substance abuse assessments, treatment refer-
be identified and utilized frequently in this type of rals, and aftercare sessions. Employees can self-refer
setting (Chapleau, Seroczynski, Meyers, Lamb, & or be referred by employers based on observation of
Haynes, 2011). declines at work. The eight goals of a typical EAP
are listed in Box 20-3.
Aftercare Programs Several different types of EAPs exist. Internal pro-
Aftercare programs are designed to provide coun- grams are implemented in-house, and the profession-
seling and support to individuals who have com- als offering services are employed by the company.
pleted a treatment program in either an inpatient External vendors are contracted individuals that the
residential facility or an intensive outpatient pro- company uses to provide services at a different loca-
gram. This counseling and support can be in the tion. Integrated programs include features of both
form of individual counseling, support group internal and external programs. Consortia programs
meetings, specialized services such as vocational include a group of employers who come together
rehabilitation, or a combination of the above.
Most programs require that the individual has
remained abstinent from alcohol and drugs for a Box 20-3 Goals of Employee Assistance
certain period of time (Everything Addiction, Programs (EAPs)
2011).
Aftercare programs have been shown to be effec- • Identify problems before work is seriously affected,
tive in helping individuals maintain abstinence for • Offer an easy evaluation and referral process to
longer periods of time than intensive treatment motivate employees to participate,
alone. Including self-help aspects, such as the 12-step • Provide participants with high-quality, best-fit
services,
philosophy, in the program increases the likelihood • Provide cost-effective, early intervention solutions,
that individuals will participate in aftercare pro- • Decrease workers’ compensation claims through
grams (Frydrych, Greene, Blondell, & Purdy, 2009). easy contact to intervention,
In addition, programs that emphasize relapse pre- • Decrease turnover rates,
vention tend to produce higher self-efficacy and • Provide employers with options other than firing
confidence ratings in participants (Brown, Seraganian, employees, and
Tremblay, & Annis, 2001). • Offer support to employees
Occupational therapists can serve clients par- Data from: U.S. Department of Labor (2011). Drug-Free Work-
ticipating in aftercare programs in numerous place Advisor: Employee Assistance Program. Retrieved from
ways, facilitating clients’ participation in different http://www.dol.gov/elaws/asp/drugfree/drugs/assistance/
screen89.asp.
environments and contexts without using alcohol
2580_Ch20_292-308 17/07/13 4:18 PM Page 298
to divide the costs of providing an EAP. Finally, means or by seeking additional substance abuse
peer assistance EAPs utilize employees who are treatment” (Substance Abuse and Mental Health
trained to offer peer counseling and services to iden- Services Administration [SAMHSA], 1999a, para.
tified employees who may be having problems 10). Brief interventions typically consist of five or
(U.S. Department of Labor, 2011). fewer sessions each of relatively brief duration,
Research on the effectiveness of EAPs has such as a few minutes up to one hour (SAMHSA,
demonstrated “improved clinical and work out- 2010). Brief interventions may occur face-to-face
comes and positive economic effects measured in a during a health care visit, via phone calls or elec-
variety of ways (Merrick, Volpe-Vartanian, Horgan, tronic communication (e-mail), or through the use
& McCann, 2007, p. 1263). Occupational thera- of written materials such as workbooks (Stoffel &
pists can play a significant role in EAPs by imple- Moyers, 2004). Because brief interventions have
menting intervention strategies that incorporate been found to be feasible, practical, and cost effec-
effective management of daily activities, and strate- tive for implementation by a wide range of profes-
gies to deal with life and work stressors that may sionals, they are increasingly being used to bridge
trigger the use of alcohol or drugs. the gap between prevention efforts and more
intensive treatment approaches for persons with
severe substance dependence disorders (SAMHSA,
Evidence-Based Practices 1999a). Consequently, Zweben and Rose (1999)
advocate the integration of brief interventions into
Occupational therapists in all areas of practice all medical and social service programs, including
work with individuals who have substance use dis- those programs staffed by occupational therapy
orders. Populations that experience particularly practitioners.
high rates of substance abuse include persons with The basic goal of brief intervention is to “reduce
mental disorders, spinal cord injuries, and trau- the risk of harm that could result from continued
matic brain injuries due to motor vehicle crashes use of substances,” which may include reducing
and other traumas (Levy, Mallonee, Miller, Smith, amount and/or frequency of use, practicing absti-
Spicer, Romano, & Fisher, 2004). No single treat- nence, or attending a 12-step meeting (SAMHSA,
ment approach is effective for all individuals. 1999a, para. 17). Occupational therapy practition-
In order to assist occupational therapy practitioners are able to integrate these strategies into the
ers to more effectively address substance abuse intervention plans of their clients in multiple set-
problems, Stoffel and Moyers (2004) completed tings, even though the client initially may be
an interdisciplinary literature review of effective referred for another reason, such as a hand injury
interventions as part of the AOTA Evidence- (Moyers & Stoffel, 1999).
Based Literature Review Project (Lieberman & One type of brief intervention provides informa-
Scheer, 2002). Interventions with demonstrated tion in a written format, such as self-help manuals,
efficacy to positively impact a “person’s engage- educational materials, pamphlets, and brief self-scoring
ment in occupations and activities necessary for questionnaires. These materials can be supplied in
role functioning, health and quality of life” (Stoffel the waiting rooms of any occupational therapy
& Moyers, 2004, p. 571) that can be incorporated setting and thus do not need to be formally dis-
into occupational therapy practice will be described cussed with the client unless the client asks specific
here. These include brief interventions, motiva- questions. The idea is to promote client responsi-
tional strategies, cognitive-behavioral therapy, and bility while still providing information that moves
12-step programs. the client into the next stage of change, such as
from precontemplation to contemplation or from
contemplation to action. Miller and Munoz (1982)
Brief Interventions developed a self-help manual to supplement treat-
Brief interventions “are those practices that aim ment that has been shown to successfully enhance
to investigate a potential problem and motivate intervention outcomes. Thus, occupational therapy
an individual to begin to do something about his practitioners might do well to review their client
substance abuse, either by natural, client-directed education materials for content related to prevention
2580_Ch20_292-308 17/07/13 4:18 PM Page 299
and treatment of substance use disorders and prob- on the client’s own responsibility during a single
lem drinking. Populations for which occupational interview. If a client, after a series of brief interven-
therapy practitioners provide services could each tions, indicates a willingness to plan and take action
have specifically designed materials addressing the about the substance use, the occupational therapy
problems related to substance use, prevention strate- practitioner readily helps the client make specific
gies, and resources for intervention. When this and realistic plans, offers to initiate a referral, and
information is presented in the context of the health provides support for implementing other change
condition that is of most concern to the client, it strategies on the menu of options.
may have a greater impact.
The key to effective brief intervention strategies
is to establish rapport and to use appropriate open- Motivational Approaches
ended questions based on a topic that is of concern According to Miller and Rollnick (2002), motiva-
to the individual (Rollnick & Bell, 1991). A brief tion consists of three critical components: readi-
intervention consists of five steps: ness, willingness, and ability. Motivation is
multidimensional and dynamic, not static. It can
1. Introducing substance use concerns in the
be influenced and modified through interpersonal
context of the person’s health
and intrapersonal factors. Motivation can be
2. Screening and evaluation of substance use
affected by critical life events, cognitive appraisal
patterns
of the impact of behavior on one’s life, recognition
3. Providing feedback based on assessment results
of negative consequences of one’s current behav-
4. Talking about change and setting goals
ior, and external incentives, both positive and neg-
5. Summarizing concerns, goals, and plans
ative. Motivation increases the “probability that a
(SAMHSA, 1999a).
person will enter into, continue, and adhere to a
Miller and Sanchez (1994) developed the specific change strategy” (SAMHSA, 1999b, para. 1).
FRAMES model for brief interventions. FRAMES Motivational approaches, such as motivational
is a mnemonic device that stands for feedback, interviewing and motivational enhancement ther-
responsibility, advice, menu, empathy, and self- apy, are based on the Transtheoretical or Stages of
efficacy. Throughout the interview, the profes- Change Model discussed in Chapter 3 of this text.
sional gives clear and specific feedback from the Strategies inherent in the motivational approaches
assessment that supports the need for change. The include:
information is not accusatory and the focus is not
• Focusing on the client’s strengths rather than
on diagnostic labeling. Instead, the emphasis is on
weaknesses
the person’s responsibility to interpret and act on
• Respecting the client’s autonomy and decisions
the information. The interviewer does give
• Using empathy rather than authority and
advice in relationship to the medical consequences
power as motivators
for continued use. The professional supplies
• Individualizing treatment
a menu of change options, ranging from self-help
• Focusing on early interventions before
programs or manuals to hospitalization. Through-
significant consequences occur
out the interview, the professional is empathetic
• Developing a therapeutic partnership
and avoids hostile confrontations, power struggles,
• Supporting small, incremental steps toward
and judgmental and paternalistic attitudes. Addi-
recovery (SAMHSA, 1999b).
tionally, the professional’s attitude promotes the
self-efficacy of the client or a belief in the individ- Motivational approaches can be used at various
ual’s ability to make decisions about when and phases of the intervention process. For example,
how to change. motivational strategies, such as motivational in-
Depending on the circumstances, the occupa- terviewing, may be used in the early phases as part
tional therapy practitioner may find that the of a brief intervention. Motivational enhancement
FRAMES process rarely occurs in one session. therapy may be used in later phases as a way of
Rather, it occurs over time. The individual may be sustaining the client’s ongoing commitment once
able to absorb only some feedback, with emphasis change has been initiated.
2580_Ch20_292-308 17/07/13 4:18 PM Page 300
Motivational Interviewing Motivational interviewing occurs in two phases.

The first phase is designed to resolve ambivalence and
According to Miller and Rollnick (2002), motiva-
build intrinsic motivation for change. The second
tional interviewing is “a client-centered, directive
phase involves strengthening commitment to change
method for enhancing intrinsic motivation to
and developing a plan of action (Miller & Rollnick,
change by exploring and resolving ambivalence”
2002). Motivational interviewing consists of:
(p. 25). The purpose of motivational interviewing
is to elicit self-motivational statements and behav- • Asking open-ended questions
ioral change from the client. Motivational inter- • Active listening and reflective responses
viewing is not a set of techniques per se but rather • Summarizing what has transpired during the
a way of interacting with a client. The spirit of session
motivational interviewing can be described by the • Affirming the client’s strengths, motivation,
following principles/directives: intentions, and progress
• Eliciting self-motivational statements
• motivation to change is intrinsic and elicited
(SAMHSA, 1999b).
from within the individual, not imposed
from the outside; Clients can be categorized along two dimensions
• it is the client’s task, not the counselor’s, to of intrinsic motivation. These dimensions are the
identify, articulate, and resolve his or her client’s perceptions of the importance of change
ambivalence; and their confidence to change. The resulting four
• the counselor uses an empathic, supportive, categories are:
and collaborative style; direct persuasion or
1. low importance, low confidence,
confrontation generally increases client
2. high importance, low confidence,
resistance and is counterproductive;
3. low importance, high confidence, and
• readiness to change is not a static trait but
4. high importance, high confidence (Miller &
rather a fluctuating product of the interper-
Rollnick, 2002).
sonal therapeutic interaction; and
• the professional respects and affirms the The motivational strategies needed vary depend-
client’s autonomy, freedom of choice, and ing on the category to which the client belongs
self-direction (Rollnick & Miller, 1995). (Fig. 20.2).
High Importance, High Confidence High Importance, Low Confidence
These individuals believe that change is These individuals believe that change is
important and they also believe in their ability important but they have little belief in their
to succeed. ability to succeed.
Intervention: affirm the person’s commitment Intervention: increase self-efficacy

to change and develop a plan of action through encouragement, support, and
feedback
Low Importance, High Confidence Low Importance, Low Confidence
These individuals believe they could succeed These individuals do not believe change
if they desired to change, but they do not is important nor do they believe they could
believe that change is necessary or important. succeed in making a change if they tried.
Intervention: identify disadvantages of the Intervention: explore goals and values,

status quo and the advantages of change identify disadvantages of the status quo
and the advantages of change, elicit
examples of other areas in the person’s
life where they were successful in making
changes
Fig. 20•2 Categories of Intrinsic Motivation. (From Miller & Rollnick (2002). Motivational
interviewing: Preparing people for change, 2/e. New York: Guilford Press.)
2580_Ch20_292-308 17/07/13 4:18 PM Page 301
Motivational Enhancement Therapy impacted by long-term use of chemicals. Results

from the DCU are used to provide feedback so that
Motivational enhancement therapy (MET) is an
the individual can successfully move through the
adaptation of motivational interviewing developed by
successive stages of change.
Miller, Zweben, DiClemente, and Rychtarik (1992)
that consists of four highly structured sessions. The
sessions include a drinker’s check-up (DCU) and the
FRAMES approach to interviewing for change Cognitive-Behavioral Approaches
(Miller & Sanchez, 1994). The DCU is a compre- Cognitive -behavioral therapy (CBT) emphasizes
hensive assessment offered as a health check-up for the impact of cognitive appraisals, attributions, and
persons with problem drinking. In addition to asking self-efficacy expectations on substance use behavior.
the individual quantity and frequency-of-use ques- CBT often focuses on the development of coping
tions, other screening tools measuring the impact of skills in order to reduce substance abuse and prevent
problem drinking are administered, the most com- relapse. CBT is equally effective when provided
mon tool being the CAGE (Ewing, 1984). CAGE individually or in groups and is best used when
stands for the following four questions: a person demonstrates a readiness to change his or
her substance use behavior. In order for cognitive-
1. Have you ever felt that you should cut down
behavioral approaches to be effective, the individual
on drinking?
must possess adequate memory, problem solving
2. Have people annoyed you by criticizing your
and judgment abilities, and the ability to process
drinking?
information and express oneself verbally (Stoffel &
3. Have you ever felt guilty about your drinking?
Moyers, 2004).
4. Have you ever had a drink first thing in the
Central to the cognitive-behavioral approach
morning to steady your nerves or get rid of
is the identification of an individual’s antecedents:
a hangover (eye opener)?
(A) to substance use behavior (B) and the short-
Two positive answers on the CAGE would indi- term and long-term consequences (C) of that use.
cate the presence of alcohol-related problems, and These are referred to as the ABCs of cognitive
three or more positive answers indicate potential behavioral therapy as depicted in Figure 20.3. An-
alcohol dependence. tecedents are those situations, conditions, loca-
The DCU would then proceed by using more tions, activities, people, cues, thoughts, or feelings
specific questionnaires, such as the Michigan Alcohol that precede and lead to substance use. Cues are
Screening Test (MAST), which analyzes the social, stimuli related to substance use, for example, the
medical, legal, and psychosocial consequences asso- smell of a substance, a setting (such as a bar, tavern,
ciated with problematic drinking, such as blackouts, club, or restaurant), an activity, or even certain
loss of employment, and drunk driving arrests times of day or special events (e.g., New Year’s
(Selzer, 1971). An occupational therapy practitioner Eve). Consequences can be positive or negative
would add an occupational history, highlighting the and refer to the physical, emotional, and social
impact of the substance use on occupational per- effects that result from substance use.
formance to the DCU (Moyers & Stoffel, 1999). A cognitive-behavioral approach was used
Blood testing for alcohol and urine testing for drugs successfully with clients with substance use disor-
may be conducted, along with medical laboratory ders who had difficulty managing anger. A 12-
screens that assess liver functions and other systems session anger management group intervention
Antecedents Behavior Consequences

Fig. 20•3 ABCs of Cognitive-Behavioral
Situations/thoughts e.g. First drink Immediate or short-term Therapy. (From Center for Substance
or use of a drug (negative or positive) Abuse Treatment (2005). Substance abuse
Feelings/emotions
relapse prevention for older adults: A group
Cues treatment approach. Rockville, MD:
Long-term Substance Abuse and Mental Health
Urges (negative)
Services Administration.)
2580_Ch20_292-308 17/07/13 4:18 PM Page 302
demonstrated effectiveness in reducing anger and 12-Step Recovery Programs

improving social-emotional functioning, as well Recovery programs based on the 12 Steps of Alco-
as decreasing substance use. Four types of CBT holics Anonymous (AA) take two basic forms. One
interventions are frequently used when treating is a professionally facilitated therapeutic process
persons with anger issues. These include: (Twelve Step Facilitation Therapy), and the other is
• Relaxation interventions to decrease the in the form of mutual support group programs, like
emotional and physiological arousal AA and others.
associated with anger; Twelve Step Facilitation (TSF) Therapy is a
• Cognitive interventions to address cognitive structured 12–15 session professionally facilitated
appraisals, irrational beliefs, and hostile program for early recovery from substance abuse
attributions that trigger anger responses; and dependence. The program is based on the
• Communication skills interventions to cognitive, behavioral, and spiritual principles of
improve assertiveness and conflict resolution 12-step recovery fellowships such as AA. The TSF
skills; and counselor assesses the client’s substance use, advo-
• Combined interventions that integrate cates abstinence, provides psychoeducational ses-
multiple intervention methods and target sions on 12-step concepts, and facilitates initial
multiple anger-related domains (Reilly & and ongoing participation in 12-step recovery
Shopshire, 2002). support groups. In a large-scale, federally funded
research project, TSF therapy clients demon-
Occupational therapists can incorporate cognitive-
strated significantly higher rates of substance
behavioral strategies through role modeling, struc-
abstinence than those who participated in
tured opportunities to practice coping skills, and
cognitive-behavioral therapy (CBT) or motiva-
timely feedback. Clients can be helped to change
tional enhancement therapy (MET) interventions.
their distorted thought patterns regarding substance
In addition, TSF participants had higher rates of
use, develop self-efficacy, and establish alternative,
involvement in AA group meetings (62%) as com-
healthy coping behaviors to manage daily stressors.
pared to those receiving MET (38%) or CBT
Behavioral rehearsal, or role-playing the practice
(25%) (National Registry of Evidence-based Pro-
and application of newly learned skills, is a key
grams and Practices, 2008). TSF can be used by
element in cognitive-behavioral therapy. The fol-
occupational therapists, and an implementation
lowing are the recommended steps for conducting
guide can be purchased from the National Institute
behavioral rehearsal:
on Alcohol Abuse and Alcoholism.
• Read the situation or scenario aloud Involvement of clients in mutual support pro-
• Discuss appropriate responses to the situation grams (those programs that do not rely on profes-
• Choose an appropriate response and explain sional intervention but on the support of group
the rationale for the choice members) is particularly important given the push
• Model the chosen behavioral response by managed-care programs to drastically reduce
• Get feedback from the group on the both inpatient and outpatient treatment days. The
effectiveness of the behavioral response occupational therapy practitioner encourages and
• Modify the response based on group recommends participation in a variety of 12-step
feedback if necessary programs, such as Alcoholics Anonymous (AA),
• Read the scenario aloud a second time Cocaine Anonymous, and Narcotics Anonymous.
• Choose a client to rehearse the behavior The 12 Steps of AA are listed in Box 20-4.
• Ask the group to provide feedback Research indicates that consistent attendance
• Coach the client if necessary at 12-step meetings is effective in achieving abstinence
• Rehearse again for persons with substance abuse disorders (Witbrodt,
• Ask for group feedback again Mertens, Kaskutas, Bond, Chi, &Weisner, 2011).
• Move to the next client and introduce a new Miller (1998) stated that spirituality-based programs,
situation or scenario (Center for Substance such as AA, are more likely to help people remain
Abuse Treatment, 2005). abstinent when compared to psychological therapy
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Box 20-4 The 12 Steps of Alcoholics Anonymous
1. We admitted we were powerless over alcohol—that our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of ourselves.
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and became willing to make amends to them all.
9. Made direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continued to take personal inventory and when we were wrong promptly admitted it.
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him,
praying only for knowledge of His will for us and the power to carry that out.
12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics,
and to practice these principles in all our affairs.
Copyright: Alcoholics Anonymous World Services, Inc. (1976). Alcoholics Anonymous (3rd Ed.). New York: AA.
devoid of spirituality. In general, AA sees the most these occupational performances, the occupational
pervasive problem of alcoholism as the spiritual therapist may use an occupational interview or
decay that results from the distorted perception that history to highlight for the client the loss of inten-
the self, rather than a higher power, is at the center tionality and the progressive abdication of control
of life. (Alcoholics Anonymous World Services, over one’s life to alcohol and drugs. Reasonable
1976). Committing to abstinence, decreasing preoc- goals are then collaboratively developed to help
cupation with the self, and living a life-long program the client change the deficient occupational per-
of spirituality are the essential elements of sobriety formance. For instance, it is important that the
according to AA (Alcoholics Anonymous World client receive help in finding a job and in locating
Services, 1970). Achievement of these goals occurs suitable living arrangements. These are two of the
by “working the 12 steps of recovery” and is facili- critical factors that support the person in recovery.
tated by group participation and the support of Additionally, the client may need social and
a sponsor. leisure counseling and opportunities to attend
Computer technology has made it possible to drug-free social activities.
access self-help resources through e-mail and the In addition to helping the client improve occu-
Web. The home pages of many of these self-help pational performance, the therapist also incorpo-
groups provide information about the organization, rates into the intervention plan the idea that
about group locations and meeting times, and about occupations are opportunities “to progressively
ordering literature; some may actually conduct reinvent the way in which the self is understood”
meetings on line. With technology, support for stay- (Moyers, 1997, p. 211). Therapeutic occupations
ing sober is immediately available at any time right are used to reinvent the self as abstinent by creat-
in the home. ing rationales for being sober, developing habits
of sobriety, and producing peak experiences when
sober. Daily occupations are organized into basic
Occupational Therapy in habits such as getting rest, eating balanced meals,
Substance Abuse Programs keeping the body neat and clean, and following
the therapy regimen necessary for maintaining
Occupational therapists use a client-centered abstinence. Occupations help re-establish inten-
approach to determine the occupational perfor- tionality as the individual deliberately selects oc-
mances that require intervention in order for the cupations according to a variety of goals, values,
client to achieve greater life satisfaction. To identify or interests. In fact, occupations may serve as a
2580_Ch20_292-308 17/07/13 4:19 PM Page 304
transition to a valued future goal and thus provide drug refusal skills, and self-monitoring of emotional
the context for learning and applying new skills extremes and negative thinking. However, this
needed for personal growth. For instance, training may be ineffective due to the disruption of
occupational therapy intervention might help the these skills by the presence of drug-using cues in
client redefine his or her qualifications, select and the environment. Contextual factors, including the
begin a program of intensive retraining, and even- physical, social, and cultural environments that
tually obtain a more satisfying and interesting job. facilitate or inhibit recovery, are also identified as
Miller (1998) has noted through a review of 12 parts of the intervention plan.
different studies that addiction is associated with Environmental modification may involve
a lack of meaning and purpose in life. Finding working with the family to help the person create
meaning is a spiritual process because the person a supportive atmosphere for change. Typical fam-
attempts to discover his or her purpose or reasons ily behaviors, such as reinforcing drug use through
for being in the world and clarifies within that attention and caretaking, protecting the individual
scheme the importance of interpersonal relation- from the consequences of substance use, and pun-
ships, daily events, and goals. Thus, rationales for ishing for infractions related to drug use, have
staying sober are firmly established through mean- been noted to increase the likelihood of continued
ingful occupations that promote spirituality and substance abuse. However, not only does the fam-
one’s connectedness to the world. ily affect the person using substances but also the
Underlying performance patterns and perfor- individual’s substance-related behaviors affect
mance skills that contribute to impairment in family members. Occupational therapy practition-
occupational performance are also key recovery ers work with family members to enhance their
factors identified and targeted for intervention. occupational performance and participation
Persons with substance abuse problems often (Moyers, 1991, 1992; Stoffel, 1994). The goals
demonstrate dysfunction in habits, routines, and are to help family members learn to cope with
role performance. Cognitive skills, communica- their emotional distress and to concentrate on
tion and social skills, and emotional regulation their own motivations for change in performance
skills are other important aspects of functioning areas, regardless of whether the individual decides
that require evaluation and intervention. to change his or her substance use.
To illustrate the influence of performance pat- Finally, occupational therapy practitioners can
terns and performance skills, consider the individ- provide instruction to clients regarding relapse
ual who states that drug and alcohol use negatively prevention strategies. Many of the risk factors that
affects school performance and interferes with the have been shown to precipitate relapse, for exam-
goal of graduating from college with a degree in ple, negative affect, low self-efficacy, limited coping
accounting. In analyzing the underlying factors or skills, lack of social support, and poor psycholog-
performance components, the client and the occu- ical functioning (Marlatt, Bowen, &Witkiewitz,
pational therapist determine that managing time, 2009), are amenable to occupational therapy
coping with stress and financial worries, develop- intervention. The Stages of Change Model
ing study habits, and socializing with classmates (described in Chapter 3) provides a useful frame-
who are truly supportive of the client’s objectives work for developing interventions appropriate for
are all important for achieving the goal of obtain- each stage (Table 20-1).
ing a degree.
The intervention plan outlines strategies to im-
prove skills in time management, coping, academ- Conclusion
ics, and socialization. Coping skills training is
important for the client to learn how to cope with Occupational therapy practitioners working in
frustration when engaging in routine occupations. community settings have tremendous potential
Coping skills training usually involves teaching to provide an occupation-focused perspective
relaxation techniques, meditation strategies, alter- on helping individuals who struggle with substance
nate coping behaviors, specific control skills (limit use disorders by enhancing their occupational
setting, planning ahead for potential difficulties), performance in environments that support their
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Table 20-1 Occupational Therapy Interventions for Substance Abuse Using the Stages of
Change Model
Stage Description Appropriate Interventions
Precontemplation Little or no awareness of effects Increasing awareness of the impact of
of substance use on occupational substance use on occupational performance
performance through self-assessment techniques and
motivational interviewing
Contemplation Some awareness of effects of Decisional balance exercises to explore the
substance use on occupational positive and negative aspects of substance use
performance but no efforts made and the resulting impact on occupational
to address the resulting problems performance
Preparation Consideration of potential ways to Exploration of a range of treatment options and
address the impact of substance community resources to support initiation and
use on occupational performance maintenance of changes in substance use
but no implementation of
strategies
Action Implementation of change Cognitive-behavioral interventions, participation
strategies to decrease substance in 12-step programs, and motivational
use and improve occupational enhancement therapy
performance
Maintenance Efforts to maintain improvements Community support programs, participation in
in occupational performance and 12-step programs, and relapse prevention skill
changes in substance use patterns development
Relapse Return to substance use after Revisit motivational strategies and decisional
a period of abstinence and the balance exercises to re-engage client in the
resulting decline in occupational action stage and identify cues to relapse
performance
CASE STUDIES
CASE STUDY 20•1 Richard
Richard is a single, 30-year-old white male with a 10-year history of cocaine and barbiturate abuse. Richard
is currently staying with various “friends” and does not have a primary residence of his own. Richard has
been employed off and on for the past 10 years as a heating and air conditioning specialist, and the
longest time he has maintained employment was 9 months. Each time he was fired from a job, it was
due to being absent or late for work secondary to substance abuse. Richard has a legal history of misde-
meanor drug possession and paraphernalia possession, and he has received inpatient treatment for
substance abuse three times. He has one daughter who is 9 years old and lives with her mother.
Richard is currently not allowed to contact his daughter. Richard has no insurance coverage and no
money to pay out-of-pocket expenses for treatment, so he has been referred to state-funded facilities.
Richard has received state-funded medical detoxification treatment at a local facility for the last 14 days,
and he has been evaluated for a state-run intensive outpatient program (IOP). Upon evaluation, Richard
stated that he would like to return to work in his field and to regain partial custody of his daughter. He
currently has no hobbies other than using drugs, and he has isolated himself from all of his friends.
The only contacts that he has are people who also use drugs. Richard states that he wants to approach
treatment differently this time, and he states that he truly wants to be successful at managing his addictions.
Continued
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CASE STUDY 20•1 Richard cont’d

1. In order for Richard to be successful, what services within the IOP would you recommend?
2. Name five ways in which an occupational therapist could help Richard meet his goals.
3. After Richard completes the IOP, what would be the next step? Find one of these types of facilities in
your local area to which Richard could be referred.
4. List five suggestions that an occupational therapist could give Richard to help him manage daily
stressors that could trigger him to use substances.
5. Name three interventions that an occupational therapist at the IOP could use to help Richard attain
and maintain employment.
health and meaningful occupational roles. Occupa- • Helping the individual make environmental
tional therapy intervention includes the following changes that are conducive to abstinence
main approaches: and that compensate for performance
• Facilitating change in occupational perform- impairments
ance and participation for the person using • Developing coping skills that assist the
substances and for the family members individual in responding to temptations and
affected by the substance use of others cravings, and to typical daily hassles and their
• Identifying occupations that are satisfying frustrations with occupational performance.
and that contribute to well-being and quality
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screen89.asp
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Chapter 21
Forensic Mental Health Practice

Within the Community
Roxanne Castaneda, MS, OTR/L, and S. Maggie Reitz, PhD, OTR/L, FAOTA
When in doubt always be human.

—Alfred J. Shulman, M.D.
Learning Objectives
• Identify and discuss several ways clients in the criminal justice system enter the community mental health system
in the United States.
• Describe the reentry process into the community following incarceration or hospitalization.
• Explain and describe the role of occupational therapy within forensic mental health practice.
• Describe the cultural dynamics of criminal justice and forensic mental health contexts and the mental health
recovery movement.
Key Terms
Insanity acquitees Specialty courts
Re-Entry After Prison/Jail (RAP)
Introduction can be very rewarding. However, it is pursued by

few. Occupational therapists employed by day and
State mental health agencies attributed an increase residential programs are rare (A. Thompson, per-
in admissions to in-state psychiatric hospitals sonal communication, March 2008). The presence
nationwide in the United States from 2002 to 2005 of forensic and corrections clientele at state institu-
to the increase of forensic admissions. Although the tions seems to increase the challenge of hiring and
dynamics of this process are not clearly understood, retaining staff in many areas of mental health prac-
experts speculate that the influx of individuals with tice due to the nature of the crimes and concerns
mental health issues into the courtroom is due to about potential violence. This difficulty in recruit-
the lack of community resources to address their ment is even more prevalent in corrections and
needs (Manderschied, Atay, & Crider, 2009). State forensic agencies. An additional factor for limited
behavioral health hospitals, formerly accustomed to occupational therapy service provision is the difficulty
only civil admissions, are seeing an influx of forensic in obtaining reimbursement.
clients. For example, in 2010 the population of a The focus of this chapter is individuals with men-
250-bed civil facility in Maryland was 75% forensic tal illness and criminal behavior with forensic
clients (P. Langmeade, personal communication, involvement. Services for the general prison popula-
February 2010). tion are beyond the scope of this chapter. Most of
Although the return from incarceration or foren- the information in this chapter comes from the pri-
sic hospitalization to the community is complex, mary author’s direct experience as a director of com-
occupational therapy practice with this population munity forensics services, as a director of forensic
309
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evaluation, and in working with the National Asso- health services may vary from state to state but is
ciation of State Mental Health Forensic Directors almost always supported by law. Forensic clients are
Group. Specific topics covered in this chapter a diverse group of adults in terms of age, gender,
include: and ethnicity. Psychiatric diagnoses vary, and crim-
inal charges range from misdemeanors to serious
• Entry process to the criminal justice system
violent felonies.
and/or the forensic mental health system
In general, defendants/clients who have been
• Route to community reintegration
arrested and sent to jail could be seen for criminal dis-
• Role of occupational therapy in community
position and possible mental health assessment in
re-entry with forensic clients
three systems: the court system, criminal justice sys-
• Challenges to community intervention
tem, and forensic mental health system. Although the
• Cultural dynamics of criminal justice and
court system is technically part of the criminal justice
forensic mental health contexts
system, for this discussion the courts have been sepa-
• Mental health recovery movement
rated to show the path of the defendant/client
• Occupational therapy community practice
through the entire complex process. The next step,
with persons with mental health and criminal
for all defendants/clients, is to go to court.
justice/forensic involvement
A case study is presented at the end of the chapter.
Court System
Depending on the nature of the charge, the defendant
Entry Process to Criminal may go to a district, circuit, or specialty court. Those
who are found guilty enter the criminal justice system
Justice System and/or the to serve their sentence in jail, prison, or a correctional
Forensic Mental Health mental health facility. Defendants/clients adjudicated
through an insanity defense could then be transferred
System: Client, Defendant, to a court-designated facility (i.e., maximum security
or Inmate? mental health hospital, state regional mental health
hospital with forensic services) to receive further foren-
Clients in the criminal justice system can come in sic evaluation and/or treatment to restore competency
contact with the mental health system in several to stand trial.
ways in the United States. Forensic clients could Another verdict, “guilty but mentally ill” (GBMI),
include: exists in some states. “Four of the twelve states that
adopted the GBMI verdict did so because of the up-
• defendants, pre-trial or undergoing evalua-
roar over the Hinckley verdict. The consequence of
tion phase inmates, post-conviction phase at
rendering a GBMI verdict is conviction and a crimi-
jails or prisons
nal sentence. A defendant will be evaluated by mental
• “‘insanity acquitees’ (those acquitted based on
health authorities to determine whether psychiatric
an insanity defense). Insanity acquitees ... typi-
treatment is warranted under the circumstances. If
cally have mental illness and often also have an
such treatment is deemed necessary, the offender is
additional diagnosis such as mental retardation
hospitalized. If discharged, the offender is sent back
or substance abuse” (Castaneda, 2010, p. 202).
to prison to serve the remainder of the sentence”
Those who avail themselves of the insanity de- (Collins, Hinkebein, & Schorgl, n.d., ¶ 24).
fense typically receive evaluation and/or treatment
through the formal state mental health forensic sys- Specialty Court
tem (i.e., maximum security hospital and/or state Specialty courts were developed to assist defendants
psychiatric hospital). who have social or behavioral health issues in addition
Other forensic clients may choose not to disclose to their criminal history. “Mental Health and Drug
mental illness, be asymptomatic, or become symp- courts have their genesis in the concept of specialty
tomatic only after incarceration in a jail or prison. courts and the idea of therapeutic jurisprudence”
The process of being identified as in need of mental (Steadman, Davidson, & Brown, 2001, p. 457).
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Chapter 21 | Forensic Mental Health Practice Within the Community 311
Therapeutic jurisprudence is the study of the law as a trial” or “Not Criminally Responsible” (NCR)
potential therapeutic or nontherapeutic agent, with usually receive further evaluation or treatment in a
the belief that the integration of the principles of maximum security hospital. This facility provides
law and care can be used as a social force to enhance treatment and rehabilitation to those accused of
quality of life (Wexler, 1999). In 1997, the first committing serious violent felonies (e.g., murder,
Mental Health Court was established in Broward arson, or rape). If the charge is of a lesser nature
County, Florida, based on the past success of Drug (e.g., a misdemeanor like vagrancy), the person may
Courts in Dade County, Florida. Mental Health be placed at a less-restrictive state behavioral mental
Courts expanded once federal funding was made health facility for further evaluation and treatment.
available upon President Clinton’s signing of U.S. It is important to mention that some states have
Senate Bill S. 1865 (Steadman et al., 2001). “integrated” criminal justice and forensic mental
Mental Health Court processes vary by state and health services. Facilities within these systems usu-
jurisdiction, but most: ally provide security and some treatment but are not
accredited by The Joint Commission (TJC) or the
• Work with persons with mental illness who
Centers for Medicare and Medicaid Services
have entered the criminal justice system
(CMS). The priority in these facilities is usually pun-
whose offenses vary; the offenses are usually
ishment (as per the mandate of the state’s penal
misdemeanors but may include serious
code) versus active treatment (D. Barton, personal
violent felonies (Callahan, 2011).
communication, January 2010).
• Divert persons with mental illness from the
criminal justice system into the community
with court-ordered mental health treatment
and support (B. Wise, personal communica- Route to Community
tion, December 2009). Reintegration
Some jurisdictions are investigating the possible Whether released from a maximum security or state
benefits of developing other types of specialty courts, psychiatric hospital, jail, prison, or mental health
such as behavioral health/drug courts (Substance court, an individual will be challenged by multiple
Abuse Mental Health Systems Administration legal and psychiatric concerns. There are expecta-
[SAMHSA], 2011a), prostitution court (B. Wise, tions for adherence to court and conditional release
personal communication, December 2010), and orders, mandated psychiatric appointments, med-
veterans court. ication compliance, required visits with parole and
probation officers, court-appointed legal guardians,
Criminal Justice System scheduled court appearances, and possible ongoing
Access to mental health care varies according to how evaluations for risk assessments, psychiatric evalua-
the person enters the criminal justice system and/or tions, medication reviews, and other stipulated
the forensic mental health system. If defendants are requirements. The path to reintegration varies
found guilty in the court system, they may get sen- depending on the original court finding and its
tenced to time in jail or prison depending on the disposition. Two routes based on disposition are
nature of the offense. Once incarcerated, if they dis- described below, one for the defendant/inmate
close mental illness or exhibit signs of mental illness, and the other for those adjudicated NCR. Those
they might be able to access limited psychiatric ser- individuals found not competent to stand trial
vices. If their illness worsens, they may be trans- are not discussed in this chapter because they
ferred from the general population to a correctional do not have an immediate path to community
mental heath hospital for further assessment and integration and the process varies significantly by
treatment. jurisdiction.
Forensic Mental Health System Defendant/Inmate

In states that have the insanity plea, individuals who Individuals may be released by the court from a
have been adjudicated as “Not Competent to stand mental health court, jail, prison, or the correctional
2580_Ch21_309-320 16/07/13 3:00 PM Page 312
mental health system into the community. These Role of Occupational

individuals may have been charged, found guilty,
and sentenced for various misdemeanors or serious Therapy Community
felonies. They may have completed their sentence Re-entry With Forensic
or are in the community on parole or probation.
Placement or release into the community is com- Clients
plex. States have their own regulations, laws, and
procedures that affect this process. A variety of knowledge and skills are used by occu-
pational therapists working in community re-entry
with forensic clients. A high degree of knowledge of
Adjudicated Not general occupational therapy, mental health and ill-
Criminally Responsible ness, community systems, and the criminal justice
In some states, patient-defendants adjudicated as system is the minimum required for this role.
NCR may reside in a maximum security state hos- Occupational therapists receive formal training in
pital but no longer need that level of supervision. the mental health needs of individuals as students
In some cases, the initial offense might have been but learn about the legal issues their clients are
so heinous and highly publicized that community experiencing through “on-the-job training.” In an
agencies are hesitant to accept the individual inpatient setting, this usually entails listening to the
directly from a maximum security hospital. In patient-defendant during evaluation and interven-
these cases, transfer to a state behavioral mental tion, reading the patient-defendant’s forensic history
health facility may be warranted. The discharge in his or her chart (if available), or discussing the
preparation continues in a less restrictive hospital planned community re-integration with other treat-
setting, and placement in the community becomes ment team members. Occupational therapists work-
less stigmatized. ing in the community, in a group home, residence,
Most states have an entity like an Office of Com- or work setting, may not have any information or
munity Forensic Services/Aftercare that is sup- knowledge of a client’s forensic hospitalization,
ported by legislation and the court. The primary criminal background, or legal history.
purpose of such an organization is to monitor Additional education gained through facility ori-
individuals who are on conditional release in the entation programs, formal continuing education ex-
community. Requests for conditional release are periences, or a self-directed reading and mentoring
usually formulated by the inpatient treatment team, program can help occupational therapy practitioners
which in some cases includes an occupational ther- understand “legal concepts and statutes pertaining
apist, in consultation with the designated forensic to insanity acquitees, sex offender registries, parole
psychiatrist or psychologist in the facility, the and probation, conditional release, victim notifica-
patient-defendant, and the patient-defendant’s legal tion, and county and state judicial operation that
counsel. are important to the life circumstances, treatment,
The court is petitioned and conditional release and outcomes of people with mental illness and
orders are presented to a judge for final approval. forensic involvement” (Castaneda, 2010, p. 202).
Most of these orders are specific to the community Programs like Re-Entry After Prison/Jail (RAP)
living needs of the person (e.g., must reside in a can be important resources for community practi-
residential setting with 12 hours of supervision) tioners (Rotter & Massaro, 2008). This program
and reflect public safety requirements related focuses on the effects of “doing time”; cultural com-
to the initial offense. They may include restric- petence within penal institutions; cognitive behav-
tions regarding alcohol and illicit drugs, contact ioral approaches to assist prisoners transitioning into
with certain individuals like family members (e.g., the community; and ongoing training, research,
children) or alleged victims, and travel across state and intervention approaches for professionals both
lines. These orders also may include monitoring “behind the walls” and in the community.
for a stipulated amount of time; for example, With the appropriate knowledge, occupational
in Maryland, an initial conditional release is therapists can assist forensic clients in reentering
usually monitored for 5 years (B. Wise, personal the community and honoring their freedom of
communication, December 2009). choice and community life as guided by the law.
2580_Ch21_309-320 16/07/13 3:00 PM Page 313
“Occupational therapy treatment at its best focuses with legal, psychiatric, and public safety issues that
on client inclusion, personal choice, and empower- are part of the forensic clients’ lives at all times.
ment” (Castaneda, 2010, p. 203). Smith-Gabai Occupational therapists also must be aware of how
(2007) identifies the occupational therapist’s role in these issues may impact their therapeutic use of self,
assisting clients to develop problem-solving skills personal safety, and ability to access community
and to increase their awareness of their own supports when needed, such as a mental health court
strengths and barriers to occupational performance. social worker. Many occupational therapists work-
The therapist helps the client to generate strategies ing with forensic clients in the community sole
and solutions that will foster the client’s empower- providers. Those who are part of health care agen-
ment and assist the client in achieving his or her cies may not have access to supervisors who know
stated goals. “However ... the opportunity for true about legal, psychiatric, public safety, and commu-
choice is limited by the parameters dictated by the nity issues. It is important for the practitioner to
judiciary, and for some the client’s concomitant seek out atypical “supervision” by gathering infor-
sociopathy” (Castaneda, 2010, p. 203). mation and mentorship from the legal, psychiatric,
Occupational therapists must provide care that is and public safety personnel that are a part of the
consistent with the Occupational Therapy Code of client’s “team.” Professional judgment and know-
Ethics and Ethics Standards 2010 (American Occu- ledge of the law are important in this area of prac-
pational Therapy Association [AOTA], 2010) and tice. One must be prepared to answer questions
avoid breaches of ethical principles such as patient about occupational therapy interventions and be
abandonment. An occupational therapy practitioner able to maximize community engagement while
cannot suddenly stop intervention with an indivi- complying with judicial requirements (Box 21-1).
dual (i.e., abandon a patient), regardless of how
difficult the circumstances. For example, an occu-
pational therapist working with a client may learn Public Safety
that the client is a pedophile and has history of of- In addition to the needs and goals of the forensic
fending with children the same age as the therapist’s client, the occupational therapist must consider
children. The occupational therapist must continue public safety. The issue of public safety generally
to see the client until arrangements for an alternate refers to protection of person and property from
caregiver (Morris, 2011) are put in place. physical or psychological harm from a variety
of dangers. Potential dangers to the community
include: felony crimes (e.g., arson, assault with
Challenges to a deadly weapon, kidnapping, murder); sex offenses
Community Intervention (e.g., pedophilia, rape); intentional transmission of
infectious diseases; and acts of terrorism (Castaneda,
When working with defendants/clients in community 2002). It is imperative that the occupational thera-
settings, occupational therapists must be well versed pist understands probation and parole criteria; state
Box 21-1 Compliance With Judicial Requirements
In the state of Maryland, a client on conditional release cannot leave the state without permission from the court.
During a bi-weekly meeting with the community occupational therapist, Dutch requests assistance with budget-
ing. Dutch is planning to purchase hot dog meals for himself and his father at a Washington Nationals baseball
game in Washington, DC, in a few weeks. The occupational therapist discusses his conditional release, asking him
if he has permission from the judge to cross state lines. Dutch is unaware whether he has permission. Further
investigation showed that the case manager, therapist, father, and the director of the residential service of the
agency did not know permission was needed for the trip. A call to the community forensic aftercare office by the
client’s therapist and director of residential services enabled them to request permission to enter another state,
for a time limited “sign out” with a parent. The client and his father were reminded of this crucial process. By rais-
ing the question, the occupational therapist was able to prevent a situation that could have resulted in the client’s
revocation of conditional release and subsequent return to a state forensic hospital.
2580_Ch21_309-320 16/07/13 3:00 PM Page 314
laws regarding victim notification and obligations institutional treatment settings. In some community
for reporting antisocial behavior; and therapeutic agencies, the staff-to-client ratio is significantly
approaches for individuals with antisocial personal- lower (e.g., 1 staff to 8 clients for a 12- to 24-hour
ity disorder; and knows how to access and appro- period) than inpatient client-to-staff ratios (e.g.,
priately interact with community forensic aftercare 2–4 staff for 5 clients for an 8-hour shift). Supports
entities. available in inpatient settings, such as PRN medica-
Castaneda (2010) discusses the dilemma occupations for anxiety or agitation or additional immedi-
tional therapists face in developing an intervention ate staff support, are not readily available in the
plan and approach that balances client/defendant community. If a client experiences a temporary
choice and public safety. Achieving this balance is resurgence of symptoms during his or her transition,
more difficult if individual behavior indicates a lack a practitioner in this setting must be prepared to
of interest in the promotion of recovery, release, or suggest interventions that do not overly depend
discharge. Snively and Dressler (2005) identified on staff or access to limited supports. Examples of
additional challenges for professionals working with appropriate suggestions include strategies such as
forensic clients, one of which is the need for “devel- environmental analysis and adaptations.
oping and maintaining relationships with patients
who are impaired in their ability to trust and coop-
erate with others, find it difficult to express their Cultural Dynamics of
thoughts and feelings, and are unable to interact in
a socially acceptable manner” (p. 544). Antisocial Criminal Justice and
personality and other personality disorders are com- Forensic Mental Health
monly encountered in the criminal justice system. In
the United Kingdom (2009), an estimated “60–80% Contexts
of male prisoners and 50% of female prisoners have
Barriers, contextual features, or cultural dynamics
a personality disorder diagnosis compared with
of multiple systems also may affect transition into
6–15% of the general population” (Sainsbury Centre
the community. The occupational therapist must
for Mental Health [SCMH], 2009, p. 3).
be aware of difficulties the individual may experi-
Diligent risk assessment and risk management
ence living in an institution, jail, or forensic hospital
must be a part of daily practice when working in the
that may impact his or her ability to make decisions,
community with individuals with mental illness and
practice choice, or implement the principles of
criminal justice histories. Occupational therapists
recovery. Examples of concerns specific to the
must implement strategies to manage difficult
following three contexts will be explored:
behavior and prevent violence. Understanding the
organizational priorities and operation of commu- • institutional jail/maximum security hospital
nity agencies is crucial. For example, a common • person
challenge may be the seeming lack of formal, struc- • community agency
tured rules and rule enforcement for extreme aber-
rant behavior within a residence, work, or day
program. Identifying consequences for breaking
Institutional Jail/Maximum
those rules is usually viewed as non-normalizing or Security Hospital
institutional; thus, the expectation is that it is the Most penal systems focus on their mandate to
clients’ responsibility to independently manage their implement punishment for crimes first and then
own behavior. Most community organizations will provide the needed mental health or substance abuse
call 9-1-1 and rely on the police to resolve the situ- treatment. Everything is considered contraband.
ation. This plan of action is considered most “nor- This can impact the individual’s performance of
malized,” and one any citizen would employ when areas of occupation (AOTA, 2008), which include
faced with a possible threat to public safety. activities of daily living (ADLs), instrumental activ-
The support and services available in community ities of daily living (IADLs), education, work, play,
settings are different from those of more structured leisure, and social participation. The opportunity to
2580_Ch21_309-320 16/07/13 3:00 PM Page 315
engage in any of these areas of occupation is severely This can increase fear and reluctance to engage in
limited for people with mental health issues living release planning. This situation can be more prob-
in any of these 24/7 types of supervised forensic lematic with people who have had an increased
environments. Regimented schedules, rules, and length of isolation from society.
regulations are part of daily life experiences over Once released, the dual stigma of mental illness
which the individual has little or no control. Most, and a criminal history with resultant gaps in work
if not all, ADLs and IADLs are completed with close history can add to the challenge of finding employ-
supervision and in groups with no autonomy to ment and successful community reentry. Upon
exercise individual preferences. The presence of cam- release, most of these individuals are faced with per-
eras, and in some settings armed guards, changes the vasive court and legal issues, requiring long-term
dynamics and health benefits of occupational monitoring. The lack of finances due to limited
engagement. For example, timing and administra- access to gainful employment while in the hospital
tion of medications are controlled by staff, and or incarcerated and no recent work history make
showers are allowed only when scheduled. Eating, a finding gainful employment a challenge. In addi-
social occupation, is usually an opportunity to select tion, laws often restrict the types of jobs or employ-
foods which gives one pleasure. This is not the case ment setting a person who has committed a serious
for individuals restricted to living in these settings. felony can access (e.g., child care, health care, teacher).
Access to food choice is extremely limited to non-
existent. The only food permitted is prepared by
dietary staff and served on a tray, with everyone eat- Community Agency Context
ing the same food. In addition, this occupation is There are unique challenges faced by clients when
heavily observed and regulated due to the need to they re-enter the community and need to meet the
count utensils before and after each meal. While expectations of the agency. These expectations may
many leisure activities are provided in forensic hos- include being completely independent in ADLs and
pital settings, they do not routinely occur in penal the ability to structure their own leisure time. Wait-
settings. Living in these environments impedes ing lists for housing are prevalent, so there is limited
decision making, and the desire to be independent to no choice in selecting their own roommates;
can be lost. There are limited to no opportunities to living with strangers or staff-assigned roommates
develop personal or professional contacts outside of becomes inevitable. The need to pay for rent, food,
the facility. For example, in maximum security pris- transportation, and medication for the first time can
ons, learning how to use public transportation has be a challenge. Agency staff are not as well versed
been considered escape planning. This limits expe- with the legal requirements that a client must follow
riences and opportunities to practice community to stay in the community; some may not be as
readiness. tolerant of “behavioral” adjustment or symptom
increase during the first few months at residence.
Person This may trigger a re-arrest or hospitalization.
Individual patients, defendants, inmates, or clients
may experience fear of the “unknown” and may be
reluctant to leave their familiar contexts. For exam- Mental Health
ple, after 30 years of institutional care, an individual Recovery Movement
scheduled for release may still be experiencing active
symptoms (e.g., being delusional, “hearing voices”) Occupational therapy, with its client-centered per-
and may dread the loss of support and acceptance spective, fits well with the principles of the recovery
from staff who in some ways have grown to be his movement. “Recovery is a unique journey for each
or her “family.” The individual has had no practice individual, and each person in recovery must choose
in being independent with IADLs, and minimal the range of services and supports ranging from clin-
knowledge or use of current technology (e.g., an ical treatment to peer services...Like other aspects of
ATM) due to limited or no community exposure. health care and unless adjudicated by courts of law,
2580_Ch21_309-320 16/07/13 3:00 PM Page 316
people have the right to choose and determine what the Duquesne University’s Occupational Therapy
services and treatments best meet their needs and Department (Eggers, Muñoz, Sciulli, & Crist,
preferences” (SAMSHA 2011b, p. 49). Pouncy and 2006). As early as 2003, this group developed
Lukens (2009) examine the inherent contradictions several community outreach projects that included
between the recovery movement and care of the a partnership with local industry, the county jail,
forensic client: and homeless shelter, providing necessary occupa-
tional therapy transition services to those released
• “The mental health recovery movement pro-
(Brachtesende, 2003).
motes patient self-determination and opposes
In addition, a Level II fieldwork program for
coercive psychiatric treatment” (p. 93).
occupational therapy students was established
• “Forensic psychiatrists routinely argue that
within a jail to assist inmates in learning about and
persons with mental illness who have commit-
practicing life skills (Provident & Joyce-Gaguzis,
ted crimes are not full moral agents” (p. 93).
2005). The program’s efforts resulted in the hiring
• “The recovery movement has not explored
of full-time occupational therapists in several com-
how its principles can extend from civil
munity settings. Although these projects did not
matters to criminal law” (p. 94).
focus solely on inmates with mental illness, these
• Limits to “moral agency in persons with
efforts identified and included services for those who
severe mental illness creates an ethical discon-
might need this support.
nect between forensic psychiatry, medical
ethics, and recovery principles” (p. 94).
It is important to recognize the possible conflicts Occupational Therapy Community
when attempting to integrate and implement the Consultation-Liaison Service
principles of recovery in community practice. It
Community providers and the literature support the
might be difficult to encourage self-determination
development of a community consultation/liaison
and empowerment without taking into considera-
service. Providing familiar, transitional therapeutic
tion judicial mandates that dictate the person’s com-
relationships to individuals moving out of the hos-
munity participation. For example, individuals who
pital, consultation with and training of community
committed a felony and wished to resume college,
staff will help to bridge the gap between the inpa-
for a career in teaching, health care, or the legal pro-
tient stay and life in the community. A consultation
fession, may not be able to work in these areas after
liaison service helps the person transfer skills learned
graduation because of their past forensic history and
in the inpatient hospital setting and adapt skills to
legal constraints. Many clients who leave the insti-
live successfully in the community.
tution, jail, or prison wish to live near friends and
In June of 2008 the Director of Rehabilitation
family but may not be able to due to restraining
Services (an occupational therapist), Social Work and
orders, victim notification, or conditional release
Psychology, of a 350-bed, state-operated behavioral
restrictions. Once again, this limits the application
/mental health inpatient hospital in Maryland decided
of some principles of recovery.
to re-examine the difficulties involved in patients’
transition to the community. The majority of patients
at this state facility are admitted through the forensic
Occupational Therapy process and were on or pending conditional release.
Community Practice The social work department requested feedback on
several clients during extended stay (i.e., a 6-month
With Persons With Mental period) discharges, in four separate and distinct
Health and Criminal Justice/ community placements.
The following client behaviors and needs were
Forensic Involvement observed by community providers:
Examples of applications to practice with the foren- • Lack of mobility/transportation skills
sic population in the United States are limited. • Lack of budgeting skills, safety skills,
However, groundbreaking work has been done by medication management skills
2580_Ch21_309-320 16/07/13 3:00 PM Page 317
• Lack of awareness of how to use entitlement the initial intake. Additional occupational therapy
funds to pay for services assessments are completed as indicated.
• Refusal to go to a physician Once the initial intake data is collected, the
• Urinary incontinence occupational therapy consultant works with the
• Difficulty with boundary issues for male client, community provider, and hospital to suggest
clients with female staff strategies to address concerns raised by all parties in
• Need for medication education regard to successful community placement. Partici-
• Need for substance abuse education; commu- pation in the consultation/liaison service is strictly
nity life provoked lapse into old lifestyle voluntary. Clients and agency visits vary from one
• Financial irresponsibility and subsequent time a week or month to once every 2–3 months as
relapse needed. The end goal is to prevent reinstitutional-
In addition, a community provider’s general ization (e.g., return to jail or hospital) and facilitate
observation about clients from the hospital was that community integration.
“Many clients are not ready for the lack of structure, Consultative visits may include, but are not lim-
lack of 24 hr. staffing, they don’t know what to do ited to, examining a client’s daily routines in detail
with unstructured time, how to cook, how to keep (i.e., by 15-minute increments), analyzing what
rooms clean, personal hygiene, how to get along occupations are causing the client difficulty. A po-
with roommates, how to handle a bank account.” tential intervention is to compare the client’s routine
Another provider commented on how helpful it was to staff routines to identify conflicts and to determine
when the client’s hospital social worker visited sev- what might be done differently by the client or staff.
eral times to ease the transition into the program. For example, a frequent source of conflict is the
Based on these findings, a new consultation liai- method used to wake a client. The client, the occu-
son service was developed by an occupational ther- pational therapist, and a staff member analyzed the
apist. Clients were referred by their current treatment situation and jointly developed a successful adaption
team and were seen if a provider: (e.g., use of multiple alarm clocks).
In order to facilitate successful community living,
• had been identified and the client had a it is helpful for the occupational therapist to analyze
targeted discharge date; the interaction of the clients’ routines and habits
• was considering accepting a client for and the contextual features of their new home. Ask-
placement but had questions or concerns; ing the following types of questions can be helpful
• requested consultation to adapt/modify in suggesting possible adaptations. Is the individual
activities or expectations for successful more successful with one staff member versus
community living for a client on a trial visit; another? If so, what can the client teach the staff
• was willing to work with a client returned member about his or her learning style? What can
from an unsuccessful stay in the community; staff teach each other about how to bring out the
• observed a client, after successful community best in the client? How does the individual cope
placement, having difficulty with daily living with staffing changes within the home?
activities and coping skills, and in danger of Another consultative strategy to maximize the
relapse. potential for successful community living is to help
Once the occupational therapy consultant receives the client and staff develop an alternate schedule
a referral, it is important to collect intake information, for the client when he or she is not well or is more
including the client’s concerns and perceived needs symptomatic. A “Plan B” is helpful in alleviating
in IADLs (e.g., health management and mainte- feelings of helplessness among the individual and
nance, safety, and emergency maintenance). In addi- staff. It involves the analysis of the occupation and
tion, clients should be asked to identify possible a recommendation as to what part of the occupation
circles of support (e.g., family, friends, staff) and can be done without exacerbating symptoms or
provide details about the perceived quality of the adding stress to the individual or staff. It requires a
relationships and the client’s expectations. The occu- partnership between the client and the staff to ob-
pational therapist uses one-on-one interviews, focus tain the appropriate supports and achieve successful
groups, and site visits to collect this information for occupational engagement.
2580_Ch21_309-320 16/07/13 3:00 PM Page 318
Conclusion deprivation in prison and how individuals miss

some of the seemingly “mundane” aspects
In order to work ethically, safely, and effectively with of everyday life. In closing she states: “I believe
individuals with mental health issues and criminal that the ordinary rhythm of daily living is the deep
justice involvement in the community, the occupa- primordial nourishment of our existence. It is the
tional therapy practitioner must be well versed in ‘truth’—the primary reality for each one of us.
multiple systems. Understanding the legal, mental After all, everyday occupation is present in our
health forensic, community corrections system, pub- lives at all times and in all places.... As occupa-
lic safety, ethics, risk management, psychiatric, and tional therapists—in this profession that we
occupational therapy principles specifically around love—we have the potential to be an exception to
difficult contexts (e.g., forensic issues/violence) is the generalized invisibility of everyday occupation
imperative. One must be knowledgeable of the pos- in people’s lives....With our clients, such a height-
sible challenges that the releasing institution, the ened awareness will enable us to enter the rich
community agency, and the individual himself pres- and singular spaces of their everyday lives, maxi-
ents to the process of transition to life in the com- mizing our abilities to work together effectively
munity. With this knowledge, occupational therapy toward the maintenance and renewal of meaning-
practitioners can facilitate clients’ reclaiming lives ful day-to-day living ... May it be so.” (Hasselkus,
outside of an institution. 2006, p. 638).
In her 2006 Eleanor Clark Slagle Lecture, May this be so with all clients, including those
Hasselkus discusses the impact of occupational with forensic and mental health issues.
CASE STUDIES
CASE STUDY 21•1 Aretha
Aretha is on conditional release after being hospitalized in a maximum security hospital for 15 years
and then transferred to a regional state psychiatric hospital for 10 years following a double homicide
(i.e., murder of both her parents). It was hard to find a community placement because of the nature of
her offense and difficulty convincing the judiciary that she was psychiatrically stable and thus less likely
to be dangerous. After several successful trial visits, Aretha was accepted to a community placement.
The agency and Aretha voluntarily agreed to visits from the occupational therapy consultant.
Several meetings were held with an agency case manager, Aretha, and the occupational therapist.
The client discussed her anxiety about having lived in a hospital for “half her life” and worried about
how to structure her time after attending the day program. Meetings focused around her goal of adjust-
ing to roommates, completing house chores, getting to know the community, and managing with
limited money.
Together, Aretha and the occupational therapist reviewed her conditional release requirements, devel-
oped simple goals, selected a bi-weekly time to meet, and discussed progress and next steps. Aretha had
many artistic hobbies (e.g., painting and playing the piano). Suggestions were made as to where she
could go in town to participate in like occupations. She was able to walk to and attend events provided
by a free arts council. A suggestion was made to visit with the local peer-run support center. Further
discussion revealed Aretha’s hesitation in meeting peers and possibly discussing her past. The therapist
commended her for “venturing out” and reassured her that there was no need to rush into what she felt
was an “uncomfortable” place or situation.
Occupational therapy consultation revolved around providing the therapeutic relationship and transi-
tional bridge between her hospitalization and the community. The client communicated her accomplish-
ments, goals, and concerns to community residential staff. The client thanked the occupational therapist
for meeting with her and stated she looked forward to their bi-weekly meetings.
2580_Ch21_309-320 16/07/13 3:00 PM Page 319

1. Would you feel comfortable working with Aretha? Why or why not?
2. What can you do to prepare yourself to work with this type of client?
3. What free activities are available in your community that Aretha might enjoy? Make a list of these
activities in rank order from least demanding to most challenging, based on your knowledge of
Aretha and activity analysis. What legal or public safety factors would need to be considered prior
to engagement in the activities?
Learning Activities Hasselkus, B. R. (2006). 2006 Eleanor Clarke Slagle

Lecture—The world of everyday occupation: Real people,
1. Review the theories discussed in Chapter 3. real lives. American Journal of Occupational Therapy, 60(6),
Then select a model and describe how you 627–640.
Manderschied, R. A., Atay, J. E., & Crider, R. A. (2009).
would use it to support your bi-weekly Changing trends in state psychiatric hospital use from
meetings. 2002 to 2005. Psychiatric Services, 60(1), 29–34.
2. Investigate whether your state has a drug or Morris, J. F. (2011). Patient abandonment. In D. Y. Slater
mental health specialty court and the level of (Ed.), Reference guide to the Occupational Therapy Code
occupational therapy involvement within the of Ethics and Ethics Standards. Bethesda, MD: American
Occupational Therapy Association.
forensic mental health system. Pouncy, C. L., & Lukens, J. M. (2009). Madness versus bad-
ness: The ethical tension between the recovery movement
and forensic psychiatry. Theoretical Medicine and Bioethics,
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Castaneda, R. (2002, April). Choice and public safety: A reha- Snively, F., & Dressler, J. (2005). Occupational therapy
bilitation professional’s role in seeking to resolve the apparent in the criminal justice system. In E. Cara & A. MacRae
conflict. Paper presented at the World Federation of (Eds.), Psychosocial occupational therapy: A clinical practice
Occupational Therapists Conference, Stockholm, Sweden. (2nd ed., pp. 567–590). Australia: Thomson Delmar
Castaneda, R. (2010). Therapeutic relationships in difficult Learning.
contexts: Involuntary commitment, forensic settings, and Steadman, H. J., Davidson, S., & Brown, C. (2001). Mental
violence. In M. K. Scheinholtz (Ed.), Occupational therapy health courts: Their promise and unanswered questions.
in mental health: Considerations for advanced practice Psychiatric Services, 52(4), 457–458.
(pp. 200–214). Bethesda, MD: AOTA Press. Substance Abuse Mental Health Systems Administration.
Collins, K., Hinkebein, G., & Schorgl, S. (n.d.). The John (2011a). FY 2011 Grant Request for Application (RFA)
Hinckley Trial & its effect on the insanity defense. In D. Grants to Develop and Expand Behavioral Health Treatment
Linder. (2002), Famous American trials: The John Hinkley Court Collaboratives. Rockville, MD: Author.
Trial, 1982. Retrieved from Substance Abuse Mental Health Systems Administration.
http://www.law.umkc.edu/faculty/projects/ftrials/ (2011b). Leading change: A plan for SAMHSA’s Roles
hinckley/hinckleyinsanity.htm and Actions 2011–2014. Rockville, MD: Author.
Eggers, M., Muñoz, J., Sciulli, J., & Crist, P. (2006). The Wexler, D. B. (1999, October 29). Therapeutic jurisprudence:
Community Reintegration Project: occupational therapy An overview. Retrieved from http://www.law.arizona.edu/
at work in a county jail. Occupational Therapy in Health depts/upr-intj/
Care, 20(1), 17–37.
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SECTION VII
Rehabilitation
and Participation
Chapter 22
Accessibility and
Community Integration
Janie B. Scott, MA, OT/L, FAOTA
Until the great mass of the people shall be filled with the sense of responsibility for each
other’s welfare, social justice can never be attained.
—Helen Keller
Learning Objectives
• Define the terms associated with accessibility and community integration.
• Discuss legislation that supports accessibility and community integration.
• Identify issues that impact home and community accessibility.
• Describe occupational therapy strategies to promote accessibility in the community.
• Discuss transportation options for community mobility.
Key Terms
Accessibility Community integration
Accommodation Community mobility
Advocacy Reasonable accommodation
Architectural barriers Stakeholders
321
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322 SECTION VII | Rehabilitation and Participation
Introduction to promote community mobility. Community in-

tegration for persons following an injury, illness,
Successful community living and occupational or exposure to war is discussed, including ways that
participation depends on the interaction of individ- occupational therapy practitioners can assist in
uals with their environments as they respond to making this transition safe and successful.
activity demands using performance skills and pat-
terns (American Occupational Therapy Association
[AOTA], 2008). Individuals with disabilities or Accessibility Issues
chronic illnesses, those who are returning home fol-
lowing a traumatic event, and those who are aging Accessibility is the “degree to which an environ-
in place may have difficulties effectively managing ment (i.e., site, facility, workplace, service or pro-
activity demands in community environments. gram) can be approached, entered, operated and/or
According to data from the U.S. Census Bureau used safely and with dignity by a person with limi-
(2010), 36 million people in the United States have tations” (Banks, 2001, p. 120). Public laws and state
at least one physical disability; this represents 12% regulations have increased accessibility to buildings,
of the civilian, non-institutionalized population. services, and opportunities by removing barriers
Five percent of children age 5–17 years, 10% of (e.g., Americans with Disabilities Act [ADA]
adults age 18–64 years, and 37% of adults 65 years of 1990, Architectural Barriers Act of 1968).
and older have a disability. Twenty-one percent of The Telecommunications Act of 1996 requires
the population age 16 and older with a disability live manufacturers of telecommunications products and
below the poverty level, as compared to 11% of the services to ensure that equipment and services are
non-disabled population of the same age (Disabled accessible to, and usable by, persons with disabilities.
World, 2011). According to the Chartbook on The occupational therapy practitioner can help
Mental Health and Disability (Jans, Stoddard, & identify appropriate devices for individual use and
Kraus, 2004), 3.5% of the adult U.S. civilian non- public accessibility. Accessibility to businesses, social
institutionalized population is estimated to have a opportunities, transportation, and other instrumen-
mental health disability (6.7 million people). This tal activities of daily living (IADLs) promotes com-
represents a significant number of community- munity participation for work, play, and leisure in
dwelling individuals who are already integrated or a variety of contexts (Fig. 22.1).
who seek assistance in identifying ways to gain Although great strides have been made in the past
accessibility and participation in community life. two decades, persons with disabilities still encounter
Chronic disease management and improved significant barriers to full participation in society,
access to preventive health care services have enabled
greater numbers of individuals to continue living
independently in the community. The numbers of
individuals with chronic illnesses and disabilities is
expected to increase in the coming years with the
aging of the baby boomer generation. These facts
make it imperative for the occupational therapy
profession to expand its community-based service
delivery focusing on accessibility, community mobil-
ity, and community integration.
This chapter contains a brief review of legisla-
tion related to accessibility and community inte-
gration for persons with disabilities. Accessibility
issues in the home and community are explored.
This includes access to public and private trans- Fig. 22•1 Making the Harbor Accessible: A Ramp
portation as well as ways that occupational therapy That Blends in With the Surroundings. (Photo by
practitioners can work with individuals and agencies Janie B. Scott, August 20, 2011)
2580_Ch22_321-331 16/07/13 3:00 PM Page 323
Chapter 22 | Accessibility and Community Integration 323
including architectural, attitudinal, technological, and Home modification can also incorporate adapta-
economic barriers. Architectural barriers, “physical tions to enhance occupational performance for per-
structures that present obstacles for individuals who sons with visual or hearing impairments. The
have mobility, visual, or sensory limitations” (Banks, technologies that are available for the home include
2001, p. 121), are the most easily changed. Home aids for the blind, computer access, environmental
and community accessibility are critical if the goal controls, speech generating devices, and cognitive
of full inclusion is to be achieved. prosthetic devices (U.S. Department of Veteran
Affairs, 2009). In addition, modifications to the
environment can support the sensory needs of resi-
Home Accessibility dents. Reducing glare, increasing color contrasts,
Individuals with disabilities or conditions that im- and improving task lighting promotes safety and
pair their performance skills may have greater diffi- comfort within the home. Electronic cognitive
culty getting around inside the home and devices help people with memory, organization, and
performing activities of daily living (ADLs). Home orientation challenges to compensate for their lim-
modifications (e.g., ramps, widened doorways, low- itations. These devices can support daily living
ered counter tops, no step entrances) increase acces- and participation in work, play, and leisure for
sibility and ultimately promote independence and people with a wide variety of mental and physical
quality of life. The majority of home modifications conditions.
are paid for privately; however, there are some pro- The Massachusetts Institute of Technology (MIT)
grams that can assist homeowners in making these and similar research centers are researching technolo-
adaptations. In some states, Medicaid programs gies that promote health and safety within the home
offer waivers (funding) for home modifications to by using computer technologies to monitor health
eligible individuals. Habitat for Humanity, Rebuild- and alert the consumer or health care provider about
ing Together, and other similar organizations offer the need to update care plans. Many technologies
assistance to individuals who need home modifica- exist that monitor the activities of individuals in the
tions. These programs welcome occupational thera- home without on-site supervision. For example,
pists as volunteers and occasionally as paid staff. there are devices that track whether a person has
The Architectural Barriers Act, Fair Housing taken his or her medications, opened the refrigerator
Act, and the Americans with Disabilities Act within a specified period of time, gotten out of bed,
address accessibility in living environments. Public or performed other activities that are important
housing is required by law “to allow persons with to health and safety. Refer to Chapter 24 for discus-
disabilities to make reasonable modifications. A rea- sion of the types of accommodations that can
sonable modification is a structural modification be made to promote community living as well as a
that is made to allow persons with disabilities the discussion of the role of occupational therapy in eval-
full enjoyment of the housing and related facilities” uation and training in the use and maintenance of
(U.S. Department of Housing and Urban Devel- these technologies.
opment, 2006, para 8). The resident is typically
responsible for paying for the modifications; how-
ever, loan or grant programs may be available to Community Accessibility
make the accommodations possible. Owners of State and federal legislation establishes rules for
public, residential properties may benefit from sub- individuals, businesses, and governments that pro-
sidies to fund the renovations. Information about tect the rights of individuals within the community,
these programs is available through local Housing often addressing issues of accessibility. Businesses,
and Urban Development (HUD) offices. Addition- health care systems, and other organizations often
ally, the Veterans Administration provides home implement access to community-based services
modification funding for eligible veterans. Finally, without the imposition of regulations. Health care
landlords may also be able to take advantage of special programs that offer telehealth services are one
loan programs offered by the federal government example. Telehealth services facilitate the monitor-
(Useful Community Development, 2011). ing of a person’s health and alert health care
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providers and caregivers when interventions may be Process, 2nd Edition (American Occupational Therapy
warranted. These programs are particularly helpful Association [AOTA], 2008) as an instrumental ac-
when the consumer lives in a remote area with poor tivity of daily living. Community mobility involves
access to health care services. Sometimes access is “moving around in the community using public or
limited due to a lack of transportation, or the private transportation such as driving, walking,
needed health care provider does not serve a partic- bicycling, or accessing and riding in buses, taxicabs
ular geographic area. Participating pharmacies may or other transportation systems” (AOTA, 2008,
ensure delivery of medications to consumers who p. 631). Some transportation services are operated
do not have transportation and for their customers’ by paid employees, and others are run by volunteers
convenience. Some pharmacies offer mail order at no cost to the individual. In order to access com-
service, and others provide home delivery and will munity services, individuals with disabilities and
set up weekly, biweekly, or monthly medication some seniors need to rely on community transporta-
boxes. tion systems for their mobility. Individuals who are
Community accessibility also includes an indi- recovering from a traumatic injury or other condi-
vidual’s physical access to community services. This tion that impairs their mobility, or individuals
is achieved by removing architectural barriers. For adapting to functional changes, may need to use
example, ramps are built to provide alternate access alternate means of transportation. Some communi-
to buildings, curb cuts are installed, restrooms are ties offer or help coordinate ride-sharing programs.
enlarged/adapted, and sign language or language For example, someone who is recovering from a
interpreter services are made available. traumatic injury may enter into an agreement with
There are many factors that make community one or more individuals that his or her car may be
integration possible. Access to education, work, used in exchange for the non-disabled individual’s
social and leisure opportunities, and health and well- driving services. Traditional ride-sharing programs
ness services is critical for individuals with new, have focused on carpooling as an environmental or
acquired, or lifelong disabilities. The occupational energy conservation strategy.
therapist uses evidence-based assessments and inter-
ventions to serve clients and can intervene directly
or through consultation with the individual, his or Personal Transportation
her representative, businesses, and agencies. Personal transportation factors are related to an indi-
Occupational therapy students, practitioners, vidual’s ability to drive, vehicle modification and main-
and others can be involved in evaluating the acces- tenance, older driver safety, driver education for special
sibility of their communities. There are many assess- groups, and the fit of the vehicle for the individual.
ment tools available to examine accessibility and Acute injury or chronic illnesses may interfere with
barriers in homes and neighborhoods. The Center the individual’s role as driver. Individuals who are
on Health Promotion Research for People with newly disabled may need occupational therapy services
Disabilities (n.d.) at the University of Chicago to develop safe driver skills or to compensate for the
provides training materials, checklists, and advocacy change in roles. Driving is an IADL and for many
activities on its Web site. Occupational therapy people in the United States is closely associated with
students and practitioners can use these materials to their personal identity and roles. Driving cessation
evaluate the accessibility of their communities and impacts an individual’s community engagement,
advocate to businesses and government for public occupational participation, and often, self-image
accommodations to meet the needs of persons with (Vrkljan & Polgar, 2007). The occupational therapy
disabilities. practitioner can explore the impact these role changes
have on the individual and significant others and sug-
gest transportation options that are available within the
Community Mobility community appropriate for the individual’s physical,
psychosocial, and financial needs. The emphasis of this
Community mobility is identified in the Occupa- collaboration is on maximizing the individual’s occu-
tional Therapy Practice Framework: Domain and pational participation. Ignoring these needs may lead
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to social deprivation, isolation, adverse health out- Transportation Safety

comes, and decreased access to health care.
There are many areas of transportation safety,
Occupational therapy helps people adjust to
including the proper use of car seats, safety seat
changed roles and develop alternate transportation
belts, and bicycle helmets. These safety features are
options. Qualified veterans can receive adaptive
regulated by individual states and their jurisdictions.
equipment for their cars or vans through the
Avoiding further injury or disability is important for
Veterans Administration. Individuals with disabil-
everyone, especially persons with disabilities. Occu-
ities with appropriate documentation may apply
pational therapists have been involved in injury pre-
to the Motor Vehicle Administration (MVA) for
vention activities focused on child safety seats, access
temporary or permanent license plates or hang
and egress to public transportation, and educating
tags to allow them to park in specially designated
transportation providers with strategies to keep pas-
parking spaces. Disabled drivers may have their
sengers safe. The Air Carrier Access Act prohibits
vehicles modified, for example, by installing hand
discrimination against individuals with disabilities
controls, or the driver may learn to use strategies
in air travel. However, if the airline determines that
to compensate for his or her disability. Occupa-
someone is unsafe to travel and can document these
tional therapy practitioners can become certified
facts, it may refuse to transport the individual.
as driving rehabilitation specialists through AOTA
In some situations, an airline can require a safety
or ADED (Association for Driver Rehabilitation
assistant for the disabled traveler (U.S. Department
Specialists). Chapter 11 discusses driving and
of Transportation, 2005).
community mobility in more detail.
Public Transportation Community Integration

Many people with disabilities rely on public trans-
portation to travel where and when they desire Community integration refers to being “happily
in order to participate in school, work, leisure, and situated, productively occupied, and effectively
health-related activities such as grocery shopping supported in the community” (McColl, Davies,
and doctor appointments. The inability to access Carlson, Johnston, & Minnes, 2001). “Reintegra-
transportation can impact social opportunities, tion” refers to returning to the community follow-
employment status, and ultimately quality of life. ing an absence due to illness, injury, or traumatic
Regulations exist that govern transportation by event. The concepts of community integration and
automobiles, trains, air travel, ships and boats, and reintegration are applicable to individuals of all
other forms of mass transit. The Americans with ages. According to McColl et al. (2001), commu-
Disability Act Amendments Act of 2008 (ADAAA) nity integration is a function of four factors: assim-
provides specific rules regarding public transporta- ilation, social support, occupation, and independent
tion, paratransit, and other publicly run services. living (Box 22-1).
Information about the ADAAA can be found at Often, reasonable accommodations are needed
http://ada.gov. Occupational therapy practitioners to facilitate the individual’s integration into the
who wish to assist their clients with reintegration community and participation in community-based
into the community and utilization of public trans- services and activities. Reasonable accommodations,
portation services should search for local or county as defined by the ADA, relate to modifications or
departments of disability, transportation, aging, or adjustments to the job application process, work
human resources. Locating on-demand, fixed-route, environment, or the ability of an employee with a
and escorted services will assist clients to utilize disability to receive benefits that are available
accessible transportation services to enhance their to other employees (U.S. Equal Employment
community participation. Occupational therapy Opportunity Commission, 2002).
practitioners can teach young and old clients how The Olmstead Act and Home and Community-
to read maps, use transportation, enter and exit Based Waiver programs were created to help individ-
vehicles, and use public conveyances. uals transition into the community and/or avoid
2580_Ch22_321-331 16/07/13 3:00 PM Page 326
Box 22-1 Components of Community Integration
Assimilation
Conformity: fitting in with other people, knowing the rules
Orientation: knowing one’s way around the community, being familiar with one’s surroundings
Acceptance: being comfortable in the community, feeling understood and acknowledged
Social Support
Close relationships: feeling connected and in close proximity to family and friends, engaged in relationships that
are important, reciprocal, mutual, and intimate
Diffuse relationships: interacting with others in the community, neighbors, service providers, co-workers, etc.
Occupation
Leisure: participating in social and recreational activities with others in the community
Productivity: making a contribution, having a sense of purpose, engaging in education, work exploration,
employment, and volunteer activities
Independent Living
Personal independence: experiencing autonomy and self-determination, having some control over one’s life
and choices
Satisfaction with living arrangement: being able to come and go as one pleases, freedom from supervision, living
independent of one’s family of origin
Data from: McColl, M. A., Davies, D., Carlson, P., Johnston, J., & Minnes, P. (2001). The Community
Integration Measure: Development and preliminary validation. Archives of Physical Medicine and
Rehabilitation, 82, 429–434.
institutionalization. Occupational therapy practition- students, employees, and employers about the needs
ers have the opportunity to facilitate community of the individual who is attempting to resume com-
integration through rehabilitation, habilitation, and munity life. These activities are best undertaken
specialized programs in both community settings and with the participation of the individual in order to
institutions. The occupational therapy emphasis is on promote his or her autonomy and privacy. Collabo-
identifying appropriate contexts for daily living, ration with community stakeholders raises awareness
work, leisure, and social participation. The occupa- that in turn facilitates successful transitions. The
tional therapy evaluation determines the client’s occupational therapy practitioner can advocate for the
occupational history, goals, and current level of func- client’s integration into the community by proposing
tion in order to maximize the client’s potential for altered work/school schedules or alternate work plans,
successful community integration. for example, telecommuting.
Occupational re-engagement may occur within
the school, home, community center, or workplace.
Family members often need assistance in how to best
Community Integration
support the individual’s functional independence and Post-Injury or Illness
autonomy. The occupational therapy process of eval- Children, youth, veterans, and adults of all ages may
uation and intervention facilitates the re-entry of the need assistance returning to the community after an
individual and creates the opportunity to support and injury or prolonged illness. Whether the individual
educate the family and caregivers. Additionally, the is recovering from a brain injury, spinal cord injury,
occupational therapist can assess the individual in the stroke, relapse from a persistent mental illness or
home and work/school environments to determine substance use disorder, amputation, or other dis-
the types of supports or environmental modifications abling condition, preparations likely have to be
that are required and facilitate the acquisition of made within the family and community. When
needed goods and services. children are transitioning from the hospital or reha-
The occupational therapy practitioner works with bilitation setting to home, they may need continued
schools and places of employment to sensitize teachers, occupational therapy services through outpatient
2580_Ch22_321-331 16/07/13 3:00 PM Page 327
clinics or home-based school, or in the classroom. develop and promote playground safety. Occupa-
Occupational therapy interventions incorporate the tional therapy practitioners may also serve as con-
child’s rehabilitation goals, academic priorities, and sultants on the construction of buildings and
social adjustment. stadiums for accessibility as well as recommend the
The home, school, or work environment may range of adaptive recreational equipment appropri-
need to be adapted to better suit the individual’s ate for community centers, public recreation pro-
mobility and occupational needs. This may take grams, and other programs where participation of
the form of increasing physical or sensory access to individuals with disabilities should be promoted.
the environment through the use of assistive tech- Occupational therapists collaborate with individ-
nologies. The occupational therapy practitioner uals and families to determine social environments
can identify accommodations that meet the indi- and opportunities that are a “good fit.” The deter-
vidual’s and family’s needs. Occupational therapy mination of fit may be based on whether social and
interventions may focus on enhancing the perform- recreational activities are in inclusive settings or
ance of ADLs or IADLs and concurrently teaching those specifically for people with disabilities. Col-
family members energy conservation techniques and laboration with the individual, family, or commu-
strategies for stress management, and helping them nity programs may provide greater exposure to play
identify community-based resources that support and leisure that may ultimately improve health and
occupational performance. The opportunity also quality of life, and decrease adverse health outcomes
exists to educate teachers, employers, and others re- among older adults and individuals with disabilities.
garding the needs of the individual and potentially
advocate when gaps in services are discovered.
Work
The unemployment and under-employment of indi-
Leisure and Recreation viduals with disabilities have been recognized for
Occupational therapy practice has stressed the im- decades. According to the U.S. Bureau of Labor Sta-
portance of balancing work, rest, and play. Engage- tistics (2011), while 69.7% of working-age adults
ment in play and leisure typically promotes a sense without a disability were employed in 2010, only
of fun or enjoyment regardless of whether the activ- 28.6% of adults with a disability were working. In
ity is planned or spontaneous. Individuals with dis- addition, the median earnings of the population age
abilities are often excluded from recreational activities 16 and older with a disability was $18, 865 in 2009,
and consequently do not have the opportunity to as compared to the median earnings of $28, 983 for
develop leisure interests and social connectedness. their non-disabled peers (Disabled World, 2011).
Occupational therapy practitioners can help individ- Occupational therapists can assess job readiness skills,
uals and families identify appropriate play and leisure identify employment opportunities in the commu-
opportunities to promote independence and social nity, determine whether the workplace is accessible,
participation. and recommend environmental modifications and
There are also national and state-specific leisure adaptations for the employee. The occupational ther-
and recreation programs accessible to people with apy practitioner is in the unique position to identify
disabilities. These programs may focus on a specific and address workplace biases, develop in-service ed-
sport (e.g., surfing) or disability (e.g., amputation) ucational programs to increase awareness, and create
and can give the participant a feeling of connected- more job opportunities for older adults and individ-
ness to a community while pursuing leisure inter- uals with disabilities. Some persons with disabilities
ests, restoring self-confidence, and developing skills will require accommodations to participate fully in
needed for occupational performance in a broader work settings.
range of activities. Accommodation is an adjustment to an environ-
Occupational therapists may develop, lead, or ment, program, or service that enables individuals
consult for programs that offer leisure activities to with disabilities to engage in occupations in similar
community-dwelling individuals with disabilities, ways as those without disabilities. “A reasonable
and work with schools and community groups to accommodation is any modification or adjustment
2580_Ch22_321-331 16/07/13 3:00 PM Page 328
to a job or the work environment that will enable a The WWP Web site provides visitors with many
qualified applicant or employee with a disability to examples of successful programs for recreation and
participate in the application process or to perform socialization for injured military personnel in com-
essential job functions. Reasonable accommodation munities around the United States. This Web site
also includes adjustments to assure that a qualified (www.woundedwarriorproject.org) posts stories
individual with a disability has rights and privileges of wounded service persons and the importance
in employment equal to those of employees without they place on becoming reintegrated into their
disabilities” (U.S. Department of Justice [USDOJ], communities and engaging in meaningful activities.
2002, ¶12).
In the case of injured workers, the worker and
the employer are stakeholders in the outcome of Advocacy
occupational therapy services. Occupational ther-
apists can provide rehabilitation interventions that Advocacy is the process of educating others to pro-
emphasize occupational performance, encourage mote opinions or views that influence policies, atti-
clients’ self-advocacy efforts, and identify environ- tudes, or the creation/modification of legislation and
mental modifications that would facilitate a return regulations. This educational process may help to
to work. remove attitudinal barriers that exist against indi-
viduals with accessibility challenges and those re-
turning to the community with disabilities or special
Wounded Warrior Project needs through enhanced awareness and sensitivity.
It can also involve teaching self-advocacy skills that
With advancements in protective gear and medical empower persons with disabilities to act or to rep-
management of battlefield injuries, an unprece- resent themselves on issues. The occupational ther-
dented number of service personnel are returning apist can teach self-advocacy strategies in classrooms,
home seriously wounded or disabled. The most clinics, homes, and elsewhere to individuals of varying
common conditions seen in returning warriors are needs and abilities.
traumatic brain injury (TBI), amputations, and In order to advocate for accessibility and commu-
post-traumatic stress disorder (PTSD). Approxi- nity integration, it is important for the occupational
mately 42,000 service members have returned therapy practitioner to identify who the stakeholders
home injured as a result of combat operations in are and promote community-based services that will
Afghanistan and Iraq from 2001 to 2011 (Wounded be most advantageous to clients. Stakeholders have
Warrior Project, 2011). an interest in particular businesses or causes, or have
The Wounded Warrior Project (WWP) was a self-interest based on personal need. Stakeholders
founded in 2003 for the purpose of raising aware- may be individuals, family members, business own-
ness of the needs of injured service members, pro- ers, employers, advocates, or government entities or
viding programs and services to meet those needs, officials. When stakeholders want to initiate services,
and facilitating the transition and reintegration of or change existing services or regulations, they be-
injured and disabled service members into their come advocates within their organization, in their
communities and into civilian life (WWP, 2011). community, or with legislators.
Services provided by the WWP include rehabili-
tation, peer support, mental health counseling,
adapted sports and recreational activities, technol- Conclusion
ogy training, employment assistance, advocacy, and
education of service personnel and their families. All As stakeholders and advocates, occupational therapy
services are free to persons with service-related ill- practitioners can use disability data to identify their
nesses, wounds, injuries, and disabilities incurred potential client base and where services may be
after the September 11, 2001, terrorist attacks on needed. This data offers a perspective on who is dis-
U.S. soil. abled, the impact of the disabilities (e.g., on ADLs
2580_Ch22_321-331 16/07/13 3:00 PM Page 329
or IADLs), the geographic distribution of the pop- may be mandated legislatively or required because
ulation, and employment status of individuals. The these concepts reflect the core values of communi-
occupational therapy practitioner can use data to ties. Individuals and groups who are stakeholders
determine where gaps in services are and how to for this population serve as advocates to increase
facilitate accessibility and community integration public awareness, create living and work opportu-
programs for people with disabilities and special nities, and facilitate transitions from more restricted
needs. Occupational therapy practitioners also need to less restricted living environments. Accessibility
to understand the population for whom special laws assessments, the development of implementation
and opportunities were established. strategies to remove barriers in built environments,
Disability data also informs community planners and programs and services will enable a greater
and health care providers regarding how to provide number of individuals to live with maximum inde-
services that meet the needs of individuals who may pendence in communities around the United
require specialized services (e.g., health care, educa- States. Consumer choice and government policies
tion, support). When demographics and trends are help guide the development and availability of ser-
understood, services can be developed or modified vices, including reduction in environmental and
that meet the current and future needs of society. programmatic barriers, and improvement in living
Occupational therapy plays an important role in environments, employment, transportation, and
assisting individuals with disabilities, recovering leisure and recreation. Occupational therapists
from traumas, and/or living with chronic condi- work with individuals, families, agencies, and com-
tions to acquire access and achieve community in- munities to support independent living and facilitate
tegration. Accessibility and community integration positive change.
CASE STUDIES
CASE STUDY 22•1 Veretta
Veretta was 19 years old and away at college when she contracted meningitis. She was hospitalized
for several weeks and was to be transferred to a nursing home in her community until she could toler-
ate a full rehabilitation program. Veretta and her family realized that about 10% of people with
meningitis do not survive (National Association of School Nurses, n.d.), and they felt fortunate even
though Veretta faced a long road in rehabilitation and potentially a life with physical challenges. At
the time of transfer, Veretta’s cognition, executive functions, and fine and gross motor coordination
were impaired.
When Veretta completed rehabilitation, she was discharged to her parents’ home. She made this move
with the hopes that this would be a temporary situation and that she eventually would be able to return
to college even though she might need physical and academic support. Veretta would continue to need
outpatient rehabilitation services to continue to strengthen her balance, motor planning, and organiza-
tional skills.

1. Contact a local college or university and discover the eligibility requirements for student disability
services. Would Veretta qualify for services?
2. Based on your assumptions of Veretta’s functioning, what occupational therapy services may be
beneficial to help her integrate back into the community?
3. What services might a Center for Independent Living (see U.S. Department of Education, 2010)
provide that could help Veretta reach her goals?
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CASE STUDY 22•2 Paul
Paul is a 61-year-old who was diagnosed with multiple sclerosis when he was in his early 40s. He has
managed his symptoms (i.e., fatigue, depression, muscle weakness, and muscle spasms) with medication
and exercise. His balance has become significantly impaired and his endurance, upper extremity
coordination, and ability to walk are also impaired. He now uses a scooter when traveling outside of his
home. Paul’s wife has been doing the majority of driving, and he wants to get his own wheels back as he
values his independence. Paul owns his own optometric business and recognizes that he will need to have
accommodations at home and at work to meet his current and future needs.

1. If Paul will need his scooter for all of his mobility needs, what environmental barriers might exist
at home and at work that require removal?
2. Visit the Job Accommodation Network (www.jan.org) Web site. Identify the type of assistance that
Paul and others with disabilities can use to modify their work sites to meet their physical and
cognitive needs. List at least three adaptations that may be useful to Paul as his needs increase.
3. Paul wants to be able to drive again. He wants to locate a driver rehabilitation specialist who can
assess his driving ability and what car/van modifications may be appropriate to meet his current and
growing needs. Locate the national resources that may help Paul find the occupational therapist with
the skill set that would be helpful. Also, visit the local Division of Rehabilitation Services or Center
for Independent Living (see U.S. Department of Education, 2010) to learn what additional services
and supports are available and their eligibility requirements.
Learning Activities local level. Identify where occupational

therapy is available and the services that
1. Visit the National Center on Workforce are available to the community. (If occupa-
and Disability Web site. Explore which of the tional therapy is not a recognized provider,
Transportation Resources are available in your suggest a minimum of three ways that
community and the eligibility requirements for occupational therapy should be involved
those services. and where to direct advocacy efforts.)
2. Individuals with disabilities continue to be
institutionalized when they would prefer to live
in the community. Consider Dave B., who was Acknowledgments: Special thanks to Melissa
injured at the age of 13 in a crash while riding Kellner, graduate assistant, Department of
his ATV. He was admitted to a nursing home Occupational Therapy and Occupational Science
following rehabilitation because his family at Towson University, for her assistance in
doubted their ability to care for him at home. updating some of the legislative information that
Identify the legislation that supports transition appears in this chapter.
from institution to community. Also identify
the state agencies that Dave’s parents would
work with to help make this transition possible. REFERENCES
3. Select one of the following laws: Rehabilitation American Occupational Therapy Association. (2008).
Act, Developmental Disabilities Act, Assistive Occupational therapy practice framework: Domain and
Technology Act, or Older Americans Act and: process (2nd ed.). Bethesda, MD: AOTA Press.
a. Determine which agency in your state is Banks, F. M. (2001). Accessibility issues. In M. E. Scaffa,
responsible for the administration and Occupational therapy in community-based practice
settings. Philadelphia: F.A. Davis.
implementation of the law. Center on Health Promotion Research for People with
b. Investigate whether occupational therapy Disabilities. (n.d.). Health Empowerment Zone: The
services are delivered through the state or Health Empowerment Zone Study Manual. University
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of Illinois at Chicago. Retrieved from http://uic-chp. U.S. Department of Housing and Urban Development,
org/Articles/HEZ/HEZ_Manual_Final_forWebsite.pdf Home & Communities. (2006). Disability Rights in
Disabled World. (2011). Latest U.S. disability statistics and Housing. Retrieved from http://hud.gov/offices/fheo/
facts. Retrieved from http://disabled-world.com/ disabilities/inhousing.cfm
disability/statistics/census-figures.php U.S. Department of Justice. (2002.) Americans with
Jans, L., Stoddard, S., & Kraus, L. (2004). Chartbook on Disabilities Act: Questions and answers. Retrieved from
mental health and disability in the United States: An http://ada.gov/q%26aeng02.htm
info use report. Washington, DC: U.S. Department of U.S. Department of Transportation. (2005). What Airline
Education, National Institute on Disability and Rehabili- Employees, Airline Contractors, and Air Travelers with
tation Research. Retrieved from http://infouse.com/ Disabilities Need to Know About Access to Air Travel for
disabilitydata/mentalhealth/index.php Persons with Disabilities. Retrieved from http://
McColl, M. A., Davies, D., Carlson, P., Johnston, J., & airconsumer.dot.gov/SA_Disability.htm
Minnes, P. (2001). The Community Integration Measure: U.S. Department of Veterans Affairs, Patient Care Services.
Development and preliminary validation. Archives of (October 27, 2009). Prosthetic and Sensory Aids Support
Physical Medicine and Rehabilitation, 82, 429–434. Veterans. Retrieved from http://www1.va.gov/women.vet/
National Association of School Nurses. (n.d.). Voices of docs/ProstheticanSensoryAids.pps
Meningitis. Retrieved from http://voicesofmeningitis.com U.S. Equal Employment Opportunity Commission. (2002).
Useful-community-development.org (2011). Government Enforcement guidance: Reasonable accommodation and undue
Housing Assistance Overview Program. Retrieved from: hardship under the Americans with disabilities act. Retrieved
http://useful-community-development.org/government- from http://eeoc.gov/policy/docs/accommodation.html
housing-assistance.html Vrkljan, B. H., & Polgar, J. M. (2007). Linking occupational
U.S. Bureau of Labor Statistics. (2011). Employment status participation and occupational identity: An exploratory
of the civilian noninstitutionalized population by disabil- study of the transition from driving to driving cessation in
ity status and age, 2009 and 2010 annual averages. older adulthood. Journal of Occupational Science, 14 (1),
Retrieved from http://bls.gov/news.release/disabl.a.htm 30–39.
U.S. Census Bureau. (2010). Selected social characteristics in Wounded Warriors Project. (2011). To honor and empower
the United States. Retrieved from http://factfinder2. wounded warriors. Retrieved from http://woundedwar-
census.gov/faces/tableservices/jsf/pages/productview.xhtml riorproject.org/mission.aspx
?pid=ACS_10_1YR_DP02&prodType=table
U.S. Department of Education. (2010). Centers for
independent living. Retrieved from http://www2.ed.gov/
programs/cil/index.html
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Chapter 23
Independent Living Centers

Courtney S. Sasse, MA EdL, MS, OTR/L
Independent living is not doing things by yourself, it is being in control of how things
are done.
—Judy Heumann in Just Like Everyone Else (World Institute on Disability, 1995, p. 8)
Learning Objectives
• List and describe the events and factors leading to the advent of the independent living movement.
• Describe the independent living philosophy.
• Identify key advocates and their associated roles in influencing the independent living movement.
• Compare and contrast the independent living movement with other civil rights movements.
• List and describe the four core services of independent living programs.
• Demonstrate an understanding of the role of occupational therapy in independent living centers.
Key Terms
Consumer control Independent living movement
Consumerism Individualized Written Independent Living Plan (IWILP)
Deinstitutionalization National Council on Independent Living (NCIL)
Demedicalization Statewide Independent Living Council (SILC)
Disability rights movement Vocational rehabilitation model
Independent Living Center (ILC) World Institute on Disability (WID)
Introduction communities of their choice (University of California

Berkeley, 2010).
The disability rights movement asserts that persons There are many similarities between the inde-
with disabilities have the same rights as their nondis- pendent living movement and the disability rights
abled peers and opposes discrimination in housing, movement. Both movements have as the primary
education, employment, and public accommoda- goal independence in thoughts, choices, decisions,
tions. The independent living movement is part of and actions for the individual with disabilities (Cen-
the broader movement for disability rights. The inter for Independent Living, SMILES, n.d.a.). The
dependent living movement is based on the prem- history, philosophy, key leaders, and advocates of
ise that all persons with disability, regardless of the the independent living movement are described in
severity, should have the right to live in settings and this chapter. In addition, the core service principles
332
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Chapter 23 | Independent Living Centers 333
of independent living programs and the role of rooted in the philosophy of normalization, founded
occupational therapy are discussed. by Canadian sociologist Wolf Wolfensburger. In
order to normalize behaviors, Wolfensburger believed
that individuals with disabilities needed exposure and
History and Philosophy immersion in living environments that mimicked
of the Independent “normal.” Deinstitutionalization was believed to sup-
port the return of people to a more normalized place.
Living Movement Although the philosophical principle was sound,
many of those who left state-run institutions found
History themselves with a lack of alternative homes and place-
Beginning as early as the 1900s, people with dis- ments due to insufficient funding and inadequate
abilities ranging from mental illness to physical political resolve. Initially intended for good purpose,
disabilities were institutionalized and dehuman- deinstitutionalization at times contributed to the
ized. State-run institutions were home to criminals, ongoing problem of a lack of suitable housing and
people with disabilities, abandoned children, and care options for those with disabilities. Many young
others shunned by society. The process of deinsti- people were wrongly placed in nursing home settings
tutionalization, or the release of persons from because of this lack of appropriate alternatives
institutions with the expectation of alternative place- (McDonald & Oxford, 1995).
ments and care within community-based settings, Simultaneously with the deinstitutionalization
began in the mid-1960s. This was an initial attempt movement, the Civil Rights Act of 1964, which
to return individuals to their family, home, or com- prohibits discrimination on the basis of race, reli-
munity of origin (McDonald & Oxford, 1995). gion, ethnicity, national origin, and creed, was
The process of giving institutionalized persons enacted. Other legislative acts that have influenced
their freedom (deinstitutionalization) was one of the the independent living movement are outlined
first recognized social movements. Deinstitutional- in Box 23-1. Many leaders of the independent living
ization, spurred by the social model of practice, is movement recall the Civil Rights Act of 1964 as
Box 23-1 Key Legislative Acts That Influenced the Independent Living Movement
• Civil Rights Act of 1964 • Established to prohibit discrimination on the basis of

race, religion, ethnicity, national origin, and creed. Later,
gender was added as a protected class.
• Rehabilitation Act of 1973 • Specific protection under Title V, Sections 501, 503, and
504, prohibits discrimination in federal programs and
services and all other programs or services receiving
federal funding.
• 1975 Education of All Handicapped Children Act, • Requires free and appropriate public education in the
Public Law 94-142 (currently recognized as the least restrictive environment possible for children with
Individuals with Disabilities Education Act (IDEA)) disabilities.
• 1975 Developmental Disabilities Bill of Rights Act • Establishes Protection and Advocacy (P&A) services for
individuals with disabilities.
• 1978 Amendments to the Rehabilitation Act • Provides for consumer-controlled independent living
centers (ILCs).
• 1983 Amendments to the Rehabilitation Act • Provides for the Client Assistance Program (CAP), an
advocacy program for consumers of rehabilitation and
independent living services.
• 1990 Americans with Disabilities Act • Provides comprehensive civil rights protection for people
with disabilities. This legislative act was modeled after the
Civil Rights Act of 1964 and Section 504 of Title V of the
Rehabilitation Act and its regulations.
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being the model and the impetus that sparked A paradigm shift was ushered in, from a medical
a realization in people with disabilities that they too model of care to a more community-based, individu-
had a unique culture. They believed they needed ally self-empowered era dominated by the social
to be a protected class, and that they should be model of care that is still growing and evolving today
afforded the same privileges that all U.S. citizens (McDonald & Oxford, 1995).
enjoy. With this realization a further push toward Consumerism, an idea and a movement that was
self-advocacy came during the era of “self-help” in popularized by its vocal advocate, Ralph Nader,
the 1970s. During this time, the capacity to help focused on societal and consumer demands for
oneself merged with the idea of peer support, and product quality, reliability, and fair pricing.
people with disabilities, particularly groups of peo- Arguably the most critical and foundational element
ple with similar types of disabilities, realized of the independent living movement is the same as
strength could be found in numbers (McDonald & that demanded in consumerism, that the user of the
Oxford, 1995). product or service has the right to control the
choices and decisions that are personally relevant,
convenient, necessary, and preferable to him or her.
Philosophy An extension of consumerism is consumer con-
The independent living philosophy emphasizes the trol, which means placing power with the consumer
rights of persons with disabilities to decide how to or empowering the individual (McDonald & Oxford,
live, work, and participate in community life, and 1995; National Council on Independent Living,
can be summarized by the principles outlined in n.d.a.; Workforce Investment Act, 1978). In the late
Box 23-2. Three of these, demedicalization, con- 1970s, Gerber DeJong developed the independent
sumerism, and consumer control, will be discussed living theory as a further extension of the principle of
here in more detail. consumer control. In this paradigm shift, the con-
Demedicalization, a movement and philosophy sumer is seen as the expert on his or her life
characterized by a more holistic approach to health choices; hence, the often-heard expression from the
care, evolved slowly and progressively from 1960 independent living movement, “Nothing about us
through 1980 but then intensified when people began without us.” Although society had long assumed the
to realize that they had the potential to change their role of attempting to “fix” people with disabilities,
own health and influence their own destiny. The the independent living paradigm helped introduce
demedicalization movement was a departure from the the idea that no medicine, program, or rehabilitation
medical profession’s authoritative reign over health could “fix” a human being. Because disability is a part
decision making and created the demand for a more of the human experience, it is not an indication of
holistic approach to health care with accessibility to a something being broken. Therefore, it is the societal
variety of health care providers. Health care provision barriers to independence and societal attitudes toward
no longer comprised medical doctors exclusively; people with disabilities that require “fixing” (Jenkins,
instead, people chose to utilize multidisciplinary teams 2011; McDonald & Oxford, 1995).
of professionals who practiced in the community.
Leaders and Advocates

Box 23-2 Principles of Independent Living
of the Independent
A Advocacy
B Barrier removal
Living Movement
C Civil rights, consumerism, and a cross-disability Ed Roberts is often called the father of the inde-
approach
D Deinstitutionalization and demedicalization
pendent living movement for his role in promoting
E Empowerment of the individual through con- self-advocacy and empowerment (Box 23-3). He
sumer control, peer role models, and self-help created the first fully funded independent living
F Fix society, not the individual with the disability center (ILC) in Berkeley, California. An ILC is a
private, non-profit, community-based, grassroots
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Box 23-3 Ed Roberts is considered the father of the Independent Living Movement. The
following is a letter written by Mr. Roberts.
Forty years ago I contracted polio. At an early age I had been taught not to stare at people with disabilities. Now
I was one of “those” people. I had been a healthy, athletic teenager. Suddenly I became a patient. But I was not,
as people thought, a helpless cripple.
In my early 20s I enrolled at the University of California. The university set up housing for me in the hospital
on campus.
There were other people like me at Berkeley. We began to discuss what we could accomplish if the school
provided services for us. We would be able to live outside of the hospital. We would be able to get into restau-
rants and other public buildings. We would be able to live a life similar to other students. We convinced the
university to provide some services, and we began to do these things.
We soon found other people like us throughout the area. The services we had initiated could help people
besides students. Shortly thereafter we sought and received funds to begin a community organization, the Center
for Independent Living. We provided information about services for people with disabilities, we had wheelchair
repair assistance, we referred attendants to people, and we provided an atmosphere for people with disabilities
to support each other. We helped make it possible for people with significant disabilities to live independent lives
in our community.
Today I travel around the country and the world speaking about the rights of people with disabilities.
Independent Living is now an international movement. Wherever I go, I hear similar concerns and needs;
people with disabilities simply want to be included in the activities of their communities.
That’s what “Independent Living” means—that every one of us (and not just people with disabilities) has
the right and capacity to participate in all of society’s activities.
From: World Institute on Disability (1995). Just like everyone else: The changing image of disability.
Oakland, CA: Author.
advocacy organization run by and for people with groups modeled how powerful a “culture” can be
disabilities. ILCs provide a wide range of services when advocating toward positive participation in the
and resources that enhance or support inclusion of community (McDonald & Oxford, 1995).
people with disabilities in all aspects of community As Ed Roberts pushed for rights for people with
living (Workforce Investment Act, 1978). disabilities on the West Coast of the United States, a
In the early 1930s, there was a powerful American teacher named Judy Heumann on the East Coast
leader who lifted U.S. citizens from the oppression of brought the battle to the New York City Board of
the Great Depression and paved the way for people Education. Heumann wanted to teach school, but
with disabilities who would follow. President Franklin when she applied for her teaching credentials she had
Delano Roosevelt contracted poliomyelitis as an adult. to be carried up two flights of steps in multiple inac-
Fear that being disabled would defeat his efforts to- cessible buildings in order to take a written exam, an
ward leadership because of the attitudes of society cre- oral exam, and submit to a physical exam. After pass-
ated his perceived need to hide his disability (Center ing the written and oral exams and learning she had
for Independent Living, SMILES, n.d.b.). Neverthe- failed the physical exam because of her inability to
less, President Roosevelt is well recognized as one of walk, she decided to take action. She sued the Board
the most powerful, popular, and productive presidents of Education, won, and was hired to teach (National
in history despite his disability. He later was revered Council on Independent Living [NCIL], n.d.b.).
as one who quietly opened the door to the reality that In 1983, the World Institute on Disability was
disability does not define, but rather ability makes founded by Ed Roberts, Judy Heumann, and an-
people powerfully shine. Additionally, disabilities other leading disabilities rights activist, Joan Leon.
activists share foundations with leagues of people who The World Institute on Disability (WID) is a
organized in the 1940s and 1950s toward political non-profit public policy, research, and training in-
change for people who were blind or deaf. In many stitute that advocates for independence and quality
ways these diagnosis-specific or disability-specific of life for all people with disabilities, regardless of
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their age. In the same year, Max Starkloff, Charlie study was the centers’ capacity for being a resource
Carr, and Marca Bristo founded the National to empower individuals with disabilities. The
Council on Independent Living. The National evaluation served three critical purposes: to provide
Council on Independent Living (NCIL) remains evidence for the consistency of ILCs in reporting
one of the only national membership organizations outcomes to the Rehabilitation Services Adminis-
that advances independent living, quality of life, tration’s Government Performance and Results
and choice for people with disabilities through con- Act reporting requirements, to assist ILCs in
sumer-controlled advocacy (NCIL, 2010). identification of best practice in service and advo-
Although the Americans with Disabilities Act cacy, and to inform advocates and legislators about
(ADA) was not passed until 1990, the original Reha- programs made possible through ILCs.
bilitation Act of 1973 had provided the legislative Data for the outcomes-based study were obtained
foundation for the ADA. Four primary people, and from three sources. A mail-out survey of all ILCs
countless others, were responsible for developing and that receive Medicare Part C federal funding was
fighting for the passage of the ADA. Justin Dart is completed. Current and former consumers, totaling
often referred to as the “spiritual leader” of the inde- 569 individuals, were selected using a random sam-
pendent living movement. Liz Savage and Pat Wright ple of 104 centers as well as an additional random
were called the maternal arms of the ADA, and sample selected at the center level to identify con-
together they worked tirelessly for the passage of sumers who would be interviewed. Finally, the
the ADA. Lex Frieden, a former chairperson of the Rehabilitation Services Administration 704 report
National Council on Disabilities, is considered the was used to select and describe the centers and the
father of the ADA. He was instrumental in conceiv- characteristics of the centers’ consumers (U.S.
ing and drafting the original ADA legislation and Department of Education, Office of Special Educa-
introducing the philosophies and ideas of the inde- tion and Rehabilitative Services, 2004). One finding
pendent living movement to the U.S. Congress for from the evaluation of ILCs was related to Statewide
the first time (McDonald & Oxford, 1995). Independent Living Councils.
It is not possible to create a fully inclusive list Independent living centers typically receive public
of the advocates who made the independent living and private grant funding, but they can also receive
movement possible. However, the unified voices federal and state funding as a result of the Workforce
of many led to more meaningful participation in Investment Act. In order to be eligible for federal and
the community for individuals with disabilities state funding, each state is required to establish a
through the development of independent living Statewide Independent Living Council (SILC).
programs. The SILC is a state agency designed to
• receive, account for, disburse, and coordinate
benefits between federal and state sources,
Independent Living • document plans recorded and received by the
state commissioner for the purposes of
Programs: Meaningful matching objectives and outcomes to
Participation in the expenditures, and
• facilitate communication between local ILCs
Community and state and federal government agencies
(Rehabilitation Services Administration,
The most prominent effect of the increasing push
2010; Workforce Investment Act, 1978).
and advocacy toward independent living and the
social paradigm, as well as the recognized emer- The survey results indicated that even though
gence of the critical importance of community 89% of the center directors believed that they had
participation, was the development within the minimal to adequate representation at the state level
community of independent living programs through their SILC, many ILC directors indicated
through ILCs. In October of 2000, an evaluative that their SILC was not measuring up to its intended
study on the role and performance outcomes of purpose of representation or its responsibility for
ILCs was conducted. The narrow focus of the meeting the requirements of the Rehabilitation Act
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Amendments (U.S. Department of Education Office for services and choices for people with disabilities
of Special Education and Rehabilitative Services, within a community to be made “by” the people
2004). The implication of this finding is what has rather than “for” or “about” the people. The concept
driven many ILCs to seek more grassroots, local of consumer control helped support advocacy ac-
community support in funding as well as in provid- tivists in creating ILCs, which led to the development
ing a powerful source of legislative strength and a of best practices for implementing community pro-
voice to state and national advocacy platforms. Other grams that would provide occupational opportunities
key findings from the Final Evaluation Report on the for all people within the community.
Centers for Independent Living (CIL) Programs are The four core services that ILCs provide for people
listed in Table 23-1. with disabilities are:
1. individual and systems advocacy,
The Four Core Services 2. information and referral,
of Independent Living 3. peer support, and
Programs and Centers 4. independent living skills training (National
Council on Independent Living).
The independent living movement envisioned a
future of equality for people with disabilities. The Through the first core service, ILC staff advocate
foundation of the independent living philosophy is on behalf of individuals and for systems change to
Table 23-1 Key Findings From the Final Evaluation Report on the Centers for Independent
Living (CIL) Programs
Key Findings Key Findings and Community Practice Implications:
One Independent Living Centers provide a variety of services while incorporating advocacy
within the community by practicing consumer empowerment and control, peer support,
and systems change across a variety of disabilities.
Two Minority groups with disabilities are being served in Independent Living Centers in
approximately the same ratio that they are present in the U.S. population.
Three Items on the evaluation related to accessibility were scored higher on average than the
other surveyed items.
Four Independent Living Centers primarily serve a population who have household incomes of
less than $20,000 per year (are considered poor), are typically unemployed or underem-
ployed, and are unmarried. These three risk factors (being unemployed, unmarried, and
poor) are correlated with a loss of independence. The typical consumers at Independent
Living Centers cannot afford many services to support their independence.
Five Clients with cognitive disabilities received fewer employment support services than other
consumer populations. Additionally, Hispanic clients were less likely to receive adaptive
technology or assistance and adaptive equipment than other populations who required
similar adaptations.
Six Significant levels of community change were reported for many centers in the areas of
transportation, housing, deinstitutionalization, education, employment, and civil rights.
Center directors reported high consumer participation in the majority of the advocacy
actions at the local level.
Seven Consumers indicated significant benefits and concrete changes in their lives as a result
of the services provided by Independent Living Centers.
Data from: U.S. Department of Education Office of Special Education and Rehabilitative Services (February 9,
2004). Final Evaluation Report on the Centers for Independent Living (CIL) Program. Rehabilitation
Services Administration, Washington, DC. Retrieved from http://ed.gov/policy/speced/leg/
eval-studies.html
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ensure the civil and human rights of persons with dis- and help individuals with disabilities rebuild their
abilities. ILC leadership can be a local source for pro- identity, improve vocational skills, and adapt to new
viding disability awareness training and advocacy situations (NCIL, Wiley, 2003). The principles of
toward enhanced accessibility and community independent living are continuously improving
mobility. ILC staff can assist individuals and families and emerging, but the four core services of ILCs
with transitions between acute rehabilitation consistently remain the foundation that supports
facilities and home, or transitions from skilled independence for people with disabilities within the
nursing facilities to independent living in the community.
community. Advocacy can result in legislation, or
alternatively, ILCs can become the watchdog that
ensures that ADA legislation is implemented The Role of Occupational
effectively (NCIL, n.d.b.).
The second core service involves providing Therapy in Independent
disability-specific information, referrals, and ac- Living Centers
cess to specific services. The goal is to provide the
information people need to initiate and maintain The principles underlying the independent living
independent living in the community. In order to movement parallel the philosophy and goals of
encourage participation and provide equitable occupational therapy. Meaningful engagement in
community experiences, a primary responsibility occupation requires choice, access, and freedom to
of ILC staff is to educate both consumers and the engage in activities that are personally relevant.
communities in which they live. Occupational therapy practitioners work to provide
The third core service, peer support, is based on accessibility in order to promote a greater degree of
the premise that peers with disabilities can be as independence among adults with disabilities. Sup-
effective as professionals in providing information porting maximum participation in work and
and support. Centers for independent living often leisure, more particularly, maximum participation
solicit peer support from within the community to in community activities for all regardless of ability,
ensure the integrity of consumer control within in- enhances quality of life and can contribute to an
dependent living programs. In this way, people who improved sense of community cohesion (American
have needs for independent living services partici- Occupational Therapy Association [AOTA], 2011;
pate in programmatic decisions. Peer support and Santoyo, 2011).
participation within the boundaries of their unique Exclusion based on physical disability is no longer
culture effectively empower people with disabilities the only consideration in accessibility. A wide variety
to direct their lives, further securing and promoting of populations with restricted capabilities are denied
independence (National Council on Independent access to participation in the community. With over
Living). half of the baby boomer generation already diag-
ILCs often design programs that utilize peer nosed with a chronic medical condition, commonly
support to provide education on skill sets necessary high blood pressure, arthritis, high cholesterol,
to navigate independence within a community diabetes, obesity, and trauma or disease-related am-
setting. Independent living skills training is the putations, the reality of accessibility becomes even
fourth core service. From an occupational therapy more critical for all community members (McUsic,
perspective, participation is often thought of as 2011). Occupational therapists have a skill set that
active engagement in occupation. However, inde- includes the ability to analyze and identify the barri-
pendent participation within the larger community ers to accessibility, which then become barriers
for people with disabilities is not successful with- to participation.
out the seamless integration of desires, choices, The independent living movement was founded
decisions, and actions being met. Through sharing on the premise of consumer control. Accessibility has
of life stories and life histories, and support historically been designed with the presumption that
of person-to-person and person-to-environment people with disabilities will be attempting to meet
interactions, ILC staff can teach coping strategies the norms of able-bodied people. Furthermore, the
2580_Ch23_332-345 16/07/13 3:04 PM Page 339
typical accessibility designs for physical adaptations their non-disabled peers (AOTA, 1993; NCIL,
assume that people with any disability, regardless n.d.c.). Research indicates that the two strongest
of the nature of the disability, require the same predictors of return to independent living at
adaptations to enhance accessibility and participa- discharge from acute care or rehabilitation, or
tion. Now we know this assumption is incorrect. following sub-acute hospitalization, are physical
Kielhofner (2002) was among the first to recognize functioning and cognitive status in older disabled
the influence of the environment on performance ca- adults. Furthermore, research supports the notion
pacity. Perhaps the most critical role for occupational that cognition is of equal value in determining
therapy in the future will be contributions to acces- fitness to live alone as physical condition (Lysack,
sibility design that align the multiple aspects of living Neufeld, Mast, MacNeill, & Lichtenberg, 2003).
with disabilities to the multiple dimensions of occu- Preventative occupational therapy interventions
pational engagement, performance capacity, envi- should reinforce the importance of community
ronmental demands, and occupational performance resources when supporting independent living in
(Jenkins, 2011). the community.
Preventative Occupational Health Promotion Services

Therapy Services One of the underlying philosophies of independent
While there are a variety of levels of prevention of living is that people with different disabilities, when
disease and disability, independent living programs linked together through common experiences and
typically focus on tertiary prevention. The focus of goals, are empowered. Not only is the empowerment
occupational intervention for people with disabilities a stimulus for advocacy and working collectively
in tertiary prevention is to minimize further dysfunc- toward positive change but also as consumer control
tion while simultaneously improving accessibility to is practiced, health promotion is an inherent result.
meaningful occupations for this population within Health promotion, or the combination of approaches
the community in a cost-effective way (Hay et al., and interventions that support positive health out-
2002; Scaffa, Desmond, & Brownson, 2001). comes, has traditionally consisted of programs that
Research by Hay et al. (2002) based on the Well- support individuals setting health-oriented goals.
Elderly Study evaluated the cost-effectiveness of a However, new programs like “Living Well with a
9-month preventive occupational therapy program Disability” incorporate a more innovative approach
for independent living older adults. The study found to independent living and health promotion by fol-
that the quality of life improvements in health, par- lowing two goals. Participants first establish goal pur-
ticipation, and function attributable to occupational suits and then encourage health behavior changes
therapy preventive interventions were significant. as objectives that focus heavily on the consumer’s
Cost-effectiveness of the services was demonstrated quality-of-life goals. Hope and positive outcomes are
by a trend toward decreasing post-intervention developed through problem solving, through the use
health care costs of participants and insurers. of attribution retraining, and by teaching positive
The goals of independent living skills training self-talk strategies (Ravesloot et al., 2007). Because
and preventive occupational therapy overlap in programs such as this promote consumer control and
many ways. Both interventions focus on adequate incorporate independent living philosophies, people
maintenance of affordable health care and the pro- with disabilities experience positive improvements in
vision of information regarding resources and health ranging from fewer limitations from secondary
options available to assist with independent living conditions and fewer unhealthy days to fewer trips to
in the community. It is the goal of occupational seek medical intervention.
therapy to help participants determine goals that are Nevertheless, positive physical changes are not
meaningful and purposeful. Independent living pro- the only significant outcomes that affect independ-
grams provide an environment where daily sched- ent living. Psychosocial and mental health improve-
ules, routines, environments, and interactions are ments have also been documented through use of
the same for people with disabilities as they are for health promotion practices (Clark et al., 2001).
2580_Ch23_332-345 16/07/13 3:04 PM Page 340
Through the independent living movement, health of the foster care system and were turned out to live
promotion can also mean promoting a culture on the streets with few resources. The lawsuit claimed
and a community where independent living is a that New York City’s child welfare system failed
way of life. Occupational therapy can support to prepare youth for independent living, leaving
independent living in the community by ensuring them uniquely “disabled” (Georgiades, 2005). From
that people with disabilities have the same choices this legislation came the inception of subsidized
with regard to housing, education, entertainment, independent living programs. Programs like this allow
transportation, and employment (World Institute teens 16 years of age or older to live in an approved
on Disability, 1995). The role of an occupational setting (which cannot be institutional), and by
therapy practitioner within the independent living meeting requirements related to education, work, and
context will consistently be to make adaptations vocational training, the teens are eligible for a mone-
to the environment that promote independence, tary stipend (Georgiades, 2005).
participation, and health. Assessment, case manage- When youth leave the foster care system, research
ment, vocational rehabilitation specialist, driving indicates that they are at an increased risk for low
assessment or driving rehabilitation specialist, levels of achievement in many domains, which often
consultant, coordinator, or director of independent presages their involvement with the criminal justice
living programs or centers are all potential roles that system and a dependency on public assistance. Youth
can be fulfilled by occupational therapists. with disabilities or complex medical needs who leave
the foster care system are at an even greater disad-
vantage, particularly if cognitive disabilities are
Services for Special Populations involved (Georgiades, 2005; Montgomery, Donkoh,
Independent living programs often target specific & Underhill, 2006). For ILCs that serve special
populations in order to more thoroughly inform populations such as children and youth, the service-
practice and concentrate services necessary for greater delivery model that often applies is the vocational
advocacy and independence of people with similar rehabilitation model. In the vocational rehabilita-
disabilities. These cohorts also often have similar tion model, participants are often required to
experiences and needs. Independent living programs commit to vocational training and form vocational
for children and youth, the elderly, and adults with goals in order to participate in the programming
acquired brain injury or spinal cord injury exist as a (Bowen, 2001).
source of support for these populations.
Regardless of the population served, ILC staff Services for Older Adults
members assess the needs and desires of the con- At the opposite end of the age continuum are older
sumer, and collaboratively determine a plan that adults, particularly those who have a long-term dis-
includes goals toward independent living in the com- ability, who will increasingly demand independent
munity and access to opportunities. An individual- living services. People who are aging with a disability
ized written independent living plan (IWILP) is require specialized programming through ILCs to
a plan that documents the rights and responsibilities support their desire to age productively within the
of the consumer and the agents of the ILC, as well communities where they live.
as a time-bound set of consumer and ILC goals and This cohort includes people who have experienced
objectives for progress toward independence of the a traumatic accident, those with degenerative dis-
individual with disability (Bowen, 2001). eases, and those who have survived poliomyelitis and
are now making adaptations in their lives to adjust
Services for Youth to post-polio syndrome (Wiley, 2003). Adaptation
When a geographical area has a greater demand for of the environment is a critical consideration for
ILCs or programs, specialty centers are sometimes cre- proponents of the independent living paradigm, as
ated. For example, legislation regarding independent disability is considered to be a human condition.
living was developed in New York in the mid-1980s Independence and quality of life are not thought to
as a response to a class action lawsuit filed by former be about changing human beings but instead about
wards of the state, teenagers who had “aged out” changing the environment to meet people’s needs.
2580_Ch23_332-345 16/07/13 3:04 PM Page 341
Independent living centers provide programs that brain injury (TBI) or spinal cord injury (SCI) and
support enabling people with chronic impairments then face a lifetime of making adaptations to pur-
to achieve a cadre of skills that produce achievements poseful occupations (Trombly, Radomski, Trexel,
of personally meaningful goals in an individual’s & Burnett-Smith, 2002). Occupational therapy
environment (Yerxa, 1998). recognizes the positive relationship between partic-
Meaningful occupation is widely recognized as ipation in goal-specific occupational therapy and
being related to well-being. Because of the advances improvement in self-identified goals in adults with
in medicine, technology, and quality of care, indi- TBI or SCI.
viduals with long-term disabilities, regardless of the When people with disabilities are considered
origin of the disability, have an increased life truly integrated into a community and products
expectancy. ILCs and the programs that they offer and services are consumer-controlled, self-identified
supply a unique set of services that meet the indi- goals are inherent in the process. Research supports
vidual at any stage following the onset or progres- that the perception of performance, satisfaction with
sion of a disability. Older adults and those with performance, and attainment of community-related
more severe cognitive impairments are likely to need skills are significantly improved and sustained by
increasing community support and community pro- individuals with TBI or SCI following occupational
gramming through ILCs for a more significant therapy intervention (Powell, Temkin, Machamer,
length of time. & Dikmen, 2007; Trombly, Radomski, Trexel, &
Just as consumer control helped shaped the inde- Burnett-Smith, 2002). Ultimately, it is both the
pendent living movement, people with disabilities goal and the challenge for occupational therapists to
who are aging should help shape the programs and encourage independence through support while
services offered in ILCs and independent living pro- mindfully considering that best practice requires
grams. In order for equality to be reached in oppor- that the client self-identifies meaningful goals and
tunities and community activities, the life stories maintains consumer control. In many respects this
of these consumers must be not only heard and con- is also the balance that is necessary for ILCs, that of
sidered but also truly embedded in advocacy efforts. facilitative support.
Occupational performance is affected by participation Although client-centered practice is considered
in meaningful activities. Performance is not possible fundamental in occupational therapy, research out-
unless active participation and engagement occurs. comes and measures often fail to compare the out-
Independence can be supported most successfully comes of an individual against either his or her
when a person’s anticipated needs and benefits self-identified goals or the functional performance
are achieved through management of a disability of those with similar disabilities and circumstances.
(Wiley, 2003). Many occupational therapy interven- Furthermore, reductions in length of stay in acute
tions, such as energy conservation, joint protection, care and rehabilitation services has meant a neces-
and physical and environmental modifications, pro- sary focus on activities of daily living (ADLs) dur-
mote the same goals for people with disabilities that ing this time, and instrumental activities of daily
the independent living movement demands, those of living (IADLs), which are of critical importance
independence and participation. for independent living in the community, have re-
ceived less attention (Powell, Temkin, Machamer,
Services for Persons With Brain & Dikmen, 2007).
and Spinal Cord Injuries
Although some special populations who use inde-
pendent living services are defined by age, such as The Future of Independent
children, youth, and the elderly with chronic health
conditions or disabilities, several special popula-
Living Centers
tions for whom independent living services are crit- The traditional service delivery model of ILCs has
ically necessary are defined by particular diagnoses. included providing site-based resources and sup-
Every year it is estimated that more than 2 million port in a consumer-controlled context. Today’s
people survive an incident that produces traumatic technology and the Internet have made advances,
2580_Ch23_332-345 16/07/13 3:04 PM Page 342
advocacy, information, and adaptation possible with the teams in ILCs and with independent living
without the need for a physical space. Consumer consumers regarding the implementation and inte-
access to resources on the Internet promotes inde- gration of computer technology for personal use.
pendence that is immediate and timely for people Accessibility continues to be enhanced by the emer-
with disabilities. The core principles and services gence of more advanced universal design features.
of independent living—advocacy, information and As universal design is integrated into society, ILCs
referrals, peer support, and independent living will continue to advocate for fair and equitable use
skills training—are now widely available and of technology toward the goal of independence and
accessible to individuals with disabilities. In the community participation for people with disabili-
presence of so many avenues of support and possi- ties, just as they have advocated for the enactment
bility, the Internet is perhaps the most influential of independent living practices historically.
tool of empowerment for advancement of the phi-
losophy of equal opportunity and equal engage-
ment that is held in such high regard for Conclusion
independent living consumers and advocates. Ful-
filling community participation for consumers Effectively participating in meaningful occupations
of independent living requires equal access to em- for people with a chronic illness or disability has
ployment opportunities, assistance with daily liv- historically been filled with challenge and discrim-
ing activities, housing options, and meaningful ination (Persson & Rydén, 2006). The independent
occupational engagement with social participation living movement can be credited with removing
that includes effective interpersonal relationships barriers that changed community life for people
with others (Ritchie & Blanck, 2003). with disabilities. Today, though much work re-
Sources of financial support and budgets of ILCs mains to be done in the form of advocacy, the focus
vary widely and are typically determined by the is now on what can be accomplished rather than
level of state funding used to supplement funds re- what cannot be accomplished.
ceived from Title VII of the Rehabilitation Act of In many ways, people with disabilities and mi-
1973, as amended in 1998. Therefore, it is fairly nority populations became the teachers and the
common for an ILC to have a modest budget and rest of society became the students, learning from
serve multiple cities across several counties. The In- those involved in the civil rights movement, the
ternet has also made services and resources more Americans with disabilities movement, and the in-
widely available through ILCs and accessible across dependent living movement. These populations
the miles (Ritchie & Blanck, 2003). Since accessi- find new ways to participate in their community
bility and availability of technology and Internet and in meaningful occupation, often demonstrat-
use can be hindered by financial constraints, many ing self-reliance and self-advocacy that is admirable
grant-based funding opportunities exist for sup- (Yerxa, 1993). Persons with disabilities have taught
porting IL programs that integrate technology into society that coping with disability is as individual
communities with restricted access (Rehabilitation as people are and that with community support,
Services Administration, 2010). they have used resiliency and hope to become a
Other than financial constraints, the most com- culture of “I CAN.”
mon barrier to effective use of technology to support People with disabilities find meaning in occupa-
independent living is the lack of knowledge, train- tion when they can live as independently as possible.
ing, and/or practice opportunities for consumers. Occupational therapy practitioners are trained
Since the Internet is arguably one of the most effec- to support adaptations, promote occupational bal-
tive consumer voices for choice, the ability of the ance, and help people develop and maintain
consumer to use a computer has become an inde- independent living skills and manage their environ-
pendent living skill (Ritchie & Blanck, 2003). ments. Occupational therapy practitioners are there-
Occupational therapists whose specialty is adaptive fore valuable assets to ILCs and the independent
technology can play an important role in consulting living movement.
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CASE STUDIES
CASE STUDY 23•1 Marianne
Marianne is a 37-year-old female diagnosed with early onset multiple sclerosis (MS). She lives with her
husband and two children in a two-story home. She has had a very difficult time coping since the onset
of her initial symptoms and dealing emotionally with the news of her diagnosis. Many of her friends are
not sure what her needs are and do not visit with her as frequently as they used to. Marianne feels lonely
and isolated. She can still perform most of her ADLs and IADLs with little assistance when she is not
experiencing exacerbations of the disease. Nevertheless, she and her husband realize that her functional
decline could happen quickly, so they would like to begin to make some preparations to their home and
their lifestyle.
During a recent visit with her occupational therapist at an outpatient rehabilitation center, Marianne
discussed the emotional burden and worry that her diagnosis had brought on. Marianne’s husband,
who also was present during the visit, openly discussed the worry and concern he had about Marianne
being able to continue to care for herself and the children with the progression of her disease.
Marianne tearfully acknowledged that she had stopped driving the children to their extracurricular
activities because one of her earliest symptoms was blurred vision and at times even double vision.
She also mentioned that one of the most difficult tasks she faces involves helping her children
understand what is happening to her.
Marianne had worked for much of her adult life as a paralegal assistant. She also delivered a variety of
legal documents around town when needed, as a temporary courier for the same law firm that employed
her for paralegal functions. She feared not only that her progressive eyesight problems would soon pre-
vent her from driving safely but also that her ability to see the legal documents on her computer screen
would become so impaired that she would no longer be able to perform her work tasks.
Marianne’s occupational therapist recommended that Marianne and her husband contact the
ILC in their town. The occupational therapist suggested that the ILC might be a source of informa-
tion on resources available in the community for assisting with changes that needed to be made as
her MS progressed. Marianne decided after several weeks of contemplation to contact the ILC. An
independent living specialist made an appointment for the following day to meet Marianne and her
husband.
The initial meeting felt somewhat awkward to Marianne because, as she later told her IL case manager,
at first she wasn’t ready to acknowledge that her condition was disabling. The sincerity, friendship, trust,
and rapport that she soon built with her case manager changed those initial feelings. The services that
followed for Marianne and her family included referrals to support groups for her and her husband.
Meeting other families who were dealing with MS was a comfort as well as an opportunity to socialize
with others, alleviating the feelings of social isolation she had experienced.
Marianne also began attending computer classes at the ILC, where she learned a variety of programs
that would allow her to do her paralegal work from home and maintain her job. Marianne became a
skilled user of community transportation, which enhanced her feelings of independence and eased her
husband’s caregiver burden. Finally, and perhaps most importantly, one of the friends that she made
at the support group told her about a counselor who specialized in grief counseling. Marianne began
weekly visits with the counselor to help alleviate the depression and grief that she felt over her loss of
independence. Her counselor also helped guide her and her husband through the process of counseling
their children through the progression of her disease. Marianne was grateful for the regained sense of
independence she felt that began with the support she received through her occupational therapist
and the ILC.
Continued
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CASE STUDY 23•1 Marianne cont’d

1. Based on the information provided in the case study, what are some additional recommendations
that Marianne’s occupational therapist could have provided?
2. Other than the services that Marianne took advantage of as suggested by her IL case manager,
research two other services, referrals, or recommendations that the IL manager could have suggested.
3. Discuss how the four core services of ILCs are demonstrated in the case study.
4. Define “health promotion” as related to occupational therapy and independent living programs.
Discuss how Marianne’s IL case manager has supported health promotion.
5. What are three ways that Marianne’s community and family will benefit from the services provided
for her at the ILC?
Learning Activities REFERENCES

1. Instead of saying ..., say .... Statement: The role of occupational therapy in the
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• Instead of saying the disabled, say.... Bowen, R. E. (2001). Independent living programs. In M. E.
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say .... ent living advocate. Retrieved from http://smilescil.org/
• Instead of saying crippled, say.... about/independent-living-philosophy/advocates-in-the-
• Instead of saying insane or crazy, say .... independent-living-movement
Clark, F., Azen, S. P., Carlson, M., Mandel, D., LaBree, L.,
• Instead of saying AIDS victim, say .... Hay, J., Lipson, L. (2001). Embedding health-promoting
Data from: United Cerebral Palsy Associations, Incorporated changes into the daily lives of independent-living older
(UCPA Public Service Announcement, n.d.). The ten adults: Long-term follow-up of occupational therapy
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care system: The state of the evidence. Children and Youth Smith, S. E. (2002). Occupational therapy and achieve-
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National Council on Independent Living. (2010). Annual drilm/introduction.html
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Persson, L. O., & Ryden, A. (2006). Themes of effective and Rehabilitative Services (February 9, 2004). Final
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26 persons who have learnt to live with their disability. (CIL) program. Rehabilitation Services Administration,
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Powell, J. M., Temkin, N. R., Machamer, J. E., & Dikmen, speced/leg/eval-studies.html
S. S. (2007). Gaining insight into patients’ perspectives Wiley, E. A. (2003). Aging with a long-term disability: Voices
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Therapy, 61, 269–279. Workforce Investment Act. (1978). Title VII of the Rehabili-
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D. E., & White, G. (2007). Health promotion for people living services and centers for independent living. Chapters 1
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Research, 22(4), 522–531. doi: 10.1093/her/cyl114 The changing image of disability. Oakland, CA: Author.
Rehabilitation Services Administration. (2010). Center for Yerxa, E. J. (1993). Occupational science: A new source of
independent living discretionary/competitive grants. power for participants in occupational therapy.
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index.html Yerxa, E. J. (1998). Health and the human spirit for occupation.
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Chapter 24
Technology and Environmental

Interventions in Community-Based
Practice
Rebecca I. Estes, PhD, OTR/L, Paula Lowrey, MOT, OTR/L, and Mary Frances
Baxter, PhD, OT, FAOTA
It’s mind-boggling when you think of the things that they’re coming up with. What higher-
level quads like me couldn’t do before, we can do now. What a big incentive to keep going.
There are so many advantages...I mean, I’m glad I broke my neck in this century!
—Sherer (1996, p. 15)
Learning Objectives
• Understand the breadth and depth of occupational therapy practice in technology and environmental interventions.
• Describe the key concepts and scope of technology and environmental interventions.
• Identify the principles of universal design.
• Describe some common home modifications recommended by occupational therapy practitioners.
• Discuss the multiple roles and level of training for occupational therapists providing community-based technology
and environmental interventions.
Key Terms
Advanced level TEI service Home modification process
Assistive technology devices Home modification product
Assistive technology services Input devices
Augmentative or alternative communication system Output devices
Electronic aid to daily living (EADL) Universal design
Entry level of TEI service Wheeled mobility
Home modification
Introduction This practice area encompasses technology, including

assistive technology services and device prescription,
The term technology and environmental intervention at both the entry and advanced level as well as elec-
(TEI) was coined to embody the vast array of tronic, information, rehabilitation, and educational
interventions occupational therapists may employ with technologies.
individuals with disabilities to facilitate full engagement The Assistive Technology Act of 2004 (Public Law
in occupations in accessible environments (American [P.L.] 108-364) defines assistive technology devices
Occupational Therapy Association [AOTA], 2009). and assistive technology services, respectively,
346
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Chapter 24 | Technology and Environmental Interventions in Community-Based Practice 347
as: “any item, piece of equipment or product sys- breadth of service provision, as identified by the
tems, whether acquired commercially off the shelf, AOTA’s Centennial Vision, will be discussed as it
modified, or customized, that is used to increase, relates to community-based TEI practice settings,
maintain, or improve functional capabilities of indi- rather than the depth or details of the multitude
viduals with disabilities” (p. 4); “any service that of service provision areas available.
directly assists an individual with a disability in the
selection, acquisition, or use of an assistive technology
device” (pp. 4–5). Technology and
Given these definitions, entry-level occupational
therapists who provide low-tech devices such as Environmental
reachers and sock aids, as well as advanced practice Intervention Outcomes
therapists who provide powered wheeled mobility
equipment, computer adaptations, and augmenta- The occupational therapist may approach technol-
tive communications devices, are all providing ogy and environmental interventions using any
assistive technology devices and services. Assistive of the current occupation-based theoretical models
technology devices include appliances or installed used in professional practice, such as the Model
equipment (e.g., hospital beds); assistive tools of Human Occupation, Occupational Adaptation,
that are used to access inaccessible items or devices Ecology of Human Performance, or the Person-
(e.g., sip-and-puff wheelchair control); prostheses; Environment-Occupational-Performance Model
and items that assist, augment, or compensate for (Cole & Tufano, 2008). These models take a holis-
existing function (e.g., cognitive aids for memory tic approach and consider all aspects of client needs
recall). within the multiple contexts and environments
The AOTA (2009) suggests that occupational in which their occupations are performed. Models
therapists may employ TEI interventions at an discussed specifically as they apply to assistive tech-
entry level of TEI service by providing the delivery nology interventions may also guide the therapist
and coordination of technologies basic to occupa- providing TEI, such as the Matching Persons and
tional performance, acting as an advocate for the Technology Model, the Human Activity Assistive
client, and acting as a gatekeeper for multiple Technology Model, and the Canadian Model
technology specialist referrals and communication. of Occupational Performance (Cook, Polgar, &
Therapists who provide more advanced level Hussey, 2008).
TEI services are involved with the integration of The evaluation of TEI outcomes requires the
multiple technological devices and deliver more application of appropriate assessments and estab-
complicated, involved arrangements of technology lishment of the appropriate team for the tasks. In
and environmental modifications. TEI, the team includes not only the therapist
Whereas entry-level TEI provision is within and consumer (client, family, caregivers, and
the skill level of all occupational therapists, the provi- significant others) but may also include a variety
sion of advanced level services requires additional of specialists, such as assistive technology practi-
training. Historically, occupational therapists have tioners, educators, rehabilitation engineers and
incorporated current technologies within interven- machinists, vendors, product distributors and
tions. Today, although computers and information manufacturers, architects, contractors and builders,
technologies are commonplace, they are not com- and funders. The team members, whether assem-
monly used in intervention. Combining assistive tech- bled or brought in as consultants, will depend on
nology with environmental interventions demonstrates the type, extent, and complexity of the TEI being
the roles occupational therapists have in accessibility provided. The assessments chosen must be com-
and modification of the different contexts in which patible with the types of outcomes being consid-
clients perform their occupations. ered. While no single evaluation tool is universally
This chapter will focus on the roles of the applicable or universally accepted, general guide-
occupational therapist in both emerging and lines are established and a variety of tools are avail-
established community-based TEI practice. The able for TEI outcomes assessment.
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Evaluation of TEI outcomes by the occupational universal design was coined by Ron Mace, a faculty
therapist begins with documentation of the client’s member at North Carolina State University, home to
baseline performance, which may be with no tech- the Center for Universal Design (CUD). Universal
nology device or environmental intervention, or it design is defined as “the design of products and envi-
may be while using a current but outmoded or out- ronments to be usable by all people, to the greatest
grown technology device or environmental interven- extent possible, without the need for adaptation or
tion. Traditional occupational therapy assessments specialized design” (CUD, 1998, p. 2). Universal
may be used to obtain information on performance design principles (Table 24-1) were established
skills such as speed, accuracy, reliability, and fatigue in 1997 by architects, product designers, engineers,
and endurance. Traditional evaluations may also be and environmental design researchers so products and
used to assess the impact of environmental features environments would meet the needs of potential
on performance. Evaluations may be used to deter- users with a wide variety of characteristics (CUD,
mine the primary physical environments, what is 1998). These principles suggest that items designed
done in each environment, how transitions between for universal access should have equitable use,
environments occur, whether each environment is with identical means of access for all users; accom-
accessible, and the interface and accessibility of fur- modate a wide range of users and avoid segregation
niture and other items in the environment. Once of users; be simple and intuitive to use to allow
baseline performance is assessed, a client’s seating access by individuals of varying cognitive level;
and positioning needs should be reviewed, if needed, convey information without requiring ideal condi-
related to the identified occupations and environ- tions for function; tolerate user error whether motor
ments. Complex seating and positioning may require or cognition based; require a low level of physical
specialized assessment and intervention by advanced effort to use; and be accessible as relates to both the
level therapists. size of the item and the space for approach and use
TEI-focused outcomes assessments are also avail- of the item.
able to supplement the more traditional occupational Many universal design items are developed using
therapy evaluations. Commercially available TEI anthropomorphic measurement standards in order
evaluations may focus on matching technology with to create items aimed at a generic standard. The
the person (Assistive Technology Device Predisposi- problem with these standards is that they do not
tion Assessment; Scherer, 1998), matching the envi- fit the mainstream individual seeking universal
ronmental needs with the person (Lifespace Access design items because most standards are based on
Profile; Williams, Stemach, Wolfe, & Stanger, 1994), the 18- to 25-year-old male in the military (Panero
or evaluating the user experience and preference of & Zelnik, 1979).
specific devices (QUEST; Demers, Weiss-Lambrou, Occupational therapists acting in the role of
& Ska, 2000). Due to the high cost of high-tech practitioner, consultant, or entrepreneur and practic-
devices and some home modifications, it is common ing across all community-based settings and centen-
practice to provide trials, if at all possible, of the top nial vision areas will find that universal design
three preferred options before actually proceeding principles may be applicable and may be incorporated
with the most preferred option. Assessment and re- into interventions. Universal design principles apply
assessment must occur with each trial in order to ob- to site planning and landscaping as well as to internal
tain information on the best option for intervention building floor plans for a variety of contexts, including
with the consumer. home, work, school, or leisure. Client dwellings may
benefit from overall site planning and landscaping for
new or existing buildings, for example, installing
Universal Design maintenance-free exterior and trim; assuring that
walkways are wide and level, with little or no slope;
Environmental modification, an aspect of TEI prac- planting low maintenance trees, shrubs, and plants;
tice, encompasses the provision of home modifica- and providing accessible yard and garden areas.
tions, assessment of public areas for accessibility, and Entrances ideally would be wide enough for
application of universal design principles. The term wheelchair entry to the main floor at ground level
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Table 24-1 Universal Design Principles and Explanations (Center for Universal Design, 1998)
Principle Explanations
Equitable Use All users should be able to use the device in a similar or equivalent manner. It should be
useful and appealing to people with diverse abilities. No users should be segregated or
stigmatized, and any user should have privacy, security, and safety during use.
Flexibility in Use The design should provide a variety of methods of use in order to accommodate a wide
range of individual preferences, pace, and accuracy and precision abilities, including
right- or left-handed use.
Simple and The design should be easy to understand and be consistent with user expectations.
Intuitive Use Complexity should be minimized, information should be arranged according to impor-
tance, and prompting should be available during and after the task. The device should
accommodate a wide range of literacy and language skills regardless of the user’s
experience, knowledge, or concentration skills.
Perceptible The design should effectively provide information to the user, regardless of environment
Information or the user’s sensory abilities. Information should be provided in multiple modes
(pictorial, verbal, tactile) for important information and be compatible with alternative
access modes of individuals with sensory disabilities.
Tolerance for The design should have fail-safe features and minimizes problems and negative
Error outcomes of accidental or unintended actions. Input should be organized so those
most used are also the most accessible. Any hazardous components should be
eliminated, isolated, or shielded.
Low Physical The device should be designed for use with the body in neutral positions and avoid
Effort repetitive actions. It should be accessed efficiently and comfortably and with a minimum
of fatigue.
Size and Space The design should allow for use by a seated or standing user, with adequate line of
for Approach sight; have adequate size and surrounding space for easy approach, use of assistive
and Use devices, or personal assistance; accommodate a variety of levels of reach, differing
hand grips, and sizes, and allow use regardless of user’s body size, posture, or mobility.
with no thresholds, steps, or ramps and would have Wheeled Mobility

door locks and lever-style door handles that are easy
to operate, peepholes at various heights or sidelights, Community integration and access would be diffi-
and good lighting both inside and outside the en- cult if not impossible without mobility. Limitations
trance. Ideally, the entrance would have a roof, in mobility may be the result of a variety of disabil-
canopy, or awning for protection and provide ample ities and may manifest to varying degrees. Children
landing space both outside and inside the entry born with neuromotor conditions or who acquire
door. These are only a few examples of an extensive movement impairments early in life may never
list of potentially beneficial applications of universal ambulate and may rely on wheeled mobility
design in the home, school, or work settings. Ther- throughout life. Adults with traumatic, degenera-
apists practicing in this area need awareness of the tive, or acquired neuromotor conditions may lose
many options available to assist clients. the ability to ambulate in part or whole and may
The following section briefly describes several require wheeled mobility for some or all of their
areas of TEI practice, including wheeled mobility, mobility needs. The inability to move effectively in
communication technology, and computer access, the environment may limit the options for partici-
and ends with a discussion of home modifications pating in school activities or gainful employment.
and electronic aids to daily living. Mobility limitations affect productive aging, mental
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health, and overall general health by restricting efficiency and effectiveness of use but may be critical
social participation. In rehabilitation, there is often to the client’s independence and safety (Giesbrecht,
emphasis on safe mobility, which should include Ripat, Quanbury, & Cooper, 2009). Features such
wheeled mobility. as seat belts or harness supports are important
Wheeled mobility is commonly divided into for safety, and tilt or recline capability is important
two categories, manual wheelchairs and powered for comfort, transport, or medical reasons. Other
wheelchairs. These categories can be further divided features include a variety of armrests and foot and
into independent and dependent wheeled mobility. leg supports. These provide comfort, function, or a
The outcomes of independent mobility include combination of both.
energy efficiency and functional and safe mobility Arthanat, Nochajski, Lenker, Bauer, and Wu
in the environments in which one participates. In- (2009) identify the factors that impact success in
dependent mobility results in many secondary ben- wheelchair use. These are: the user’s perception of the
efits, such as increased participation in community effect of the wheelchair on participation in activities
activities, better access to health care, enhanced self- in contexts; the user’s perception of the ease of use,
esteem, and an increased quality of life. Independent safety, and comfort; the effective use of the wheelchair
mobility can be achieved through the use of manual as measured by the abilities and skills of the user as
wheelchairs, power wheelchairs or scooters, or a he or she interacts with the wheelchair; and the
combination of any of these and other mobility aids influence of environmental or contextual factors that
such as walkers and canes. interrelate with mobility. Kreutz and Taylor (2002)
However, independent mobility is not possible for indicate independence in community propulsion will
everyone. A child with severe spastic athetoid cerebral depend on factors such as the ability to:
palsy, a person with physical limitations and impaired
• propel on a variety of indoor and outdoor
vision, and an elderly person who is very frail are
surfaces and ability to
examples of people for whom independent mobility
ascend and descend a 1:12 ramp
may be difficult to achieve. When independence is
• manage environmental features such as curb
not possible, manual wheelchairs, operated by some-
cuts, ramps, and doors
one other than the client, strollers, and travel chairs
• transfer to and from the wheelchair
become the options of choice.
• load and unload wheelchair from a vehicle
There are many custom features for seating, po-
• manage or communicate information related
sitioning, control, and other options available in
to wheelchair maintenance and repair, includ-
both manual and powered mobility. When the cus-
ing knowledge of and access to a supplier and
tom features are combined with user input to meet
funding sources.
the users’ unique needs, an effective, efficient, and
comfortable mobility system can be created for the Pedersen and Taylor (2004) provide a detailed de-
user. Fundamental wheelchair features include: the scription of the role of the occupational therapist in
seat and back configuration (i.e., height, depth, and wheeled mobility and seating. With input from the
seat/back angle), whether the chair construction is user and other team members, the process of wheel-
rigid or is a folding wheelchair, the type and posi- chair prescription involves matching the person’s
tion of the wheels, and the type and configuration abilities with the features of the wheelchair. A knowl-
of the casters, if any. Each of these features con- edgeable wheelchair vendor or supplier is important
tributes to the stability or mobility of the wheelchair to this process and an important team member.
and therefore the smoothness of the ride and effec- A fundamental outcome of wheeled mobility is
tive and efficient use of the wheelchair. For mobil- increased level of function. Cost-effectiveness of the
ity, further consideration may be given to new wheeled mobility may also be used as a measurable
technology, such as push rim-activated wheels, outcome. Issues such as decreased need for attendant
power assist features on manual chairs, and the care, decreased occurrence of medical complications
many driving mechanisms of powered wheelchairs. such as decubiti, and reduced length of stay in reha-
Other features of the wheelchair may not impact the bilitation or long-term care facilities are justifiable
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outcomes of wheeled mobility. Additionally, wheeled enhance an individual’s communication (American

mobility can increase access to public transportation Speech-Language-Hearing Association, 1989).
and thereby potential work opportunities, and provide The features of AAC include the output, feedback,
a means to engage in or perform activities that would input method, symbol type or set and size, language
not be possible otherwise, such as attending school for storage and retrieval method, flexibility of use, porta-
a young child, participating in religious activities and bility, durability, cost (including warranty), manu-
groups for an elderly person, or caring for family facturer support, and ability to integrate with other
members (Mortenson, Miller, & Auger, 2008). devices. Because of advances in technology, these
features change rapidly (Table 24-2). Regardless, it
is important to understand the concept related to
Communication Technology each feature and how that feature may impact the
individual’s ability to use the device successfully.
Communication is a vital function for participation Communication usually falls under the purview
in daily activities, especially when the daily activities of speech language pathologists (SLPs), and many
intersect with community contexts. From simple reimbursement systems will pay for a communica-
daily greetings and pleasantries to ordering a meal tion system only when an SLP has performed the
at a restaurant to calling 911 in an emergency evaluation. The role of the occupational therapist
situation, communication takes many forms. In (OT) in the evaluation for and intervention in
ddition to verbal interactions, communication augmentative and alternative communication may
also encompasses a wide range of non-verbal forms, include evaluation of physical positioning, both of
including facial expressions, gestures, e-mail, text the individual and the AAC device, and method of
messaging and tweeting, and computer use. device access. Proper positioning of both the client’s
When communication is difficult or ineffective body and the device will optimize access and usabil-
because of impairment, independence and partic- ity. The OT also plays an integral role in analyzing
ipation in daily activities may be compromised. the activities and contexts in which the device,
The communication disability that results from strategies, or systems may be used.
impairment may be temporary or permanent, and It is important to consider that not all persons
developmental or acquired. Many impairments will be independent communicators in all situa-
affect communication, for example, children with tions. People with complex communication needs
cerebral palsy and adults who have had a cere- may not have all their needs met with any one
brovascular accident or cancer of the throat or lar- device. As mentioned earlier, a system of devices
ynx. The person’s diagnosis, symptoms, and age and techniques will increase the likelihood of par-
will uniquely influence the communication im- ticipation in community settings, yet there may still
pairment as well as his or her communication be communication barriers. One strategy for over-
needs and interventions. coming communication barriers is the use of com-
Augmentative and alternative communication munication assistants. A communication assistant
(AAC) intervention is a practice area with a focus might be used to ensure accurate or detailed com-
on increasing independence and participation, munication with a third party via face-to-face
increasing quality of life, increasing safety, improv- interactions, over the telephone, or through written
ing personal relationships, and providing access to communication. Examples of when a communica-
the environment and communities in which one tion assistant might be used are when a college
interacts. AAC intervention often provides a com- student needs to complete a written application,
bination of devices and strategies that increases com- or when a person makes an appointment for med-
munication for the recipient, often referred to as a ical care or communicates medical needs to a
communication system. An augmentative or alter- provider. Through the assistance of a communica-
native communication system is defined as a tion partner or assistant, access to and interaction
system that uses an integrated group of components in community activities may be successful (Collier,
such as symbols, aids, strategies, and techniques to McGhie-Richmond, & Self, 2010).
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Table 24-2 Descriptions of Features to Consider in AAC Device Selection

Function Purpose Feature Options
Output Helps the user interact with Auditory: digitized or synthesized
communication partners. Visual display: static vs. dynamic display, written output
Feedback As the user interacts with the Auditory: beep, click, tones
device, what type of feedback Visual: lights, written display
do they receive? Tactile: key movement, touch of keys
Input method Often motoric. How does the Direct selection: use of the fingers, hands,
user interact with the device; mouthstick to access the device
what method is used to Scanning: used with switch access; there are
access messages? multiple ways to scan and many different switches
available.
Symbol type or What symbols are used in the Symbols: Photographs, black-and-white line
set and size display; what symbols does drawings, colored line drawings, or symbol
the user understand? language systems such as Blissymbol or Minspeak.
Size matters especially for visual impairments.
Language Messages and words can be Multiple levels of display as in a dynamic display;
storage and stored in combinations for encoding through color, letters, or icons
retrieval method efficient retrieval so each Prediction: letter, word, or phrase
letter of an utterance does
not have to be accessed.
Flexibility of use Meeting the client’s needs Accommodates a variety of access methods.
Output can be modified for user needs, e.g., print
display can be enlarged. Can generate new phrases
if needed.
Portability How easy is it to carry or Weight for carrying. Method for mounting on
transport? wheelchair or walker.
Durability Will it withstand dropping, Waterproof and cushioned covers
rough use, or weather
extremes?
Cost Overall costs for use Is it covered by insurance? Is there a warranty
available in case of accident or breakage?
Manufacturer Overall support from the Is there a local product representative? How
support manufacturer available is the manufacturer?
Does it have a toll-free number, e-mail access,
and available assistance?
Integration with Can the device be used with Environmental controls, power wheelchairs,
other devices other systems? computer access
Computer Access is simple, but for those with age-related deterioration

or a disability, adaptations or alternative access
In today’s society, computers are integral to everyday may be necessary. Thus, the role of the OT in
life. Computers or computer-based devices are used this TEI practice area may be as a regional education
across the life span, by children and youth through technology specialist, as a consultant, or as a rehabil-
older adults, and across occupations and contexts, itation practitioner providing services in evaluation
from schools and universities to private homes, work, of computer access and computer use at school,
and industry. For most individuals, computer access in the home, or at a work site. Whatever the
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setting and age of the client, the evaluation of com- viewing. Voice narration may also be a built-in fea-
puter access is a process that includes assessment of ture, providing auditory output of content on the
the consumer’s abilities and limitations, analysis screen and benefitting those with visual or cogni-
of contextual and environmental factors, and match- tive limitations. A few of the keyboard and mouse
ing the client’s abilities and interests to appropriate operations that may be adjusted include:
computer access options.
• keyboard layout or use of an onscreen
keyboard,
Universal Design in Computer Use • speed of response and sensitivity,
• cursor size and shape,
As in other areas, there is a trend toward increased • alternative controls for mouse use and mouse
incorporation of universal design principles in the buttons,
development of new computer hardware, software, • visual or auditory feedback for actions
and peripherals. Numerous options abound in com- performed, and
puter peripherals with universal design characteristics • shortcuts that allow information to be auto-
such as detachable keyboards, monitors that tilt, com- matically filled in on Web addresses, routine
pact disks, external memory sticks, large hard drives, forms, and user name and password fields.
power switches and strips at convenient locations,
touch screens, and many others. Software options Additionally, numerous options are available to
with built-in universal design characteristics include make navigating the Web and use of the Web
word processing software that allows changes in the browser more streamlined and accessible.
size and/or color of the text, as well as speech-to-text
and text-to-speech options.
Numerous universal design accessibility options Adaptations for Computer Access
are now built into most computer operating sys- Alternative computer access may be considered in
tems and are available for any user population in the two broad areas of input and output devices.
any context. The Windows accessibilities options Input devices provide ways to enter information
are discussed below; however, similar options are into the computer, for example through typing on a
available for other popular computer operating computer keyboard, manipulating the mouse, or
systems. Windows accessibility options may be voicing commands. Output devices provide ways to
accessed through the accessibility wizard, control obtain information from the computer; common
panel, properties, Internet Explorer options, and examples are visually from the monitor or in written
a variety of other locations. A caution is offered to format from the printer. Alternative computer access
practitioners with limited experience: the Win- is an area in need of ongoing research to address, in
dows accessibility wizard may seem easy and sim- part, the safe use of alternative input or output
ple to use; however, while it provides alternatives devices, the issue of device abandonment, and con-
for individuals with hearing, vision, or physical cerns about unique health issues related to computer
limitations, they are “canned” alternatives and do overuse by disabled users (Burton, Nieuwenhuijsen,
not allow for the application of the great diversity & Epstein, 2008).
of options that may make the computer optimally Adaptations for inputting data to the computer
accessible to each unique client. may be found in the form of software to increase typ-
The ability to alter the display and readability of ing speed and efficiency, such as abbreviation
the content displayed on the computer screen is avail- expansion software or word prediction software.
able. These controls allow for alteration of font size Software is also available to access the keyboard from
and style and icon size as well as manipulation of the the screen level through on-screen keyboard pro-
font and background colors. These options may be grams that may be used through touch screens, scan-
useful for individuals with decreased vision, those ning, or hands-free access devices. Hardware devices
with poor figure ground discrimination, or those who that alter the method of keyboard input include
need alteration to facilitate cognitive organization. A expanded keyboards, mini keyboards, and touch
screen magnifier may be built in, allowing for mag- screens. Devices are also available that alter the
nification of specific areas the consumer has difficulty method of mouse access through infrared control,
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switch control for scanning, sip-and-puff options, adding fixtures, appliances, or features in a home;
and many others. Universal design options are also changing or adding to the structure; or automating
plentiful, such as ergonomic mouse options, track- environmental controls (Jones & Sanford, 2002).
balls, joysticks, and graphic pads. The type of alter- The modification may be as simple as an alternate
native input device must be chosen to meet the doorknob, a grab bar in the shower, or a ramp to
unique needs of individuals with disabilities. Clients provide access to the house. It may be as complex as
with spinal cord injuries may benefit from low-cost rebuilding an entire bathroom to meet a client’s
alternative computer input devices such as mouth- accessibility and functional needs. Home modifica-
sticks, sticky keys, mouth-controlled joysticks, track- tion interventions may be instrumental in provid-
balls, onscreen keyboards, mouse emulators, or ing safe, accessible housing environments across the
speech recognition software (McKinley, Tewksbury, life span and across disabling conditions, including
Sitter, Reed, & Floyd, 2004). Individuals with com- those with physical or mental health conditions.
plex or multiple motor performance impairments There is a growing need to increase awareness
will need more complex alternative computer access within our communities of the potential for home
solutions to meet their unique needs (Capilouto, modifications to allow individuals to remain in
Higginbotham, McClenaghan, Williams, & Dick- their homes.
erson, 2005; Man & Wong, 2007). The OT may simply recommend a home modi-
Adaptations for obtaining output from the com- fication product to minimize environmental
puter include options such as a larger monitors for demands on the client and/or his or her caregivers.
clients with difficulty seeing items on the screen as However, a more holistic approach, using a home
well as software programs to change text size and modification process, may be needed to meet the
text and background contrast. Various refreshable complex situational and contextual needs for pro-
braille display screen reader options are available for moting performance of occupations as indepen-
individuals who are blind to provide real-time access dently and safely as possible. A home modification
of information on the computer screen; hard copies product is defined as any alteration, adjustment, or
may be provided using a braille printer/embosser. addition to the layout or structure of the home to
Software programs may be installed that read each improve the client’s functional capability. A home
character, word, or sentence as it is typed or that modification process is a combination of activities
read all typed text or graphics on the screen and and delivery of services that contributes to change,
transform those images into voice output for clients adjustment, or addition to the home environment
with visual, cognitive, or learning disabilities who and includes assessing needs, identifying solutions,
would benefit from auditory presentation. implementing solutions, training in use of solutions,
and evaluating outcomes.
Many OTs are involved in fundamental home
Home Modifications modifications, such as replacing or adding fixtures,
appliances, or features in a home. Therapists
and Electronic Aids frequently evaluate client homes before discharge
to Daily Living and make recommendations to increase safety,
function, mobility, and access to increase the
Home modification, defined in the most straight- client’s ability to participate in activities in his or
forward way, is making changes or adaptations to a her home and community. This level of home mod-
home to increase safety, accessibility, independence, ifications includes low-tech adaptive equipment for
security, or comfort (Sanford, 2004). These changes the home, such as a tub transfer bench, grab bars,
may be needed for immediate access or may be the raised seating, brighter lighting, and many other
result of planning for needs that might arise in the recommendations.
future; either way, modifying a home is customizing Home modifications may require changing or
based on an individual’s needs to increase indepen- adding to the structure, such as when considering
dence (Sebring-Cale, 2008). Home modifications bathroom accessibility for an individual in a wheel-
may take a variety of forms, such as replacing or chair (Sebring-Cale, 2008). The first priority in
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bathrooms designed for people who use wheelchairs window treatments; or open doors. EADLs may
is adequate space for access and maneuvering. be configured to control one device or a variety
Wheelchairs need a minimum of a 32-inch door of devices. An EADL sends a signal to the device
width for a straight-in approach. If the doorway is through infrared rays, ultrasound waves, radio fre-
located in a typical hallway and requires turning a quency waves, or alternating current house wiring.
wheelchair, a 36-inch door width is needed. A home The first three utilize remote control transmitters;
modification project for a person in a wheelchair the fourth sends out its signals over the home’s elec-
may include projects such as installation of a swing- trical wires. The EADL provision requires the con-
away door hinge that will increase the width by a sideration of a variety of options including the
few inches, installation of a pocket door, or remod- number and types of devices to be controlled, type
eling to widen the doorway. Additionally, the bath- of transmission, access methods, setting changes,
room door should swing outward rather than type of user feedback provided (i.e., auditory, visual,
inward, and should be fitted with a lever-type han- or tactile), sequencing required to operate, training
dle, not a knob, for easier accessibility. For wheel- requirements, flexibility, reliability, maintenance,
chair accessibility, the shower stall should have no and price (Rakoski, 2006). Another consideration
threshold to impede entrance and exit and should is the ability of the EADL to integrate with other
include a handheld nozzle that may be accessed technologies such as computers, augmentative com-
from a seated position. Sink access may be attained munication devices, and powered wheelchair con-
by removal of vanity cabinets to provide knee space trols. The occupational therapist will need to
underneath or installation of a pedestal-style or a provide training in the use of the EADL and other
wall-mounted sink. Additional features that may be modifications after they have been installed.
needed include faucets with single lever controls, an Outcomes of improved functional performance
anti-scald temperature control, grab bars beside the after home modifications may be assessed through
tub and toilet, a bidet, a telephone, an emergency traditional occupational therapy evaluations such as
notification system, and lower light switches. the Canadian Occupational Performance Measure or
A supportive home environment is important for the Functional Performance Record. Evaluations
successful aging-in-place, and home modifications designed especially for home modifications range
can enhance the home as a place of personal and from detailed measurements to simple checklists. The
social meaning in addition to improving safety and Comprehensive Assessment and Solution Process for
comfort for the disabled or older person (Tanner, Aging Residents (CASPAR) is a home modification
Tilse, & de Jonge, 2008). With the aging of the “baby assessment tool designed for use by a health care pro-
boomers,” productive aging and aging-in-place are fessional to collect information on client goals, prob-
growing concerns, and baby boomers are a key pop- lems, and abilities (MM&I Construction & Design,
ulation that may benefit from modifications to the 2007). HomeFit is available through AARP and is a
physical environment. Home modifications can checklist of questions to help clients make a decision
accommodate individuals across the life span and on whether their home is suitable or if modifications
address the needs of most health conditions, whether need to be made. LifeEase is a company that sells a
physical, cognitive, or psychosocial. variety of computer-generated assessments that look
at environmental barriers and functional perform-
ance. Regardless of which evaluation tool is used, the
Electronic Aids to Daily Living evaluation should be performed in the home, prefer-
Making a home accessible may involve installation ably with the client present to contribute to
of an automated environmental control or elec- the evaluation of environmental requirements and
tronic aid to daily living (EADL), previously concerns, and for cultural sensitivity.
referred to as environmental control units. EADLs
range from simple to complex technology options
that provide a way to access and control items in the Funding for Home Modification
environment. These may turn on appliances, lights, Home modifications can be expensive, and funding
and small electronic devices; control thermostats or is difficult to obtain. Most modifications are paid for
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using personal savings, but there are some alterna- ascertain the needs of the client. The National Asso-
tives, such as home mortgage loans or even reverse ciation of Home Builders (NAHB) offers training to
mortgages if the client is 62 or older (Fagan, become a Certified Aging in Place Specialist (CAPS).
2007). Medicare and Medicaid generally require sub- This series of three courses teaches the strategies and
stantiation of medical necessity for any funding; techniques for marketing, designing, and building
therefore, they do not pay for most low-tech adaptive aesthetically enriching barrier-free living environ-
equipment, much less home modifications. Home ments, and addresses the communication and tech-
modifications are found in the majority of these nical needs of the older adult population. The
waivers, but coverage applies only to the limited training is available to occupational therapists, and
number of persons enrolled. Individuals with disabil- AOTA collaborates with NAHB to assure that
ities who have served in the armed forces may be occupational therapy is fully integrated into the
eligible for limited funding through the Veterans Ad- training. CAPS training and certification is valu-
ministration (VA), and some veterans may qualify for able as it increases the occupational therapists’
a VA home loan that can be used to simultaneously knowledge base and improves consultation skills
purchase and modify a home. The U.S. Department with a variety of home modification organizations
of Housing and Urban Development awards Com- and entities.
munity Block Development Grants (CBDGs) to In addition, AOTA offers an Environmental
eligible city and county housing and community de- Modification Specialty Certification, available to
velopment departments to revitalize neighborhoods all occupational therapy practitioners, that covers
and improve community facilities and services. Com- implementing environmental modifications in
munities develop their own funding priorities, and senior housing, assisted living, long-term-care
many choose to provide home modification programs facilities, and private homes. The Home Modifi-
with part of their CBDG funds. The U.S. Depart- cation Network, within the AOTA Home and
ment of Agriculture has created the Rural Develop- Community Special Interest Section, was formed
ment Home Repair Loan and Grant Programs to in 2004 and is an excellent resource for accurate
provide assistance to individuals who live in areas information and networking.
with a population fewer than 10,000. Finally, there
are a few foundations and national organizations,
such as Easter Seals, that may provide a limited Conclusion
amount of home modification funding for specific
conditions and disabilities. In some cases, automobile The role of OTs in the community-based TEI prac-
insurance policies, workers’ compensation programs, tice area is multi-faceted. Practitioners may function
accident insurance plans, or other insurance programs as consultants, entrepreneurs, educators, trainers,
will pay for home modifications, especially if the advocates, or direct service providers. OTs have ex-
need for home modifications arose as the result of an pertise and training in recommending and applying
accident or injury. TEI that may increase and promote independence,
quality of life, health, and safety in the environment
as well as prevent further decline or injury. TEI may
Advanced Training be provided, at either the entry or advanced level,
in Home Modification by a licensed occupational therapist with or with-
There are expanding opportunities available for out additional specialty certification. OTs incorpo-
occupational therapists to work with contractors rate the physical, sensory, psychological, cognitive,
as they build accessible housing. In this situation, the and social aspects of disabilities, illness, and aging
role of the occupational therapy practitioner is as as they analyze occupational performance, assess
a consultant to contractors, builders, architects, needs, identify solutions, and evaluate outcomes
remodelers, interior designers, or lawyers that spe- of TEI. OTs incorporate TEI on a daily basis in
cialize in elder law, and community programs. Fre- both traditional practice areas and emerging practice
quently, occupational therapists are a part of a team areas; this expertise in TEI is a valuable contribution
of experts that work together to meet with and to clients in their communities.
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CASE STUDIES
CASE STUDY 24•1 RP
RP is a 56-year-old female who was diagnosed with Amyotrophic Lateral Sclerosis (ALS) 8 years ago. She is
currently in a manual wheelchair that has tilt in space and recline functions, elevating leg rests, and a head
rest. She has limited mobility in her right thumb, and in neck flexion, extension, and rotation. She has no
other controllable movement. She speaks in a whisper and is able to control her eye gaze. Her mobility is
currently accomplished by her husband and caretaker pushing her wheelchair. She is experiencing ongoing,
slow deterioration in function as a result of ALS and is declining from stage 3 to stage 4. She is referred to
occupational therapy for evaluation of her technology needs. She indicates that she used to work on the
computer, using e-mail to interact with friends as well as Web sites for shopping and support group partici-
pation. She is no longer able to access the computer. Her husband reports difficulty in understanding her
and is concerned about leaving her alone in another room because he cannot hear her call for help.

1. What are the evaluation issues the occupational therapist needs to consider, and what would be the
best process to address them?
2. There are at least two major assistive technology needs imbedded in the scenario. What needs are you
able to identify? How would you prioritize the needs?
3. What specific recommendations and justification would you determine for your AT choices priori-
tized in #2 above? Resources may include the Internet, texts, journal articles, equipment catalogs,
and other professionals.
4. What considerations need to be included to address RP’s continuing functional decline as a result
of ALS?
5. What are the expected outcomes of the TEI for this scenario?
Learning Activities 3. Access the Internet and go to: http://aarp.org

Search for HomeFit and download the check-
1. Access the Internet and go to: http://lifease.com/ list. Use the checklist to evaluate your home
PracticalGuideToUniversalHomeDesign.pdf environment for an aging person with debili-
and download a free copy of “A Practical tating arthritis. What recommendations
Guide to Universal Home Design,” produced would you make after reviewing the results?
by East Metro Seniors Agenda for Independent 4. Access the Internet and go to: http://abilityhub.
Living, Saint Paul, Minnesota with support com . Click on the link on the left under
from the Minnesota Department of Human Computer Access for blind and visually
Services. Review the guide and use the checklist impaired. Explore the options listed there
to determine the accessibility of your home or and learn the difference between screen reader,
apartment for a wheelchair-bound person, an screen magnifier, and text reader. Which options
elderly person using a walker, or a person with would best suit an individual with low vision as
low vision. compared to a person who is blind?
2. Access the Internet and go to: http://microsoft. 5. Wheelchair resources.
com/enable Go to the sections on training and Access the Internet and go to: http://
guides by disability. In the Training option wheelchairnet.org. Click on the first-time
select Step-by-Step. Complete the training for user link to learn about the resources and
the Windows version you have. Experiment information available through this Web site.
with some of the options on your own computer What areas would you suggest for a client
(be sure to write down what changes you make who is new to using a wheelchair?
so you can undo them later).
2580_Ch24_346-358 16/07/13 3:12 PM Page 358
REFERENCES Jones, M. L., & Sanford, J. (2002). Home environments,

automation, and environmental controls. In D. A.
American Occupational Therapy Association (AOTA).
Olson & F. DeRuyter (Eds.), Clincian’s guide to assistive
(2009). Specialized knowledge and skills in technology
technology (pp. 405–424). St Louis, MO: Mosby.
and environmental interventions for occupational
Kreutz, D., & Taylor, S. J. (2002). Wheelchair mobility. In
therapy. American Journal of Occupational Therapy,
D. A. Olson & F. DeRuyter (Eds.), Clincian’s guide to
63(6), 1–13.
assistive technology (pp. 311–330). St Louis, MO: Mosby.
American Speech-Language-Hearing Association (ASHA).
Man, D. W. K., & Wong, M-S. L. (2007). Evaluation of
(1989). Competencies for speech language pathologists
computer-access solutions for students with quadriplegic
providing services in augmentative communication.
athetoid cerebral palsy. American Journal of Occupational
ASHA: A Journal of the American Speech-Language-Hearing
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Association, 31, 107–110.
McKinley W., Tewksbury, M. A., Sitter, P., Reed, J., &
Arthanat, S., Nochajski, S. M., Lenker, J. A., Bauer, S. B., &
Floyd, S. (2004). Assistive technology and computer
Wu, Y. W. B. (2009). Measuring usability of assistive
adaptations for individuals with spinal cord injury.
technology from a multicontextual perspective: The case
NeuroRehabilitation, 19, 141–146.
of power wheelchairs. American Journal of Occupational
MM&I Construction and Design, Inc. (2007). CASPAR:
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Comprehensive assessment and solution process for aging
Burton, M., Nieuwenhuijsen, E. R., & Epstein, M. J. (2008).
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Computer-related assistive technology: Satisfaction and
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experiences among users with disabilities. Assistive
Mortenson, W. B., Miller, W. C., & Auger, C. (2008). Issues
Technology, 20, 99–106.
for the selection of wheelchair- specific activity and
Capilouto, G. J., Higginbotham, D. J., McClenaghan, B.,
participation outcome measures: A review. Archives of
Williams, H. G., & Dickerson, J. (2005). Performance
Physical Medicine and Rehabilitation, 89, 1177–1186.
investigation of a head-operated device and expanded
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membrane cursor keys in a target acquisition task.
interior space. New York: Whitney Library of Design.
Technology and Disability, 17, 173–183.
Pedersen, J. P., & Taylor, S. J. (2004). Wheeled-mobility
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Public Law 108-364. (2004). Retrieved from http://ataporg.
Cole, M. B., & Tufano R. (2008). Applied theories in
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Rakoski, D. (2006, October). Assessment for and exploration
Collier, B., McGhie-Richmond, D., & Self, H. (2010).
of current electronic aids to daily living. Presentation at
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people who use augmentative communication. Augmenta-
Sanford, J. A. (2004, May). Definition of home modifications.
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Cook, A. M., Polgar, J. M., & Hussey, S. M. (2008).
Association Annual Conference & Expo, Minneapolis, MN.
Assistive technologies: Principles and practice. St. Louis,
Scherer, M. J. (1998). Matching persons to technology. Web-
MO: Mosby Elsevier.
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Demers, L., Weiss-Lambrou, R., & Ska, B. (2000). Item
Sebring-Cale, N. J. (2008). Accessibility issues with long-term
analysis of the Quebec User Evaluation of Satisfaction
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Sherer, M. J. (1996). Living in the state of stuck. Cambridge,
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Fagan, L. A. (2007, September). Funding sources for home
Tanner, B., Tilse, C., & de Jonge, D. (2008). Restoring and
modifications. Home and Community Health Special
sustaining home: The impact of home modifications on
Interest Section Quarterly, 14(3), 1–3.
the meaning of home for older people. Journal of Housing
Giesbrecht, E. M., Ripat, J. D., Quanbury, A. O., & Cooper,
for the Elderly, 22(3), 195–215.
J. E. (2009). Participation in community-based activities
Williams, W. B., Stemach, B., Wolfe, S., & Stanger, C.
of daily living: Comparison of a pushrim-activated,
(1994). Lifespace access profile upper extension: Assistive
power-assisted wheelchair and a power wheelchair.
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Disability and Rehabilitation: Assistive Technology, 4(3),
physical disabilities. Sebastopol, CA: Lifespace Access.
198–207.
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SECTION VIII
Health Promotion
and Wellness
Chapter 25
Occupational Therapy in
Faith-Based Organizations
Lynn M. Swedberg, MS, OT, and Shirley A. Blanchard, PhD, ABDA, OTR/L, FAOTA
I hosted a booth on “Occupational Therapy in the Church” at the American Occupational

Therapy Association Conference in St. Louis. The booth was swamped the entire time.
Practitioners said, “This is what I’ve been looking for. I’ve wanted to integrate my
faith and my practice.”
—R. Mourey, personal communication, September 4, 2009
Learning Objectives
• Discuss the rationale and roles for occupational therapy involvement in faith-based organizations.
• Identify background requirements, training needs, cautions, and resources for practitioners interested in developing
health programs in faith-based settings.
• Describe the seven functions of a faith-community health minister.
• Compare and contrast the roles of faith-community practitioner with those of home health practitioner and
faith-community nurse.
Key Terms
Denomination Health ministry
Disability ministry Missions
Faith-based intervention Parachurch
Faith-based organization Parish (or faith-community) nurse
Faith-placed Stewardship
Health minister
359
2580_Ch25_359-376 16/07/13 3:14 PM Page 360
360 SECTION VIII | Health Promotion and Wellness
Introduction (Public Health Foundation, 2002, pp. 71–72).

Eleven U.S. federal agencies have Centers for Faith-
Amid the noise of politically based health care Based and Neighborhood Partnerships, with a goal
reform, a quiet health-care revolution is taking place of coordinating agency services with local faith-
in faith communities around the United States and based organizations and with other agencies and the
many other nations. The revolution comes from the White House (Dubois, 2009).
realization that medical model interventions are not In the United States, there are an estimated
the whole answer to achieving health. Faith-based 345,000 faith communities (Peterson, Atwood, &
organizations are showing leadership in implement- Yates, 2002). Despite membership declines in main-
ing health promotion strategies that affect their line Protestant denominations, 80% self-identify as
members and reaching out to underserved popula- belonging to a faith tradition (Kosmin & Keysar,
tions in their communities. While nursing is leading 2009). Of these, 76% claim the Christian faith;
this movement, occupational therapists also are 4% relate to other religious traditions, including
playing a role. Judaism, Islam, Buddhism, and other less well-
The purpose of this chapter is to describe occu- known religions (Kosmin & Keysar, 2009); these
pational therapy in community-based, faith-based numbers are growing with the influx of immigrants
organizations. Faith-based organizations include from non-European countries (Pew Forum on
churches, synagogues, and mosques, but also out- Religion and Public Life, 2008). Recent surveys
reach programs sponsored by religious groups. These indicate that 39% of residents in the United States
may include cultural community centers, religious attend religious services once a week, 15% once
camping programs, and social service agencies that or twice a month, and another 18% attend at least
target specific populations such as people who are several times a year (Pew Forum).
homeless or recent immigrants. Some congregations are organized independently
With few exceptions (Shamberg & Kidd, 2010; of other bodies, but most are part of a larger reli-
Smith, 2003a, 2003b; Swedberg, 2001; Voltz, 2005), gious umbrella organization or denomination.
there is little published by occupational therapy prac- This means there are networks and communication
titioners working in faith-based settings, so interviews systems in place to reach large numbers of people
were a primary source of information for this chapter. and to disseminate information about new initia-
Other material comes from the literature of the nurs- tives and ideas.
ing, health promotion, health ministry, and disability
ministry fields and from the authors’ experience. Faith Communities and Health
Faith communities have provided health care and
noted the connections between physical and spiri-
Historical Background tual well-being for centuries. In the United States,
many hospitals were founded by religious organiza-
Faith Community as a Resource tions and staffed by nuns and deaconesses. When
As occupational therapy moves into the community, medicine became more science-driven and the body
faith communities are natural partners for address- was reduced to a series of organs and systems, the
ing health disparities and promoting optimal health effects of spirituality were dismissed as irrelevant,
and participation. The U.S. government has recog- and the medical community and the church went
nized the potential benefit of partnerships between separate ways (Olson, 2000).
faith-based and health care organizations and has In the late 1970s, Granger Westberg, a hospital
developed resources (e.g., National Center for chaplain, attempted to integrate spirituality and
Cultural Competence, 2001) to facilitate interac- health. He established health care clinics, operated
tion. The Healthy People 2010 initiative included in partnership with hospitals, in a number of
churches among recommended organizations that congregations (Westberg, 1999). He believed that
should be cooperating to improve health outcomes nurses were best equipped to speak the languages of
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Chapter 25 | Occupational Therapy in Faith-Based Organizations 361
the faith community and of medicine, and could and meditation are associated with positive emo-
serve as interpreters between both worlds. As med- tional responses that calm the autonomic nervous
ical practice and insurance issues became more com- system. This calming effect may reduce release of the
plex, the clinics closed, but the movement of parish stress hormones norepinephrine and cortisol, thus
nursing (now called faith-community nursing/ decreasing anxiety, blood pressure, and heart rate.
health ministry) endured and is expanding on a
worldwide basis.
and Spirituality
Spirituality and Health
The founders of occupational therapy recognized a
There is growing interest in the relationship between spiritual component as vital to restoring health,
spiritual health and well-being. Spirituality and function, and well-being (Stevenson, 2003). Reed
health research investigates assumptions such as (2006) summarized the values and beliefs of the pro-
whether religious behaviors including attending fession during the formative years, listing principles
church and praying have a positive impact on health derived from the literature of that time, including:
(Mueller, Plevak, & Rummans, 2001). Research
• “The primary goal of occupational therapy is
suggests that spirituality aids in the development of
to return the person to active life and for the
coping skills, which may result in longevity. Mueller
person to function in normal society as a
and colleagues used a meta-analysis to examine
whole person in body and soul.
health outcomes following intervention for major
• Occupational therapy is the making of a man
disease states, including cardiovascular disease and
(individual) stronger physically, mentally,
mental illness, when religion or spirituality was
and spiritually than he was before.
included. Both systolic and diastolic blood pressure
• Sick minds, bodies, and souls can be healed
levels were lower among patients with who attended
through occupation.” (pp. 24–25)
church once a week; frequent attendees who en-
gaged in private religious activities such as prayer The American Occupational Therapy Associa-
were 40% less likely to have diastolic hypertension. tion (AOTA) includes spirituality as a client factor
Religiously involved persons also were more likely within the Occupational Therapy Practice Frame-
to be compliant with pharmacological interventions work (AOTA, 2008). Values, beliefs, and spiritual-
for blood pressure. ity explain why individuals select and engage in
Persons diagnosed with depression and treated various occupations. The occupation of attending
with a combination of cognitive behavioral therapy worship services is important to the development
(CBT) and spiritual pastoral care had less post- of relationships, connectedness, meaning, beliefs,
treatment depression than with CBT alone. Reli- and well-being (Faull & Hills, 2006; Meyer, 1977;
gious involvement was associated with less anxiety Reilly, 1962). Spirituality often implies resilience
and substance abuse, and there was an inverse rela- and coping. It is a fundamental need to perceive life
tionship between suicidal ideation and attendance experiences as manageable, comprehensible, and
at religious services (Mueller et al., 2001). meaningful (Faull & Hills, 2006).
Health-related quality of life diminishes when Because illness interrupts spiritual and religious
spiritual and religious involvement is compromised. routines, occupational therapy practitioners need to
Mueller and colleagues (2001) found that persons understand how spirituality may positively affect
involved in faith communities were more likely to health during an acute episode, during the recu-
practice health-enhancing lifestyles including con- peration period, or when living with disability or
suming a healthier diet and decreased participation chronic conditions. Occupational therapy practi-
in risky behaviors such as smoking and substance tioners who practice in the medical model may per-
use. Religiously active persons were more likely to ceive that they do not have the knowledge to address
participate in health prevention screenings and com- the spiritual needs of the client (Belcham, 2004;
ply with recommended treatment. Prayer, worship, Egan & Swedersky, 2003). Occupational therapists
2580_Ch25_359-376 16/07/13 3:14 PM Page 362
use the occupational profile to connect client nar- many underserved groups have difficulty accessing
ratives to past and present life experiences and traditional health care providers (Black & Wells,
health. Similar to obtaining an occupational profile, 2007). Faith-based outreach programs within neigh-
Puchalski and Romer (2000) suggest the need for borhoods and communities may be a first point
a spiritual history using the Faith, Importance, of contact.
Community, and Address (FICA) assessment: A major area of need is the lack of accessibility
and inclusion in many faith communities. Persons
• “Faith: Do you consider yourself spiritual?
with disabilities, who could benefit from the support
Do you have a religious faith?
and fellowship they might find, are underrepresented
• Importance: How important are your religious
in nearly every congregation (Carter, 2007, p. 6).
beliefs and spirituality, and how might they
Physical inaccessibility of buildings is a primary bar-
influence decisions related to your health?
rier, yet many people with disabilities report that at-
• Community: Are you part of a religious or
titudinal and programmatic barriers have a stronger
spiritual or other community? If so, how does
impact on participation. Most able-bodied persons
this community support you?
fail to realize that a ramp alone does not guarantee
• Address: How might I address your spiritual
that persons with disabilities will feel welcome and
needs?” (Puchalski & Romer, 2000, p. 131)
included in the activities of the community (National
This tool allows the practitioner to discern the Organization on Disability, 1992). Yet having a
spiritual need of the client and whether or not ramp or level entrance is a necessary starting place.
the client is open to faith-based intervention. Faith communities have been slow to make physical
accommodations, due in part to the fact that denom-
inations lobbied for and won exemption from the
Need for Occupational landmark Americans with Disabilities Act (Pridmore,
2006). Opponents cited concerns about potential
Therapy Involvement in expenses and separation of church and state. Only
Faith-Based Organizations congregations employing more than 15 persons are
currently required to comply with the standards
Occupational therapy literature increasingly addresses for workers.
wellness (“a state of mental and physical balance and Leaders in the profession have urged practitioners
fitness” [AOTA, 2008, p. 676]) and health promo- to become involved in enhancing community par-
tion interventions. The AOTA has issued statements ticipation and inclusion (Grady, 1995; Hansen &
on the role of occupational therapy in health promo- Hinojosa, 2009; Neufeld, 2004). Yet Carter’s com-
tion and disease prevention (Scaffa, Van Slyke, prehensive book, Including People with Disabilities
& Brownson, 2008) and in the management of in Faith Communities: A Guide for Service Providers,
obesity (Reingold & Jordan, 2013), among others. Families, and Congregations (2007), has no mention
Yet the potential impact of occupational therapy skills of occupational therapy as a potential resource for
and the profession’s unique perspective are largely addressing the concerns identified.
unrecognized in the larger arenas of health ministry
and health promotion.
Health disparities point to another direction Health Ministry
that occupational therapy involvement may take
(Bass-Haugen, 2009). Persons with disabilities have Health ministry describes an overall process of
decreased access to health and wellness services health-related activities carried out in or through
(Smeltzer, 2007). Underserved and marginalized the faith community in order to promote health
populations, including Native Americans, homeless and wholeness (Chase-Ziolek, 2005; Wylie &
persons with mental illness, persons with disabilities, Solari-Twadell, 1999). Health ministry is carried
and ethnic communities, often have unmet health- out by professionals, acting on a volunteer or paid
related needs. Due to inequitable distribution of basis, with the assistance of lay volunteers. The
health care resources as well as historic distrust, most common health ministry worker is the parish
2580_Ch25_359-376 16/07/13 3:14 PM Page 363
(or faith-community) nurse, who assumes a established from within and there is joint planning.
staff role in the parish, addressing health needs. An example of this would be university–faith
Non-nurses are called health ministers. community partnerships where the educational
One aim of health ministry is to help persons in component is developed or taught by faculty or
faith communities take the necessary steps to avoid students but the faith community adds the religious
preventable illnesses and conditions by utilizing spir- and cultural content.
itual and faith-community resources. Ministries of In faith-based initiatives, persons are encouraged
health benefit all, clergy and laypersons alike. In fact, to practice good stewardship as caretakers of the
clergy exceed the general population in the percent- gift of their bodies (Peterson, Atwood, & Yates,
age who are overweight and obese: 76% of clergy are 2002; Rediger, 2000) because they need health in
obese or overweight, compared with 61% of adults order to carry out the ongoing ministries to which
in general (Maykus, 2006). Clergy responsibilities they are called. Living out their faith is the motiva-
that sometimes require being on call 24 hours a day tor, not losing weight or exercising for the sake of
lead to neglect of self-care (Rediger, 2000). health. This understanding of health is similar to the
Health promotion interventions in faith-based definition of health in the Ottawa Charter of the
settings can be viewed on a continuum. Programs World Health Organization (WHO, 1986): health
held in churches and other faith-based settings is “a resource for living” and not as an end in itself.
as an outreach to members or the community but Holistic health in this sense is not absence of disease
planned or carried out by outside leadership, and but rather well-being in all spheres of life, including
not including faith-related content, are considered the physical, the emotional, and the spiritual realms.
faith-placed (Steinman & Bambakidis, 2008).
These efforts may target the faith community but Functions and Roles of the
are not tailored, or specifically designed (Walker,
Pullen, Boeckner, Hageman, Hertzog, Oberdorfer,
Faith-Community Practitioner
& Ruthledge, 2009), to meet the values, needs, and as Health Minister
culture of the participants. An example of a faith- The functions of health ministers, including occupa-
placed program is offering classroom space to groups tional therapists, fall primarily into one or more of
such as the Red Cross for CPR and first aid courses. seven areas of practice: health education, health coun-
A faith-based intervention for health promo- seling, health advocacy, referral advising, volunteer
tion incorporates faith-related content and is a pro- coordination, development of support groups, and
gram of the sponsoring group (Steinman & integration of faith and health (Brudenell, 2003;
Bambakidis, 2008). While outside persons may Holstrom, 1999; Patterson, 2003), which are de-
provide leadership, the need for the program is scribed in Box 25-1.
Box 25-1 Roles of the Health Minister
• Health Educator: implements health fairs, health screenings, and back-to-school backpack safety events; creates
newsletter articles and bulletin board displays on health topics; recruits speakers or teaches classes; expands
the faith-community library to include books on caregiving and living with chronic illness.
• Health Counselor: supports individuals in modifying occupations to make needed lifestyle changes; helps inter-
pret medical findings and recommendations, assisting the individual to formulate questions to ask his or her
provider; accompanies individuals through the maze of health care services; provides home safety assessments
for persons who do not otherwise qualify; monitors follow-through and home programs.
• Health Advocate: empowers clients to become self-advocates; helps the congregation identify physical,
communication, and programmatic barriers to full participation, along with recommendations for overcoming
these in order to achieve accessibility.
• Referral Advisor: researches community resources and collaborates with other agencies; refers clients to service
providers and follows up to ensure that the client’s needs were met; helps families develop criteria for making
placement decisions.
Continued
2580_Ch25_359-376 16/07/13 3:14 PM Page 364
Box 25-1 Roles of the Health Minister—cont’d
• Volunteer Coordinator: develops job descriptions for volunteer placement, then recruits, trains, assigns, and
supervises volunteers who carry out programs such as caregiving teams and respite services; provides ongoing
support, periodic evaluation, and recognition for services rendered; works with a health committee/cabinet of
laypersons and health professionals, which shares in oversight and development of programs.
• Developer of Support Groups: identifies needs and sets up or runs support groups for caregivers, recently
widowed persons, people with a specific chronic illness or disability, siblings of children with disabilities, or those
wanting to band together for weight loss support; helps group members access their beliefs and spirituality to
facilitate coping or making needed changes.
• Integrator of Faith and Health: educates the congregation regarding the role of healing and health in their
particular faith tradition through articles, workshops, sermons, and other means of communication; provides
visitation in homes and health care facilities and offers listening, supportive presence, touch, and prayer
(Tuck, Pullen, & Wallace, 2001); assists persons to find meaning and hope in illness, disability, or loss; helps
members explore personal values around end-of-life decisions; educates the congregation on ethical issues
from a faith perspective; helps plan and implement healing services.
Faith-community nursing does not involve direct stress. Both document their interventions in order
hands-on care (Cassidy, 2002; Patterson, 2003), nor to provide continuity and assess outcomes (Johnson,
should faith-community occupational therapy. The Ludwig-Beymer, & Micek, 1999).
roles and tasks are to supplement available resources Faith-community occupational therapy differs
and fill in the gaps. The seven functions of health from home health therapy in that the therapist does
ministry are the same whether being carried out by not provide treatment, is not focused on remedia-
a nurse or an occupational therapy practitioner, but tion of deficits, and does not need a physician’s re-
specific implementation reflects the professional’s ferral. Many interventions are on a group basis.
background, experience, and scope of practice. For Faith-community occupational therapy incorporates
instance, either professional may take blood pressure the client’s beliefs and spirituality as an important
readings. The nurse provides more specific medical component of any intervention. See Tables 25-1
teaching while the occupational therapy focus is on and 25-2 for further examples of how health pro-
occupations of shopping and meal preparation, and motion initiatives can be adapted by practitioners
those that increase physical activity and decrease in faith-based settings.
Table 25-1 Examples of Faith-Based or Easily Adaptable Interventions

Program Area Description Faith-Based Component
Children and Youth
*Camp Noah for Disaster Structured curriculum for school Study materials/ activities are
Survivors (Zotti, Graham, age children followed “disaster based on Noah’s ark story;
Whitt, Anad, & Replogle, 2006) cycle of recovery” (p. 401) using includes spiritual coping
skits, crafts, fun activities strategies
*Project Transformation After-school academic and Faith-based setting, activities in-
(Campbell, Rhynders, Riley, enrichment programs with cluded scripture lessons; trained
Merryman, Scaffa, 2010) for games, meal, play time, young adult interns; outreach to
at-risk children presentations; served as Level I community
fieldwork site
*Jump Kids Jump (Yamkovenko, Fun, progressive exercise pro- Easily adapted to faith-based
2009) grams for obesity prevention programs and groups
and bone health
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Table 25-1 Examples of Faith-Based or Easily Adaptable Interventions—cont’d

*Healthy Homes Assessments Assessed homes for safety and Can be carried out through faith
(U.S. Dept. of Health and Human accessibility, but also for toxins communities and organizations,
Services, 2009) and allergens that may affect using pool of volunteers for
child development modifications
Productive Aging
*Exercise for Fall Risk Reduction Evidence for effectiveness of Faith-community exercise and
(Arnold, Sran, & Harrison, 2009; exercise in reducing fall risk in walking groups offer support,
Voltz, 2005) community-dwelling older adults. accountability, and motivation
for change.
*Energy Conservation Workshop Instruction in work simplification Participants were recruited from
for Well Elderly (Bunyog & Griffin, for ADLs/IADLs, including use of churches; program easily adapt-
2007) adaptive equipment able to faith-based setting
*Designing a Life of Wellness for Six months of weekly classes Easily adaptable to faith-based
Community Elders (Matuska, based on Lifestyle Redesign con- setting, with benefit of addi-
Giles-Heinz, Flinn, Neighbor, & cepts with focus on increasing tional spiritual and community
Bass-Haugen, 2003) communication and participation resources
Work and Industry
*Ergonomic Consultation Analysis of job requirements and Addresses specific needs of
(Fecko, Errico, & Jabobs, 2004; design of specific interventions clergy, office staff, youth worker,
Noack, 2005) custodian
*Clergy Wellness (Rediger, 2000) Lifestyle modification for clergy Includes spiritual fitness along
on disability leave or at risk for with mental and physical fitness
burnout
*Job Development for Persons Analysis of volunteer tasks that Taps volunteer base and spirit
with Developmental Disabilities can be shadowed and learned of faith-based organization,
(Carter, 2007) for skills development; job addresses occupational
referral and placement deprivation
Mental Health
*Caregiver Training and Support Education on balance of daily oc- Support group includes devo-
Groups (Brachtesende, 2004; cupations, strategies for promot- tionals, sharing, prayer support
Dooley & Hinojosa, 2004) ing occupational involvement for for members
care recipient
*Community Practice with Persons Identified needs of shelter resi- Many shelters and day programs
who are Homeless (Herzberg & dents and developed empower- are faith-based and welcome
Petrenchik, 2010; Hotchkiss & ing interventions, addressed interventions that address
Fisher, 2004) mental health needs, high in spirituality
this population
Rehabilitation and Participation
*Accessibility Consultation Analyzed faith-community build- Requires knowledge of religious
(Shamberg, 1993; Shamberg ing and programs, adapted occupations and of aspects
& Kidd, 2010; Swedberg, 2001) ADA concepts to enable full of building that serve religious
participation of all members functions
*Emergency Preparedness for Addressed specialized needs Mobilizes faith communities to
Persons with Disabilities (Scaffa, and developed individualized develop safety net; offer spiritual
Gerardi, Herzberg, & McColl, plans that address support support to persons displaced by
2006) personnel, DME and service disaster
animals
Continued
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Table 25-1 Examples of Faith-Based or Easily Adaptable Interventions—cont’d

*Skill Development for Immigrants Assessed skills, role changes, Faith communities will offer
and Refugees (Gupta & Sullivan, IADL needs; developed training space and volunteers; need to
2008) for mentors to facilitate participa- assess cultural and religious
tion in society worldview of immigrants
Health Promotion and Wellness
*Self-Management Programs for Focus is on training, exercise for Easily adapted to a faith-based
Persons with Chronic Conditions specific needs of persons with program, empowers individuals
(Neufeld & Kneippman, 2003) multiple sclerosis, Parkinson’s, and caregivers to stay positive,
etc.; included group process, find support.
workbook
*Faithfully Fit Forever (White, Educated trainers/group leaders Leaders come from faith com-
Drechsel, & Johnson, 2006) in faith-based exercise program munities; program incorporates
for body, mind, and spirit inspirational readings and
spiritual support.
*Faith-Based Health Training Educated lay health ministers in Participants offer prayer, faith-
Program (Kotecki, 2002) health promotion based on based resources; pastors are in-
Healthy People 2010; included volved and speak at graduation
updates for graduates
*Health Ministry Fair (Wilson, Identified priorities, invited re- Both secular and faith-based
2000) sources, ensured accessibility of services and products are in-
venue and materials, evaluated cluded in booths and activities
program effectiveness
Table 25-2 Examples of Occupational Therapy Faith-Based Interventions

Faith-Based Occupational Therapy
Topic Organization Roles Contact
Health Ministry Greater Pleasant Educator, program developer, Letha Mosley, PhD, OT,
Branch Missionary community-based participatory Conway, AR
Baptist Church; Primary research partner, health ministry
affiliation: University of coordinator, speaker—local and
Central Arkansas national levels
Disability Ministry Twin Oaks Presbyte- Disability ministry coordinator, Robin Mourey, OT,
rian Church, Special program developer, speaker— St. Louis, MO
Needs Ministry local church and community
levels
Parachurch Disability Joni and Friends Disability ministry coordinator, Care Tuk, OT, MEd, Elk,
Ministry program developer, consultant, WA; and Kim Schartow,
writer, speaker, short-term OT, Bay Area, CA
missionary—local, regional, and
national/international levels
Missionary Work JianHua Foundation Long-term missionary, program Ann Churchwell, OT,
(Hong Kong–based developer, consultant– local RN, Tianjin, China
Christian non- level (international)
governmental
organization)
2580_Ch25_359-376 16/07/13 3:14 PM Page 367
Table 25-2 Examples of Occupational Therapy Faith-Based Interventions—cont’d

Faith-Based Occupational Therapy
Topic Organization Roles Contact
Consultation to UMCOR Health, Consultant, advocate, writer, Jennifer Yound, OTD,
Faith-Based United Methodist researcher—local and national/ St. Louis, MO, and
Organization Church denominational levels New York
Advocacy with Samuel Merritt Univer- Program developer, board Marcia Goodman-Lavey,
Jewish Faith sity; Jewish Family and member of community agency, OT, JD, Walnut Creek, CA
Communities Children’s Services of community-based researcher,
the East Bay advocate, educator, grant
writer—local and regional
levels
Initiatives of an Presbyterian Outreach; Program developer, community- Joy Voltz Doll, OTD,
Occupational Creighton University; based researcher, university, Omaha, NE
Therapy Educator International Child educator, grant writer, writer,
Care (Dominican board member of community
Republic) agency—local, regional, inter-
national levels
Ordained Ministry Health educator, health coun- Charmaine Kathmann,
selor, advocate, referral advisor, New Orleans, LA;
program developer—local Suzanne Trump,
level—in addition to primary Allentown, PA; and
role as deacon/pastor Donna Twardowski,
Sarasota, FL
Initiatives of an Cadence International— Program developer, community- Sunny Anderson,
Occupational Port of Call Hospitality based health ministry OTA; BS (nutrition),
Therapy Assistant House coordinator, long-term Bremerton, WA
missionary within the United
States—local level
Disability Ministry Missions and Outreach

A natural fit for occupational therapy practitioners Another model of ministry is that of mission work,
is disability ministry, a form of ministry that which may incorporate health ministry, disability
focuses on expanding opportunities for full par- ministry, and/or other roles. To be in mission
ticipation of persons with disabilities. Inclusion means to be sent out from the parent religious or-
ministry would be a better term for this combina- ganization, either to an underserved area in one’s
tion of advocacy and practical suggestions that own country or to another country. Mission trips
enables faith communities to embrace all persons are usually short-term ventures involving a group
and families as essential participants (Saliers, that partners with a local hosting organization over
1998). Inclusion focuses on helping persons carry a several-week period to accomplish a specific ob-
out their lives in community locations they select, jective. Examples include medical clinics for under-
participating in all feasible aspects of activities served groups or raising the walls for a building and
they choose. National disability ministries include providing activities for the children of a community.
parachurch organizations, which are faith-based Orloff (2007) shared her pediatric occupational
groups that operate independently of a specific therapy experience with and learned from profes-
denomination. sionals and families during a team outreach to
2580_Ch25_359-376 16/07/13 3:14 PM Page 368
Moldova through Jewish Healthcare International. belongs to the organization functions as an internal
Service-learning trips offered by some occupational consultant with the advantage of understanding
therapy educational programs fall into this category more of the context and performance patterns
if they incorporate a faith-based component. Other underlying the current status. The request for
initiatives take place in urban areas of the United consultation may originate from the organization,
States, such as the Door of Hope program for but astute therapists who note areas in need of
homeless persons (Stokes & Nolan, 2006). improvement may also initiate the process. Consul-
Another example of a short-term mission trip tation is provided on a contractual, time-limited
that includes occupational therapists is wheelchair basis, for a specific project. At the end of the time
distribution outreach. Team members travel to or project, renegotiation for an additional period
developing countries to fit persons who could may be possible.
otherwise not afford a wheelchair with donated, Occupational therapy education equips therapists
refurbished wheelchairs. While wheelchairs may with basic skills for task analysis, problem solving,
not be appropriate for persons in some environ- and group process, which are useful in consulting.
ments (Zollars & Ruppelt, 1999), for many Eastern A practitioner needs to gain advanced skills and
Europeans and others who live in cities with paved experience, and to develop an extensive toolkit of
surfaces, a restored wheelchair facilitates community resources pertaining to the area of consultation,
access and participation. Both short- and long-term prior to offering consultation services (Epstein &
programs need to ensure that the intervention ben- Jaffe, 2003; Scott, 2009).
efits the indigenous people as well as the trip partic- A practitioner provides person-level (case) con-
ipants (DeCamp, 2007). Ethical considerations sultation (AOTA, 2008) when developing individ-
include local participation in planning the outreach, ualized plans for inclusion of children or adults
training team members about cultural issues they who need adaptive supports in faith-community
will face, consideration for long-term sustainability, programs. Examples of organization-level consulta-
and having evaluation built into the process tion are helping a congregation or camp complete
(DeCamp, 2007; U.S. Standards of Excellence in an accessibility audit and prioritize recommenda-
Short-Term Mission, 2009). tions for action, or working with the education
Long-term mission work involves assignment of department to adapt the overall curriculum for chil-
individuals for a period of a year or more. While the dren with differing learning abilities. At both levels
missionaries themselves experience a religious calling the therapist helps the organization understand
to the work, the faith-based component of their the need to modify activity demands, contexts,
work is often subtle and introduced only after they and environments for successful participation.
are specifically asked what motivates them to leave Population-level consultation might involve work-
a comfortable life at home and reach out to others. ing with an entire denomination to change policies
and implement procedures, or developing awareness
and training materials to be used throughout the
Other Community-Based Occupational system (Herzog, 2006).
Therapy Roles in Faith-Based
Organizations Board Member and Advocate
Consultation Practitioners who engage in community-based prac-
The Occupational Therapy Practice Framework (AOTA, tice find they are more effective if they work in con-
2008) includes consultation as a valid occupational junction with other individuals and groups (Stokes
therapy intervention. A therapist providing consul- & Nolan, 2006). Serving as a board member for a
tation services to a faith-based organization will local, state, or national faith-based organization is
equip the organization with skills to improve ser- one way of influencing the community. Occupa-
vices and programming in arenas defined by the tional therapy practitioners have skills that make
organization. A consultant may come from outside them valued board members (Daly, 2008). Most
the organization and offer a fresh, objective view start with serving on a local level and then gradually
(Epstein & Jaffe, 2003). The practitioner who progress to state or national levels. Like consultants,
2580_Ch25_359-376 16/07/13 3:14 PM Page 369
board members must understand organizational be- participation in faith communities and on the role
havior and the change process (Braveman, 2006). of the faith-community occupational therapist
Advocacy means speaking or acting on behalf (Swedberg & Tuk, 2001; Swedberg, 2004). Parish
of another person or group to help them achieve nursing and health education association meetings
services, status, or support that has been denied. and symposia on local, state, and national levels
Advocacy is not limited to lobbying legislators and provide receptive audiences. Presenting to groups
other politicians (Patterson, 2007) but rather is outside occupational therapy develops partnerships
applied to systems wherever power and resources are and expands awareness of the skills occupational
unequally distributed and marginalized persons are therapists offer as team players in faith communities
excluded. Practitioners working with such popula- and faith-based organizations. Practitioners who are
tions teach self-advocacy and community-building drawn to faith-based work often realize the need for
skills (Hammel, Charlton, Jones, Kramer, & Wilson, credentials recognized within their religion. Many
2009). Causes that occupational therapy advocates denominations offer lay speaking training, and prac-
embrace may include health care access for the unin- titioners who earn this certification can lead worship
sured (Voltz, 2006) or improved services for men- in their own and other congregations, preaching ser-
tally ill homeless persons. mons that illustrate scriptural principles of whole-
The first author has applied her occupational ness and inclusion and draw on their occupational
therapy skills and interest in accessibility by serving therapy perspective and experience.
as a chairperson of a state-level denominational
committee on disability concerns. She is now chair Ordained Ministry
of a national task force on disability ministries A minority of occupational therapists involved in
that is charged with advocating for and increasing faith communities become ordained as ministers.
inclusion of persons with disabilities throughout Three pastors interviewed for this chapter sensed a
the denomination. calling to the ministry earlier in life, but when ordi-
nation for women was not an option they discov-
Communications ered occupational therapy as a means to be in service
One reason so little is known about occupational to others. After traditional occupational therapy
therapy practitioners’ involvement in faith-based careers in direct services and academic settings,
organizations is that few have written about their they chose to pursue formal seminary training and
programs. There are no books about faith-based oc- ordination.
cupational therapy and few articles written about
evidence-based interventions or practice models in
faith communities. Several scholar-writers have pub- Recommended Training
lished on spirituality and occupational therapy, but and Experience
the articles are focused on theory, applications for
occupational therapy education, or practice in Before taking formal training in a faith-community
medical model settings (Donica, 2008; Egan & nursing/health ministry program, significant self-
Swedersky, 2003; Unruh, Versnel, & Kerr, 2004). examination is called for. A new practitioner or one
The profession will lack credibility until there is who lacks experience in community practice could
more published evidence of effective faith-based start as a volunteer in an existing program. Another
occupational therapy interventions. The Journal entry point is participation in a structured mission
of Religion, Disability and Health is the premier experience. The therapist must have a sense of call-
interdisciplinary journal addressing concerns of ing to this service and a desire to grow spiritually.
disability ministry. Experience in home and community health, in case
Speaking opportunities abound for approaching management, or in settings where the therapist must
health and disability ministry from an occupational operate independently is an advantage for health
therapy perspective. The first author presented ministry. A holistic orientation is crucial, and the
workshops at state and AOTA conferences on using therapist should supplement traditional occupa-
the skills of occupational therapy to facilitate full tional therapy education with information about
2580_Ch25_359-376 16/07/13 3:14 PM Page 370
health promotion, community organizing, religion, germane to this frame of reference are “inclusion,
and the particular denomination or faith community. diversity, participation, empowerment, social justice,
Formal training is provided through faith- advocacy, and interdependence” (p. 65), which form
community (parish) nursing programs, many of an effective foundation for practice in the commu-
which—but not all—are open to including other nity. The Public Health Leadership Society devel-
professionals who have the appropriate background oped a Code of Ethics (2002) that further elaborates
and experience. The International Parish Nurse on the application of ethics in community practice.
Resource Center sets the standards for program A growing number of occupational therapy pub-
curriculum so the content is similar even though lications address the need for the profession to
the venue and time frame for the course varies address social justice and/or occupational injustice
(McDermott, Solari-Twadell, & Matheus, 1999; issues (Arnold & Rybski, 2010; Kronenberg & Pol-
Patterson, 2003). lard, 2006; Wilcock & Townsend, 2009), including
Within occupational therapy the question of the Occupational Therapy Code of Ethics and Ethics
roles needs clarification. The likely outcome of a Standards (2010) (AOTA, 2010). Many faith-based
dialogue would be that occupational therapy assis- organizations reach out to underserved groups within
tants and occupational therapists alike may become their communities, offering partnering practitioners
faith-community practitioners if each group restricts a chance to bring about social change and increased
their activity to tasks and roles within their respec- participation in occupational opportunities.
tive scope of practice for which they have training
and experience.
Self-Care
Self-care is vital to successful health ministry.
Ethical Considerations Prochnau, Liu, and Boman (2003) discuss coping
strategies for hospice therapists, including finding
A practitioner working or volunteering in a faith- appropriate means to ventilate and practicing self-
based organization will encounter circumstances nurturance, which would benefit therapists in faith-
that require ethical analysis and decision making. based settings. Attention to one’s spiritual life allows
The Occupational Therapy Code of Ethics and Ethics continued reserves to serve others. Authenticity is
Standards (2010) (AOTA, 2010) provides guidance required; the practitioner must model any behaviors
regarding principles that help the therapist deter- that he or she expects others to follow. Beyond that,
mine the best course to take. Principle 3, Autonomy if the practitioner is not leading a balanced life,
and Confidentiality, provides guidance and is up- burnout and the tendency to try to carry out the
held when the practitioner empowers parishioners program alone are probable consequences. Each
to learn skills for making their own decisions and practitioner needs to seek out support from others
assesses the values of each individual, avoiding doing similar work; this may be possible through a
assumptions based on religious affiliation. local organizations. A community health ministry
Occupational therapy practitioners should be or disability ministry group also enables sharing of
familiar with standard health care ethical approaches program ideas and resource information, and may
that emphasize rights and rules and treat persons as offer retreats and continuing education.
autonomous agents. While these principles are effec-
tive in addressing typical dilemmas in medical model
settings, they have less to offer those in community Future Directions
practice (Racher, 2007). The Ethic of Care, which
comes from the nursing feminist ethics perspective The nursing profession has standards of practice for
(Vollbrecht, 2002), is more readily applied to com- faith-community nursing. As more occupational
munity-based faith-community settings. This theory therapy practitioners work in this area, they can
emphasizes relationships and community, assuming contribute to setting standards for faith-based oc-
that persons operate out of a natural sense of caring cupational therapy practice. Standards should be
rather than in response to principles. Concepts developed collaboratively, in a similar manner to the
2580_Ch25_359-376 16/07/13 3:14 PM Page 371
nursing standards that were jointly written by rep- cultural context and spiritual domain, and as they
resentatives from the American Nursing Association look for trends in society that point to opportunities
and the Health Ministry Association. A preliminary and concerns that occupational therapists can
step would be a position paper or white paper de- address, there is no limit to the types of services that
veloped through the AOTA. can be developed in faith-based settings.
Before standards of practice are created, more
informal and formal networking is needed among
practitioners working in faith-based settings. Options Conclusion
for communication include establishing a listserv or
online group through AOTA or another organiza- By partnering with faith-based organizations, occu-
tion, affinity group meetings at national or regional pational therapy can contribute to the development
conferences of both occupational therapy and health of a new health care system that fosters well-being
ministry, and use of social networking sites. and participation rather than merely addressing dis-
Occupational therapists working in faith-based ease. Dehaven, Hunter, Wilder, Walton, and Berry
settings can contribute to the expansion of this (2004) completed a comprehensive literature review
specialty by offering fieldwork placements through of health programs in faith-based organizations and
occupational therapy schools that emphasize emerg- concluded that for programs that assessed outcomes,
ing practice areas and community-based fieldwork. results were overwhelmingly positive. Outcomes
Educators can collaborate with community practi- included improved cholesterol and blood pressure
tioners and students to carry out needed research on levels, decreased weight, and increased screening
the effectiveness of faith-based health and inclusion for potential breast cancer.
initiatives. Clearly, health promotion will play an increas-
While currently nearly all occupational therapy ingly important role in reducing the current costly
faith-based involvement is in Judeo-Christian or- health care focus on extensive diagnostic workups
ganizations, future growth will be in diverse settings. and high-tech and pharmaceutical interventions. If
Occupational therapy is less developed in predom- occupational therapists are to fully embrace their
inately Muslim countries and will succeed only if claim to holistic practice, they need to address the
faith-based factors are incorporated. Asian occupa- spiritual domain along with the physical, social,
tional therapists have realized that the Western focus emotional, cognitive, and environmental influences.
on independence and autonomy has limited rele- All practitioners can become more comfortable with
vance in their cultures where the family and society addressing spiritual and religious occupational per-
are more prominent than the individual. Developed formance. Practitioners from health care settings can
initially for Asian clients, the Kawa (river) model of routinely ensure that clients can fully participate in
rehabilitation (Iwama, 2005) may prove a better their faith communities. Practitioners within faith
conceptual fit for persons from Native American communities can use their skills as agents of change
cultures as well as for immigrants in North America. so that congregations become places where all are
As therapists become attuned to considering the welcome and healthy behaviors are upheld.
CASE STUDIES
CASE STUDY 25•1 Elaine
Elaine is a woman in her mid-70s who has always been active in her church and community, with music
as her passion. After receiving a degree in voice and communications, she married Scott, an Air Force
officer, and raised two children. Both children are grown, have their own families, and live at a distance.
When Elaine had a major stroke with deficits including left-sided paralysis that required using a wheel-
chair, left visual field loss and neglect, and voice and swallowing impairment, she felt a loss of self-
identity. “Where is Elaine?” was a common question. She had looked out for her husband, so he was
Continued
2580_Ch25_359-376 16/07/13 3:14 PM Page 372
CASE STUDY 25•1 Elaine cont’d
overwhelmed when confronted with the myriad decisions and tasks involved with the onset of a disability.
The son and daughter visited as often as possible, but there was a gap in support. When the occupational
therapist who had been their small group leader at the church offered to accompany Scott and Elaine
through the rehabilitation process, they graciously accepted. Several months later, Elaine was overheard to
tell someone that while her church didn’t have a parish nurse, it had a parish occupational therapist.
Some of the functions carried out by the occupational therapist included the following:
Health Counselor: Throughout the active therapy phase, the faith-community occupational therapist
helped interpret interventions provided by the facility therapists and reinforced what was taught. The
occupational therapist assisted Scott with the home evaluation form and supplemented information pro-
vided by the inpatient program regarding accommodations needed to allow Elaine to return home from
the rehabilitation facility. When the dietitian provided education on following a modified diet, Scott and
Elaine needed support to learn to read labels, select appropriate foods, and find new favorites to replace
items no longer allowed.
Health Advocate: The faith-community occupational therapist supplemented the social work inter-
ventions by assisting the couple to fill out forms needed for long-term care insurance. When issues arose
regarding care and follow-through in the rehabilitation center and later the skilled nursing facility, the
occupational therapist provided advocacy.
Referral Advisor: The occupational therapist helped the family sort through the options available for
rehabilitation after Elaine’s short hospital stay, as the brief visit by social services was not sufficient for
an informed decision. When Elaine was not strong enough to return home at discharge from the reha-
bilitation center, the occupational therapist assisted the family in planning for continuing care.
Volunteer Coordinator: After Elaine came home with her husband and part-time caregivers, the oc-
cupational therapist helped the family determine how and when church volunteers could assist without
giving direct care. The primary task selected was providing respite—staying with Elaine so that Scott
could continue his involvement in musical groups.
Integrator of Faith and Health: Elaine was able to verbalize that her angst was more spiritual than
physical, so the occupational therapist’s interventions focused on supporting Elaine’s continued involve-
ment in valued spiritual occupations. Elaine appreciated being informed of prayer concerns from each
Sunday service, happy to pray for others when she could do little else. Later, when Elaine was able to
attend church, the occupational therapist modified the bulletin and hymns by printing them in a large
font with narrow columns and a red anchor line on the left. Though she never recovered from her paralysis,
Elaine reclaimed her faith and discovered a new sense of self through the spiritual journey she faced in
her tenacious style.

1. After discharge from the skilled nursing facility, Elaine intentionally opted to use the home health
agency where the faith-community therapist was the sole occupational therapist. Describe potential
conflicts of interest and boundary issues that would need to be very clear for such an arrangement
to work.
2. What are additional spiritual occupations and interventions that Elaine may find meaningful?
3. What criteria does the practitioner use to decide when to assist the caregiver and when to empower
him or her to carry out the necessary task independently with support? Task examples in this case
were the completion of long-term-care insurance paperwork and the home assessment form.
2580_Ch25_359-376 16/07/13 3:14 PM Page 373
Learning Activities Braveman, B. (2006). Leading and managing occupational

therapy services: An evidence-based approach. Philadelphia:
1. Locate a faith-community nurse (parish nurse) F.A. Davis.
in your community and arrange to interview Brudenell, I. (2003). Parish nursing: Nurturing body, mind,
spirit, and community. Public Health Nursing, 20(2),
him or her to discuss roles and functions. 85–94.
Identify which roles could be carried out by Bunyog, V. M., & Griffin, C. (2007). Educating the well
a faith-community occupational therapist. If elderly on work simplification and energy conservation
no one is available, search nationally and inter- techniques. OT Practice, 12(6), 11–12.
view a faith-community nurse by telephone. Campbell, R. M., Rhynders, P. A., Riley, M., Merryman,
M. B., & Scaffa, M. E. (2010). Educating practitioners for
2. Select an accessibility audit from the resources health promotion practice. In M. E. Scaffa, S. M. Reitz, &
and carry out an assessment of a house of wor- M. A. Pizzi, Occupational therapy in the promotion of health
ship or a faith-based organization. Interview and wellness (pp. 512–527). Philadelphia: F.A. Davis.
a person with a disability who uses the build- Carter, E. W. (2007). Including people with disabilities in
ing to get his or her input. Make preliminary faith communities: A guide for service providers, families, &
congregations. Baltimore: Paul H. Brookes.
recommendations based on your findings and Cassidy, K. (2002). Partners in healing: Home care,
the Americans with Disabilities Act (ADA) hospice, and parish nurses. Home Healthcare Nurse,
regulations. 20(3), 179–183.
3. Interview a client about how participation in Chase-Ziolek, M. (2005). Health, healing, and wholeness.
a faith community affects that person’s health Cleveland, OH: Pilgrim Press.
Churchwell, A. (2007). JHF classroom recognized as model
and well-being, and about any current limita- classroom by central government. Retrieved from
tions to participation. https://jhfchina.org/cms/index.php?id=22&L=&tx_ttnews
4. Design a faith-based occupational therapy [backPid]=71&tx_ttnews[tt_news]=47&print=1&no_
intervention that could be conducted during cache=1
a health fair in a faith community. Daly, C. (2008). Expanding the role of OT to board rooms.
OT Practice, 13(21), 23–24.
DeCamp, M. (2007). Scrutinizing global short-term medical
outreach. Hastings Center Report, 37(6), 21–23.
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Chapter 26
Lifestyle Redesign Programs

Camille Dieterle, OTD, OTR/L
Live a balanced life—learn some and think some and draw and paint and sing and
dance and play and work every day some.
—Robert Fulghum (2004)
Learning Objectives
• Understand the need for Lifestyle Redesign intervention.
• Identify the key components that make up “lifestyle.”
• Describe the history and development of Lifestyle Redesign.
• Describe different types of Lifestyle Redesign programs and how Lifestyle Redesign interventions can be applied
to various populations and settings.
• Identify reimbursement and education/marketing issues relevant to Lifestyle Redesign programming.
Key Terms
Accountability structure Occupational self-analysis
Didactic presentation Occupational storytelling and story making
Direct experience Peer exchange
Lifestyle Personal exploration
Lifestyle Redesign Wellness
Obesogenic
Introduction and emotional issues, diabetes, stroke, cancer, hyper-

tension, and kidney problems (CDC, 2009). Addi-
According to the Centers for Disease Control and Pre- tionally, the number of U.S. adults age 65 and older
vention (CDC), chronic diseases such as heart disease, is projected to double by 2030, and experts are expect-
diabetes, and cancer are the leading causes of death ing to see an increase in the incidence of disability
and disability in the United States (CDC, 2010). from chronic conditions (CDC, 2009). Although the
Among its residents in 2005, 7 out of 10 deaths could statistics within the United States alone are staggering,
be attributed to such chronic diseases (Kung, Hoyert, such health concerns appear internationally. The
Xu, & Murphy, 2008), with almost one half of adults World Health Organization (WHO) reports that
living with at least one chronic condition (CDC, chronic diseases, such as heart disease, stroke, cancer,
2007). Heart disease, cancer, and stroke account for chronic respiratory diseases, and diabetes, are the most
more than 50% of deaths per year (Kung et al., 2008), common cause of mortality in the world and represent
and of the top 30 causes of self-reported disability in 60% of all deaths (WHO, 2012).
adults, the following chronic conditions were ranked The need for prevention and self-management of
among the top 15: arthritis, spine and back pain, heart chronic conditions is paramount, and both the CDC
disease, lung and respiratory problems, mental health and WHO, among others, are calling for more
377
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health professionals to address these conditions with Lifestyle also refers to daily choices, great and small,
more vigor. According to the CDC, “Greater num- and includes the tangible and intangible aspects
bers of trained professionals will be needed to expand of a person’s occupational repertoire, such as nutri-
the reach of effective community-based programs to tional choices, cultural preferences, physical activity
mitigate the effects of disability. Modifiable lifestyle patterns, and sources of pleasure and motivation.
characteristics (e.g., physical inactivity, obesity, and The various components of lifestyle are listed in
tobacco use) are major contributors to the most com- Box 26-1. Lifestyle is created by what an individual
mon causes of disability, and sometimes stem from places his or her attention on throughout daily and
a primary disabling condition” (2009, Editorial weekly occupations and routines. Lifestyle Redesign
Note, ¶ 4). is the intentional process of analyzing occupations
Occupational therapists, with their emphasis on the and lifestyle choices, and then making changes based
impact of activity on health, are among the key health on articulated personal priorities, values, and health-
professionals to provide preventive interventions and related goals. Lifestyle Redesign places the client as
management of chronic conditions. As a community- an empowered director over his own life, his health,
based occupational therapy approach and set of tech- and what he does. It helps clients to become their
niques and tools specifically developed to address own health advocate and to see how what they do
chronic conditions, Lifestyle Redesign intervention affects their health and life satisfaction.
can both prevent chronic conditions and help to better Often during the process of Lifestyle Redesign
manage them after onset. Through clinical trial a need to make considerable changes in lifestyle arises,
research, Lifestyle Redesign was demonstrated to be such as a change in living environment, employment,
an effective preventive technique in community-based relationship status, or a significant meaningful occu-
settings. It enhances health, improves quality of life, pation. Throughout this process of transformation,
and reduces health care costs (Clark, Azen, Zemka, Lifestyle Redesign always targets the minutia of
Jackson, Carlson, Mandel,...Lipson, 1997; Mandel,
Jackson, Zemke, Nelson, & Clark, 1999). Occupa-
tional therapists can use Lifestyle Redesign as an Box 26-1 Lifestyle Components
approach for widening the scope of occupational ther-
apy practice to include facilitating self-management • Attitude and Mood
of chronic conditions on a broader scale. • Daily Habits and Routines
Presently, the University of Southern California • Eating Routines and Nutrition
(USC) Occupational Therapy Faculty Practice • Health Status
(OTFP) provides occupational therapy interven- • Meaningful Activities
• Pacing and Energy Conservation
tions for the prevention and management of chronic • Personal Motivation and Habit Change
conditions. The OTFP is an outpatient clinic situ- • Physical Activity Patterns
ated on the campus of USC, where occupational • Pleasure, Play, and Leisure
therapists utilize the Lifestyle Redesign approach to • Relaxation and Sleep
address chronic conditions. • Roles and their impact on daily routines
• Social Relationships, Demands, Support, and
Community
Lifestyle Redesign Defined • Spirituality
• Stressors and Stress Management
• Time Management
Lifestyle Redesign is defined by Clark as “the
process of developing and enacting a customized Additional client factors related to lifestyle:
routine of health promoting and meaningful daily • Abuse
activities” (Mandel et al., 1999, Introduction page). • Increased risk factors for chronic condition(s)
and/or disability
The term lifestyle includes several occupational fac- • Occupational deprivation
tors, such as activities of daily living (ADLs), instru- • Occupational role overload
mental activities of daily living (IADLs), habits, and • Poverty
routines, as well as other factors, such as health • Presence of chronic condition(s) and/or disability
status, environmental press, attitude, and mood.
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Chapter 26 | Lifestyle Redesign Programs 379
life, such as daily water or caffeine consumption, spe- becomes a practice or tool that the client can use
cific nutritional choices, taking the stairs to increase perpetually.
physical activity, taking deep breaths to relax while
stuck in traffic, listening to a portable music device
while engaged in an activity, or keeping a gratitude Development of
journal. Occupational therapists have an in-depth
knowledge of the importance of detail and how it can
Lifestyle Redesign
completely change occupation or motivate one to In Lifestyle Redesign: Implementing the Well Elderly
stop an undesirable habit or begin to cherish a new Program, Mandel and colleagues summarize four
one. It is these kinds of finely calibrated changes that core ideas from the occupational therapy profes-
can have powerful radiating effects on many aspects sion that shaped the development of Lifestyle
of lifestyle and lead to total lifestyle redesign. Redesign:
The Lifestyle Redesign approach aims to facilitate
• Occupation is life itself.
gradual lifestyle changes over a prolonged period,
• Occupation can create new visions of possible
which has a profound and extensive effect on occu-
lives.
pation, health outcomes, and quality of life. The
• Occupation has a curative effect on physical
goal is to help clients determine lifestyle changes
and mental health and on a sense of life order
that they want to make and would like to maintain
and routine.
indefinitely since Lifestyle Redesign is an ongoing
• Occupation has a place in preventive care.
lifelong process. As the client undergoes the process
(pp. 12–13)
of Lifestyle Redesign, he or she acquires the tools,
including attitudes, beliefs, strategies, and actions, Additionally, occupational science greatly influ-
that will eventually allow the client to continue this ences Lifestyle Redesign (Carlson, Clark, &
process for the rest of his or her life. Young, 1998). Mandel et al. and Jackson, Carlson,
The wellness construct is an important part of Mandel, Zemke, and Clark describe four occupa-
Lifestyle Redesign. The American Occupational Ther- tional science concepts that shape Lifestyle
apy Association (AOTA) defines wellness as “more Redesign as:
than a lack of disease symptoms. It is a state of mental
• the “dynamic and generative quality of
and physical balance and fitness” (AOTA, 2008,
occupations,” which have the power to create
p. 676). Each client can develop his or her own sense
transformation,
of what wellness means for him or her, taking into
• the meaning evoked from occupation
account individual factors, preferences, and situations.
including life narratives,
Occupational therapists can work with clients to
• dynamic systems theory, and
analyze the activities, environments, and people that
• the “view of the human as occupational
either energize and restore or drain and deplete. Then
being” (pp. 14–17) (1998).
the client and therapist work to decrease any barriers
to enacting a customized routine of health promoting Other theoretical and philosophical influences on
activities while utilizing supports. This analytic process Lifestyle Redesign are listed in Box 26-2.
Box 26-2 Theoretical and Philosophical Influences in the Creation of Lifestyle Redesign
• Grounded theory for qualitative research (Polkinghorne, 1988)

• Grounded theory for occupational narrative analysis (Clark, 1993; Clark, Ennevor, & Richardson, 1996)
• Narrative Analysis and Reasoning (Mattingly, 1991)
• Problematiques and Technologies of the Self (Foucault, 1984)
• Human Condition—Heidegger (Calhoun & Solomon, 1984)
• Hermenuetics (Chessick, 1990)
• Stages of Change (Prochaska & Norcross, 2001)
• Motivational Interviewing—used more recently in treatment and in the Pressure Ulcer Prevention Study (PUPS)
after the original development of Lifestyle Redesign (Miller & Rollnick, 2002)
2580_Ch26_377-389 16/07/13 3:15 PM Page 380
With its many theoretical and philosophical success in living in the community were: “personal
influences, the Lifestyle Redesign approach was themes of meaning as motifs for occupations, risk
created to be the intervention for the University and challenge in occupations, activity patterns and
of Southern California (USC) Well Elderly Study, temporal rhythms, control, identity through occu-
a randomized clinical trial that was conducted with pations, maintaining continuity, and promoting
community-dwelling seniors living in Los Angeles, social change” (Jackson, 1996, p. 345).
California, from 1994–1997. The primary objective The second qualitative study examined the
of the study was to determine if occupational ther- adaptive strategies that were being utilized by suc-
apy was effective for preventing declines in function cessful community-dwelling elderly persons not
and well-being in a healthy aging population. living with disabilities. Researchers interviewed
Funded by the National Institute of Health and the 29 community-dwelling well older people and
American Occupational Therapy Foundation, the found that the following 11 life domains were
study had 361 men and women participants over most threatening to the participants: activities of
the age of 60 (with a mean age of 74.4) who were daily living (ADL), adaptation to a multicultural
African American, Asian, Caucasian, and Hispanic. environment, use of free time, grave illness and
The participants were randomly assigned to one death, spirituality, health maintenance, mobility
of three groups: occupational therapy, social activi- maintenance, personal finances, personal safety,
ties led by a non-professional, and no treatment. psychological well-being and happiness, and rela-
Treatment lasted 9 months, and groups of 8–10 tionships with others (Clark, Carlson, Zemka,
participants met once per week for 2 hours and Frank, Patterson, Ennevor, ...Lipson, 1996). This
once per month individually with their occupational study was especially significant because it identified
therapist. certain areas that occupational therapy had not tra-
Results demonstrated that the participants who ditionally addressed at the time with elders. These
received occupational therapy experienced greater needs were specific to this particular group of
gains or fewer declines in physical health, physical elders and their environment, an urban multicultural
functioning, social functioning, vitality, mental high-rise apartment building. This pilot study was
health, and life satisfaction with p values < .05 (Clark important because it highlighted the need for
et al., 1997). Not only were the results maintained occupational therapists to perform extensive needs
after the 6-month follow-up period but additional assessments for the specific populations they work
findings also demonstrated that the Lifestyle Redesign with to tailor interventions. Thorough needs assess-
intervention was cost-effective (Clark, Azen, Carlson, ments allow occupational therapists to identify
Mandel, LaBree, Hay,...Lipson, 2001) (Hay, LaBree, significant factors affecting a unique population
Luo, Clark, Carlson, Mandel,...Azen, 2002). that may be different from those associated with the
Several steps were taken to develop the Lifestyle general population.
Redesign intervention implemented in the study. Another step was the development by Clark of
The following summarizes this process as occupational self-analysis in a course taught for
described by Mandel et al. in their Well Elderly several years at USC. The students were challenged
manual. The needs assessment phase included to analyze their own occupational patterns and then
conducting focus groups, interviewing key in- make changes according to what they thought
formants, administering surveys, community pro- would make their lives more satisfying, productive,
filing, and literature reviews. Formal studies to and meaningful. Specifically, they looked at how
identify what the intervention would target in- their childhood occupations shaped their current oc-
cluded two qualitative pilot studies and a literature cupational choices, how their daily occupations and
review (Mandel et al., 1999). choices affect their health and well-being, and how
The first was a qualitative study that identified their everyday routines were promoting or inhibit-
seven categories of adaptation used by community ing the achievement of personal goals. Interveners
dwelling elders living with disabilities. Jackson found in the Well Elderly study utilized this process
that the adaptations they made to promote their throughout the sessions.
2580_Ch26_377-389 16/07/13 3:15 PM Page 381
Key Components of the Service delivery incorporated four key methods,

as outlined by Mandel et al.: didactic presentation,
Lifestyle Redesign peer exchange, direct experience, and personal
Intervention Created for exploration (1999). Didactic presentation included
new information about a topic relevant to the par-
the USC Well Elderly Study ticipant(s) as well as about occupation and how it
The following summarizes the work of Mandel affects each participant. Occupational therapists led
et al. and Jackson et al. in describing the Lifestyle the participants through a process of occupational
Redesign intervention of the USC Well Elderly self-analysis in regard to the topic (1999). The ther-
Study. As the process of Lifestyle Redesign un- apist facilitated peer exchange, where each partici-
folded, each client developed a personal action pant had the opportunity to tell stories from his or
plan. The occupational therapist educated the client her own life and how his or her experiences relate
about how to harness the “power of ordinary occu- to the topic at hand. Time was provided for group
pations” in order to “optimize health and wellbe- problem solving, and group members were encour-
ing” (Jackson, et al., 1998, p. 329). For example, the aged to offer solutions to each other. The Lifestyle
occupational therapists educated the participants Redesign intervention also provided direct experi-
about how occupational engagement contributes ence through an activity or outing. Some examples
to physical health, productivity, creativity, and sat- from the Well Elderly study include: creating
isfaction, and, conversely, depression, loneliness, resource booklets with transportation information,
helplessness, and both physical and cognitive fa- inexpensive things to do in the community, the
tigue. The participants gained “occupational range of motion (ROM) dance, planning, shopping
knowledge and reflective skills” and then could for and preparing a meal together, and creating and
“imagine and enact healthy occupational lives as displaying personal history time lines. Direct expe-
they age” (1998, p. 329). rience, both inside and outside of sessions, provided
Several components were crucial to the success participants with the opportunity to increase their
of Lifestyle Redesign. The attitude of the therapist self-efficacy and sense of control, and to better
and the environment that she/he created for inter- self-regulate (1999).
vention was paramount. The therapist created an Personal exploration and application happened
environment where the participant was the expert throughout each of these processes and consisted of
and where he or she felt safe and inspired to take specific time for reflection on the content of each
risks and initiate change. For example, the occupa- session. This reflection could take shape in a writing
tional therapist would prepare a document of the exercise, discussion, or another format. These activ-
participants’ thoughts, feelings, and ideas from a ities allowed the participants to see how far they
previous session and then distribute them to the have come and increased their awareness of the
participants at the following session to create a graduated nature of the Lifestyle Redesign process
notebook. Such physical representations validated (1999). The process of intervention is described in
their ideas and contributions (Mandel et al., 1999). Box 26-3.
Box 26-3 Mandel et al.’s Outline of the Lifestyle Redesign® Intervention Process
1. Acquiring knowledge of the factors related to occupation that promote health and happiness
2. Performing a personal inventory and reflecting on one’s fears and occupational choices, interests, life goals,
and so forth (occupational self-analysis)
3. Overcoming one’s fears by taking incremental risks in the real world of activity in small steps over time
4. Weaving together the outcomes of prior steps to develop a health-promoting daily routine
Data from: Carlson, Clark & Young, 1998; Mandel et al., 1999, p. 29.
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Four keys ideas that participants learned that occupational therapist one time per week for an
contributed to the success of the intervention were: extended period of time, usually 12–16 weeks or
longer. In the group sessions, the same participants
“1. Experience in occupation creates radiating,
meet together for the duration and become sources
not linear change.
of support for one another. This format intentionally
2. Occupational self-analysis is possible,” and
allows for a feeling of both familiarity and novelty
through this process participants are encour-
simultaneously. Meetings occur at the same location
aged to identify barriers to desired changes
and time weekly; however, the occupational therapist
and the small next steps to get them there.
presents a different topic each week, providing spon-
“3. When people understand the elements of
taneity and variation. Activities and outings also
occupation, they have the tool kit to
sprinkle the process with more variety as well as the
redesign their lives.” Selection of occupa-
continual social shifting as participants get to know
tions becomes more intentional, and partici-
one another better (Mandel et al., 1999).
pants are guided through the process of
recognizing and experiencing meaning in
their selected occupations.
“4. Occupation is the impetus that propels people Lifestyle Redesign Programs
forward.” (Mandel et al., 1999, pp. 30–31). and Applications Since the
Both the therapist and the participant engage in USC Well Elderly Study
occupational storytelling and story making to
create the future lifestyle they will begin to enact. All of the Lifestyle Redesign programs created since
Through this approach, participants are able to see the USC Well Elderly Study contain the same key
that their life, or story, is still moving forward and components outlined previously. Differences in-
they are experiencing transformation (pp. 30–31). clude the content of the didactic material, which is
Lifestyle Redesign interventions can be con- based on each population’s needs, and variations in
ducted in both group and individual formats, and format (e.g., individual, group, or a combination of
often participants utilize both formats to maximize both), frequency, duration, and location. The occu-
their experience. The benefits from group and indi- pational therapist may see clients in an outpatient
vidual formats share similarities and differences, occupational therapy clinic, physician clinics, uni-
yet when done concurrently can enhance one versity offices and conference rooms, or clients’
another (Carlson, Franchiang, Zemke, & Clark, homes. A list of Lifestyle Redesign programs offered
1996). Groups and individuals meet with their by the OTFP is provided in Box 26-4.
Box 26-4 Lifestyle Redesign Programs Developed at the USC Occupational Therapy Faculty
Practice
• Weight Management, including bariatric surgery—Development and enactment of a customized routine of

health promoting and meaningful activities designed to result in weight loss and improved life satisfaction.
• Type II Diabetes—Integration of health promoting and meaningful activities into one’s daily routine to prevent or
management diabetes, improve life satisfaction, and increase quality of life.
• Chronic Pain Management—Development and enactment of a customized routine of health promoting and
meaningful activities designed to decrease debilitating habits; reduce pain levels; increase ability to cope with
pain; and utilize strategies including energy conservation, pacing, adaptive equipment, and time management.
• Chronic Headaches—Identification of triggers and other lifestyle factors associated with headaches and
incorporation of strategies to prevent headaches throughout routines.
• College Student—Development and optimization of routines to improve overall well-being and academic
performance through increasing time management, stress management, organization, lifestyle balance,
motivation, and focus.
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Box 26-4 Lifestyle Redesign Programs Developed at the USC Occupational Therapy Faculty
Practice—cont’d
• Movement Disorders / Parkinson’s Disease / Multiple Sclerosis—Integration of healthy routines and habits that
focus on engagement in occupation, stress management, ergonomics, energy conservation, pacing techniques,
healthy eating, relaxation, and fall safety.
• Mental Health—Integration of health promoting and meaningful activities into one’s daily routine to improve
mental wellness, stress management, lifestyle balance, time management, organization, and life satisfaction.
• Breast Cancer—Integration of healthy habits to support remission and life re-integration, increase functional and
meaningful activity, and prevent chronic conditions through eating routines, physical activity, stress management,
and more.
• Smoking Cessation and Relapse Prevention—Development of health promoting daily habits and routines to
replace smoking and manage triggers, including eating routines, physical activity, and stress management.
• Truck Drivers—A 7-week pilot program which utilized a combination of group and individual sessions in
response to the health risks associated with the trucking industry including weight and stress management,
and incorporation of physical activity while on the road.
• Green Lifestyle Redesign—Integration of environmentally sustainable activities into daily habits and routines to
strengthen stewardship of the environment and improve physical and mental health and well-being.
Lifestyle Redesign Weight The most common co-morbid conditions asso-

Management Program ciated with overweight/obesity include: hyperten-
sion, hypercholesterolemia, heart disease, and type 2
In 2007–2008, a third of adults in the United States diabetes. Other common diagnoses for weight
were categorized as obese (body mass index (BMI) management include: pre-diabetes, glucose intoler-
>30) and another third as overweight (BMI of ance, metabolic syndrome, coronary heart disease
25–29.9) (Flegal, Carroll, Ogden, & Curtin, 2010). (CHD), coronary artery disease (CAD), hyper-
The Lifestyle Redesign Weight Management Pro- triglyceridemia, fatty liver, candidates for bariatric
gram was created to address the growing need to ad- surgery, joint pain, sleep apnea, thyroid issues,
dress overweight, obesity, and associated co-morbid depression, anxiety, and multiple sclerosis, among
conditions. By far the largest program at the OTFP, others. A co-morbid diagnosis is usually necessary
its therapists have seen hundreds of clients since its for reimbursement by a third-party payer, since
inception in 2000. Due to the chronic nature of overweight/obesity is not currently considered a re-
overweight/obesity and common co-morbidities, imbursable diagnosis. This requirement is especially
Lifestyle Redesign is an appropriate method and has challenging for pediatric clients who are overweight
yielded positive results. According to a 2006 analy- or obese but have not yet acquired a co-morbid
sis, after attending eight or more Lifestyle Redesign condition.
sessions, participants lost, on average, 4.2% of their Weight management intervention is based on
original body weight and 7.5% of their original fat implementing gradual lifestyle changes, which
mass. The more sessions a client attended, the more affect weight, co-morbid conditions, overall phys-
weight he or she lost. Clients attend group or indi- ical and psychosocial health, self-efficacy, and life
vidual sessions for 16 consecutive weeks and often satisfaction. Emphasis is placed on goal setting and
continue as needed. Because healthy weight loss accountability during each session. First clients
(about 1–2 pounds per week) is critical (National learn to analyze their own habits and routines and
Institutes of Health [NIH], 1988), in a 16-week relate their personal experience to the weekly topic.
program clients lose a maximum of 32 pounds. As Topics include eating routines, meal/snack prepa-
many clients have more weight to lose, they may ration, physical activity, time management, and
choose to continue treatment and/or often continue addressing occupational role overload and depri-
to lose weight on their own following intervention. vation. Throughout the intervention, clients consider
2580_Ch26_377-389 16/07/13 3:15 PM Page 384
how their routines and environments impact their check-in are each a crucial part of the habit change
weight management, sleep, relaxation, lifestyle process (Clark, 2000).
balance, stress management, and emotional eating. Additionally, the weight management program
Through occupational self-analysis, clients can places particular emphasis on the environments in
begin to enact change. They become savvy con- which the clients are situated in their daily lives. The
sumers regarding food labels, dining out, and fad built environment includes the foods they are ex-
diets. They address psychosocial and emotional posed to and is a key contributor to weight gain or
issues related to healthy habit formation and find loss. The built environment also includes sidewalks,
new healthy pleasures and meaningful activities to transportation, local parks, neighborhood safety,
replace habits related to overeating. Weight Man- and density of the surrounding area. Occupational
agement Program occupational therapists ensure therapists in Los Angeles frequently address the built
that clients have the experience and understanding environment because it has become so “obeso-
to independently make the best choices for them- genic,” defined by the CDC as an environment that
selves to manage their weight effectively. Clients “offers access to high-calorie foods but limits oppor-
gain experience in reading food and menu labels, tunities for physical activity” (CDC, n.d., para 1).
and learn how to reach comfortable satiety while Many clients find it impossible or inconvenient to
consuming less calories, how to balance blood sugar, walk or bike to their daily activities such as work,
and how to choose foods to decrease cholesterol and markets, restaurants, and other recreational activi-
blood pressure. A registered dietitian provides con- ties. With longer commutes and more sedentary
sultation during the development of the program jobs, physical activity embedded into daily routines
and approves an eating plan. can become very limited. The therapist works with
Next, the sessions focus on problem solving with the client to increase physical activity in home,
the therapist and other participants (if applicable) work, and transportation environments when
on how to make the best choices within a client’s possible, and advises how to navigate the deluge of
current occupational repertoires and environments calorie-dense food available at every turn (Clark,
and how to overcome barriers to the changes the Saliman Reingold, & Salles-Jordan, 2007).
client has decided he or she would like to make. The
occupational therapist places emphasis on the rela- Bariatric Surgery
tionship between stress, occupation, and eating, and Many insurance companies now require lifestyle
helps the client see and transform reactionary eating intervention/modification programs before author-
patterns that contribute to weight gain. Clients es- izing bariatric surgery. Because bariatric surgery is
tablish accountability structures for their short-term only one of the tools clients may use to maintain a
action oriented goals each week. healthy weight, it is crucial for clients to learn and
The occupational therapist helps the client incorporate the skills and habits necessary to con-
to create his or her own accountability structures tinue to lose and maintain their desired weight for
in order to increase the likelihood of achieving life after surgery. The surgery is essentially a jump-
short-term goals and to have accountability when start and can enable clients to engage in physical
occupational therapy intervention is complete. Ex- activity more comfortably as well as decrease or
amples of accountability structures include making eliminate symptoms and co-morbidities associated
an appointment to walk or exercise with a friend with type 2 diabetes and obesity. Lifestyle Redesign
or family member; being responsible for walking intervention for bariatric clients emphasizes prepa-
the dog once or twice per day; or paying for a ser- ration for engagement in increased meaningful
vice in advance, such as a class or massage. It is activity that is not associated with food.
essential for the client to determine his or her own Because clients must drastically decrease their
goals and accountability structures each week with caloric intake and food options after surgery, many
the therapist and other group members (if appli- clients lose some of their cherished meaningful
cable). Developing relationships with other group occupations that revolve around mealtimes and
members and the occupational therapist, practic- pleasure from food. As a result, they must begin to
ing the new habit, and performing the weekly identify other healthy pleasures, reward systems,
2580_Ch26_377-389 16/07/13 3:15 PM Page 385
and emotional outlets to replace eating. Similarly, Lifestyle Redesign for

eating routines change drastically. Prior to surgery, the College Student
as part of the Lifestyle Redesign program, bariatric
clients prepare to change their eating routines to eat In 2007, the Association for University and College
more frequently, decrease portion sizes, and incor- Counseling Center Directors reported that 87%
porate new nutritional needs such as supplements of college counseling centers observed an increase
and protein. Clients who undergo bariatric surgery in the number of students who visit their centers
must also increase their physical activity in order to and are taking psychotropic medications (Nauert,
prevent muscle loss. The OTFP has partnered with 2008). College students experience frequent habit
the bariatric surgeons at USC to provide this ser- and routine changes every year and often every se-
vice. At the time of this writing, two large insurance mester. Many students, away from home for the first
companies require clients to complete the Lifestyle time, have to learn how to engage in new occupa-
Redesign program before surgery. tions, create their own occupational routines, and
structure their time independently. Lifestyle Re-
design helps students acquire skills to successfully
Lifestyle Redesign for Diabetes meet academic, social, and other developmentally
The Lifestyle Redesign for Diabetes program natu- appropriate demands. The program helps students
rally evolved from the weight management program manage time, become more self-motivated, improve
to address the growing population with diabetes. focus, problem solve, better organize their activities,
In 2008, 8% of people in the United States, or decrease procrastination, optimize study/work envi-
24 million, had diabetes (CDC, 2008). This program ronments, reduce stress, engage in dating and other
utilizes similar didactic content but adds information social occupations, and promote lifestyle balance.
about both preventing and managing diabetes and its Other topics include leisure, money management,
associated co-morbid conditions, sustaining healthy community transportation, effective communica-
eating routines and blood sugar levels, and engaging tion, eating routines/cooking, exercise, substance
in physical activity and stress management to help to abuse, psychosocial issues, learning styles, and goal
decrease blood sugar levels and symptoms of diabetes. setting. Common diagnoses include difficulty adjust-
ing to college roles, learning disabilities, attention
deficit disorder (ADD), attention deficit hyperactive
Lifestyle Redesign for disorder (ADHD), mental health diagnoses, and
Chronic Headaches acute reactions to stress as well as diagnoses related
As was the case with the diabetes program, the to weight management and chronic pain.
Lifestyle Redesign program for clients with headaches The intervention is usually delivered individually
and migraines grew out of the pain management because most students prefer this format. In addition,
program. The prevalence of migraines is 18% of OTFP affects six to eight open-enrollment occupational
American women and 6% of American men, which therapy groups in conjunction with counseling per
is more than 28 million people (Sun-Edelstein & semester on topics such as lifestyle balance, time man-
Mauskop, 2009). Inspired by Lifestyle Redesign, a agement, stress management, communication/conflict
neurologist at USC requested occupational therapy resolution, self-awareness and embracing diversity, and
for her patients with headaches, where lifestyle relationship success. In the community setting of a large
factors play such an important part in pain and university campus, intervention can conveniently occur
pain management. The chronic headache population in work, home, and leisure environments, including
lends itself well to a group format because of dorm rooms, eating places, grocery stores, and the
commonly shared traits and demographics. Depend- student fitness center.
ing on their needs, many clients with chronic
headaches often choose individual or both group
and individual sessions simultaneously. The program Lifestyle Redesign for Mental Health
lasts for 8 weeks, though many clients continue for Lifestyle Redesign for any population addresses the
additional sessions. psychosocial realm of clients and their lifestyle, health
2580_Ch26_377-389 16/07/13 3:15 PM Page 386
status, and situations. This can be an appropriate in- offered at the OTFP primarily comes from the
tervention method for people who have moderate to clients’ health insurance. Common occupational
mild symptoms from psychosocial disease. For more therapy codes are used, such as evaluation, thera-
serious and severe mental health issues, a client may peutic group, functional therapeutic activity, ADLs,
not be able to set appropriate goals and follow and therapeutic exercise. Even though the diagnoses
through with them independently. Intervention em- treated using Lifestyle Redesign may be different
phasizes using lifestyle factors and lifestyle changes as than those of more traditional occupational ther-
a way to improve self-regulation, mood, attention, apy practice, many insurance companies pay for
concentration, and motivation. For example, main- occupational therapy services for these diagnoses.
taining proper blood sugar and getting consistent Self-pay, grants, and special contracts also have
physical activity can greatly improve concentration demonstrated to be viable methods of reimburse-
and mood, which can lead to greater gains in moti- ment. Grants also may be secured because there are
vation and productivity. Addressing lifestyle factors many specific populations that need weight man-
also gives clients a sense of control over themselves agement interventions and are often prioritized by
and their daily lives. This population receives weekly funding agencies. For the past 8 years, a major in-
individual sessions, usually over several months. surer of USC employees has contracted with OTFP
to create a prevention model for reimbursement.
Those covered by this plan do not need a diagnosis
Lifestyle Redesign Interventions or physician prescription to participate and are in-
Outside of USC Settings centivized to lose weight and maintain their weight
The name “Lifestyle Redesign” has been registered loss. The member has a co-payment for each visit
and trademarked by USC in order to maintain the for the 16 weeks of services. If he or she loses weight
precision and consistency of its successful clinical and keeps it off for 3 months, the insurance com-
trial interventions. In addition to the Well Elderly pany reimburses the member for co-pays. Members
study, USC is creating other Lifestyle Redesign of this plan may participate in the 16-week program
research trials, such as the Pressure Ulcer Prevention and receive reimbursement up to three times. This
Study (PUPS). Occupational therapy practitioners arrangement significantly increases access to the
are encouraged to draw from the Lifestyle Redesign Lifestyle Redesign service.
format and methods in their settings; however, they Students who have the USC student health in-
must use a different name. surance are entitled to 26 visits per academic year
The following are three examples of interventions for occupational therapy shared with physical ther-
in other settings using a Lifestyle Redesign approach. apy and chiropractic services and pay either a small
Employee Wellness is an 8-week program for employ- or no co-payment. Often students have not used
ees at USC designed to encourage acquisition of any of these visits for other services, so they are able
health promoting habits in the workplace by Daley. to come once per week for almost two full semesters
Live Your Best Life, created by Chu, is a stroke pre- per year. Again, the reimbursement arrangement
vention program at Rancho Los Amigos Rehabilita- significantly increases clients’ access to Lifestyle
tion Center in Downey, California, near Los Angeles, Redesign.
that targets women age 35–65 who have had a stroke
or transient ischemic attack (TIA) and are interested
in learning healthy lifestyle habits to prevent a second Conclusion
stroke. Lifestyle Matters is an adapted version of the
USC Well Elderly Study in Great Britain (Mountain, Lifestyle Redesign provides occupational therapists
Craig, Mozley, & Ball, 2006). with a community-based intervention approach
that addresses the critical need for prevention and
self-management of chronic conditions.This method
Reimbursement for Lifestyle Redesign draws from the roots of occupational therapy but
Reimbursement for the weight management pro- also looks to the future by widening the scope of
gram and for the other Lifestyle Redesign programs practice to include a much broader client base.
2580_Ch26_377-389 16/07/13 3:15 PM Page 387
Anyone who wants to live a healthier and happier society’s occupational needs” (AOTA, 2006, ¶1).
life and to prevent or better manage chronic con- As the needs of society shift, occupational therapy
ditions can benefit from this approach. With both intervention must shift as well. With the sheer
the evidence to support its efficacy with certain numbers of people living with chronic conditions
populations and a practical format, Lifestyle and diseases and predicted to acquire chronic con-
Redesign programs are situated to directly address ditions in the coming years, the profession must
each of the goals in the AOTA Centennial Vision more fully utilize its unique and effective Lifestyle
to become a more “powerful, widely recognized, Redesign approach to increase the role of occupa-
science-driven, and evidence-based profession with tional therapy practice in prevention and health
a globally connected and diverse workforce meeting promotion.
CASE STUDIES
CASE STUDY 26•1 Linda
Linda is a 58-year-old female with a diagnosis of obesity and diabetes. After being referred by her physi-
cian, Linda started the Lifestyle Redesign program for diabetes. Biomeasures on her first session were:
weight: 227.4 pounds, BMI: 37.8, fat mass: 102.8 pounds, and blood pressure: 142/72 (with medica-
tion). Her concerns included diabetes and escalating blood sugar, continued weight gain from increased
amounts of insulin required to manage her blood sugar, fatigue, and increased stress at work. Linda is a
registered nurse and the manager of a large nursing unit in a hospital. Her work demands high energy,
constant communication with others, and attention to detail. She attended a Lifestyle Redesign for Dia-
betes group for 24 sessions. During these sessions, Linda realized that she focused most of her attention
throughout her long workday and at home on other people. She is a caregiver in some capacity for most
of her time. Additionally, while completing a “balance wheel” activity in which she colored a circular
picture of a wheel divided into 24 hours according to how she spends her typical day, Linda realized
that she spends very little time engaging in leisure activities. In another session, she learned that her
caffeine consumption of six to eight diet sodas per day was excessive and could be contributing to her
weight gain.
Linda was guided in prioritizing her own health and well-being, planning ahead for healthy eating,
engaging in consistent physical activity, improving self-esteem, managing stress and relaxation tech-
niques, cultivating happiness in daily routines, and substituting new healthy pleasures for caloric rewards.
After 24 weeks, Linda lowered and maintained her blood sugar to a level where she was able to stop
using insulin completely. She also stopped her weight gain. She lost 2 pounds overall and 5 pounds of
fat mass. She developed and maintained consistent exercise for three days per week. She started a
routine at the YMCA and had a trainer there who guided her through both cardiovascular and resistance
exercises that were appropriate for her and made her feel good. Linda was able to reduce her caffeine
consumption by 75%, and she reported that she felt happier at work and less stressed most of the time.
When reflecting on her accomplishments, she wrote, “I feel great! I have so much more energy now.”

1. Identify the lifestyle factors that contribute to Linda’s concerns.
2. Identify additional lifestyle factors that Linda discovered were contributing to her presenting concerns
through occupational self-analysis.
3. Identify and discuss lifestyle changes that Linda made and how they had radiating effects in other
aspects of her lifestyle and health outcomes.
4. What do you think motivated Linda to stay consistent with her lifestyle changes over 24 weeks?
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Learning Activities Centers for Disease Control and Prevention. (2008). Number
of people with diabetes increases to 24 million. Retrieved
1. Find articles from popular media (e.g., news- from http://cdc.gov/media/pressrel/2008/r080624.htm
papers, magazines, Web sites, etc.) about a sit- Centers for Disease Control and Prevention. (2009). Common
Causes of Disability Among Adults—United States 2005
uation, issue, or population that could benefit [electronic version]. MMWR Weekly, 58(16), 421–426.
from Lifestyle Redesign both in the United Retrieved from http://cdc.gov/mmwr/preview/
States and in another country. mmwrhtml/mm5816a2.htm
2. Create a list of 8–10 interview questions to use Centers for Disease Control and Prevention. (2010). Chronic
as part of a needs assessment for a particular disease prevention and health promotion. Retrieved from
http://cdc.gov/chronicdisease/index.htm
community-based population that you think Chessick, R. D. (1990). Hermeneutics for psychotherapists.
may have a need for a lifestyle intervention. American Journal of Psychotherapy, 44(2), 256–273.
Craft the questions in order to obtain specific Clark, F. (1993). Occupation embedded in a real life:
detailed information about this population’s Interweaving occupational science and occupational
threats to health, well-being, and engagement therapy. American Journal of Occupational Therapy,
47(12), 1067–1078.
in occupation as well as their current occupa- Clark, F. A. (2000). The concepts of habits and routine: A
tional patterns and lifestyle factors. preliminary theoretical synthesis. Occupational Therapy
3. Plan a group activity for a specific population Journal of Research, 20 (supplement I), 123S–137S.
in a community-based setting that engages the Clark, F., Azen, S. P, Carlson, M., Mandel, D., LaBree,
participants in the process of occupational L., Hay, J.,...Lipson, L. (2001). Embedding health-
promoting changes into the daily lives of independent-
self-analysis. Determine the population and living older adults: Long-term follow-up of occupational
setting, and take into consideration the clients’ therapy intervention. Journal of Gerontology: Psychological
occupational and lifestyle factors. Sciences, 56, 60–63.
4. Think of a habit that you would like to start or Clark, F., Azen, S. P., Zemke, R., Jackson, J., Carlson, M.,
stop. What are some accountability structures Mandel, D.,...Lipson, L. (1997). Occupational therapy for
independent-living older adults: A randomized control
that you could set up to help you to engage in trial. JAMA 278(16), 1321–1326.
or cease this habit? Clark, F., Carlson, M., Zemke, R., Frank, G., Patterson, K.,
Ennevor, L,... Lipson, L. (1996). Life domains and
adaptive strategies of the low income well elderly.
American Journal of Occupational Therapy, 50, 99–108.
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nvsr/nvsr56/nvsr56_10.pdf 2816.html
Mandel, D. R., Jackson, J. M., Zemke, R., Nelson, L., & Prochaska, J. O., & Norcross, J. C. (2001). Stages of change.
Clark, F. A. (1999). Lifestyle redesign®: Implementing the Psychotherapy, 38(4), 443–448.
well elderly program. Bethesda, MD: American Polkinghorne, D. (1988). Narrative knowing and the human
Occupational Therapy Association. sciences. Alban, NY: State University of New York Press.
Mattingly, C. (1991). Healing dramas and clinical plots: Sun-Edelstein, C., & Maskop, A. (2009). Foods and supple-
The narrative structure of experience. Cambridge, UK: ments in the management of migraine headaches
Cambridge University Press. [electronic version]. Clinical Journal of Pain, 25, 446–452.
Miller, W. R., & Rollnick, S. (2002). Motivational Interviewing: Retrieved from http://clinicalpain.com.
Preparing People to Change. New York, NY: Guilford Press. World Health Organization. (2012). Chronic diseases and
Mountain, G., Craig, C., Mozley, C., & Ball, L. (2006). health promotion. Retrieved from http://who.int/chp/en/
Lifestyle matters: An occupational approach towards health
and wellbeing in later life. Sheffield, England: Sheffield
Hallam University.
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Chapter 27
Occupational Therapy in Primary

Health Care Settings
S. Blaise Chromiak, MD; Marjorie E. Scaffa, PhD, OTR/L, FAOTA; and Shannon Norris, OTR/L
Primary health care is essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals
and families in the community through their full participation and at a cost that the
community and country can afford to maintain at every stage of their development in
the spirit of self-reliance and self-determination.
—World Health Organization [WHO], 1978, section VI
Learning Objectives
• Describe primary health care, including the types of providers, settings, and populations served.
• Identify the objectives of Healthy People 2020 that apply to primary health care.
• Discuss potential roles for occupational therapy in primary care settings.
• Discuss the most commonly addressed prevention and health promotion issues in primary health care practice.
• Describe the impact of health literacy on individual health and strategies for addressing the problem of health
illiteracy.
• Discuss the evidence-based components of chronic disease self-management programs.
Key Terms
Brief office intervention Medical home
Chronic disease self-management Primary care physician
Health literacy Primary health care
Health risk appraisals (HRAs) Teachable moments
Introduction However, the stress of today’s complex lifestyles is

resulting in new epidemics of illness that seriously
Over the past century or so, public health measures endanger the health of individuals and families in
have spurred major gains in health, mostly by the United States. Deleterious societal influences
controlling infectious diseases. In recent decades, and living conditions are accelerating the prevalence
advances in preventive medicine have significantly of risk factors for illness and impeding opportunities
reduced or delayed the morbidity and mortality for promoting health.
associated with cardiovascular disease, hypertension, The incidence of obesity, poor nutrition, sedentary
stroke, diabetes, and some types of cancer (Ganiats lifestyle, and diabetes is increasing and has negative
& King, 2003). This has been aided by improved implications for the cardiovascular system and other
medications and technological breakthroughs. body structures. As a result, today’s youth will likely
390
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Chapter 27 | Occupational Therapy in Primary Health Care Settings 391
experience increased morbidity and earlier mortality the potential roles for occupational therapists as
when compared to their parents (Olshansky, Passaro, service extenders for individuals throughout the life
Hershow, et. al, 2005). In addition, other contrib- span in these settings (Box 27-1).
utors to the epidemic of poor health include behav-
iorally influenced diseases and rising numbers of
those with mental health conditions, including Primary Health Care Services
depression and post-traumatic stress disorders.
These physical and mental illnesses may present The American Academy of Family Physicians
acutely, but their risk of morbidity may become (AAFP) defines primary health care as “care pro-
chronic and persist throughout the life span. vided by physicians specifically trained for and skilled
Although the challenges of modern life may be a in comprehensive first contact and continuing care
barrier to achieving sustained positive changes in for persons with any undiagnosed sign, symptom,
health and quality of life, primary care physicians or health concern (the “undifferentiated” patient)
are ideally situated to address many types of medical not limited by problem origin (biological, behav-
problems and disabilities, whether physical or ioral, or social), organ system, or diagnosis. Primary
mental and emotional. The focus of this chapter is care includes health promotion, disease prevention,
on the most common lifestyle-related health prob- health maintenance, counseling, patient education,
lems treated in the primary health care setting and diagnosis and treatment of acute and chronic
Box 27-1 Selected Occupational Therapy Contributions to Health Promotion in Primary

Care Settings throughout the Life Span
Children
• Childhood developmental assessments, including infant reflexes
• Evaluation of and intervention for learning disabilities
• Identification of sensory integration deficits
• Assessment and intervention for infant and child feeding problems
• Safety and injury prevention education for parents, including the appropriate use of car safety seats, playground
safety, stranger safety, etc.
• Suggestions for “child-proofing” the home
• Providing parents with toilet training strategies
• Facilitating parent-child attachment, bonding, and communication
• Parental education regarding developmental toys and facilitating age-appropriate play
• Identification of child neglect and abuse
• Guiding families in their search for and evaluation of appropriate child-care services
• Assisting families in identifying governmental and community resources
• Childhood mental health screenings
• Preschool readiness screening
• Educating parents regarding strategies for preventing childhood obesity
• Providing handwriting assessment and intervention for school-aged children
• Assisting parents with problem-behavior management
Adolescents
• Mental health screenings
• Sexuality education
• Prevention and intervention for tobacco, alcohol, and other drug use
• Identification of and intervention for eating disorders
• Encouraging the development of healthy habits
• Facilitating adaptive coping and use of healthy stress management strategies
• Educating parents about signs of suicide and suicide prevention strategies
Continued
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Box 27-1 Selected Occupational Therapy Contributions to Health Promotion in Primary

Care Settings throughout the Life Span—cont’d
• Educating teens about injury prevention, including high-risk behaviors, sports injuries, etc.
• Development of conflict resolution skills and anger management
• Coping with peer pressure
• Promoting health literacy
Adults
• Work injury prevention, assessment, and treatment
• Chronic pain management
• Parenting training and support
• Ergonomics, body mechanics
• Facilitating adaptive coping and managing psychosocial stress
• Smoking cessation
• Prevention of and intervention for back pain
• Weight loss and healthy meal planning
• Mental health screening
• Identification of and intervention for alcohol and other drug abuse
• Identification of family violence
• Grief and bereavement support
• Identification of resources for elder care, evaluating assistive living and long-term care options
• Managing caregiver stress and preventing burnout
• Incorporating physical activity into the daily routine
• Reducing or managing disability associated with chronic conditions
• Promoting chronic disease self-management
Elderly
• Medication management
• Energy conservation
• Joint protection
• Fall prevention
• Driving evaluations and identifying alternative transportation
• Low vision adaptations
• Retirement preparation and adjustment
• Adaptive equipment
• Dementia management
• Work simplification strategies
• Identification of elder neglect and abuse
• Mental health screening
• Identification of and intervention for alcohol and other drug abuse
• Grief and bereavement support
• Reducing or managing disability associated with chronic conditions
• Weight management
• Incorporating physical activity into the daily routine
• Managing health care visits and insurance issues
• Home assessment and modification to increase safety and functional independence
• Incontinence management
• Assisting elders in identifying governmental and community resources
• Facilitating adaptive coping and managing psychosocial stress
• Facilitating “aging-in-place”
• Chronic disease self-management
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illnesses in a variety of health care settings (e.g., themselves and their patients to providers and ser-
office, inpatient, critical care, long-term care, home vices in their communities” (Agency for Healthcare
care, day care, etc.). Primary care is performed and Research and Quality, 2011, para 3).
managed by a personal physician often collaborating
with other health professionals, and utilizing con-
sultation or referral as appropriate” (AAFP, 2011, Health Promotion in Primary
para 3–4). Care Settings
Primary health care is continuous, comprehensive
care designed to maximize health and prevent disease Health promotion is an important component of
that is provided near where people live, work, and helping patients reach their health goals. The purpose
play (Edelman & Mandle, 2002). The term primary of health promotion is “to enable people to gain
care physician “is used to describe all physicians greater control over the determinants of their own
whose practice includes the provision of medical care health” (World Health Organization [WHO],
for well individuals and who act as ‘gatekeepers’ to 1986, p. iii). According to the U.S. Preventive
specialist services” (Goel & McIsaac, 2000, p. 230). Services Task Force [USPSTF], modifying personal
The physicians who today provide the bulk of health behaviors is the most promising approach for
primary health care are family and general practition- health promotion within current medical practice
ers, medical internists, and pediatricians. In addition, (USPSTF, 2007). Health promotion and disease
there are obstetrician-gynecologists for women’s prevention activities in primary care settings are
primary health care and psychiatrists for primary guided by Healthy People 2020, the national health
mental health services. Physician extenders, such as agenda in the United States (USDHHS, 2011).
nurse practitioners and physician assistants, are also Many objectives in HP 2020 refer to primary care,
involved in the delivery of primary care services. a selection of which appears in Table 27-1.
There are many types of primary care settings. Primary care physicians’ offices are ideal settings
Usually the physical setting is an office or hospital, for disease prevention and health promotion. Physi-
but primary care physicians and physician extenders cians are generally viewed as authoritative and cred-
may provide services in the home and for assisted ible sources of information and advice on health and
living, rehabilitation, long-term, and hospice care. illness. A significant number of studies have demon-
Patient populations include all age groups: infants, strated that physician advice is a strong determinant
children, adolescents, pregnant women, adults, and of compliance with preventive practices, such as
the elderly. mammograms. In addition, brief office interven-
The long-term relationships that primary care tions have demonstrated effectiveness for smoking
physicians develop and share with those in their cessation, reducing alcohol consumption, and other
care make the primary physician the entry point in health-related behaviors. Teachable moments,
accessing the health care system. This makes the when direct links can be made between symptoms,
primary physician’s office the patient’s medical behavior, and outcome, occur routinely during of-
home.The primary care medical home “is account- fice visits. For example, an office visit for angina is a
able for meeting the large majority of each patient’s teachable moment to address smoking cessation,
physical and mental health care needs, including nutrition, and weight loss with a patient. However,
prevention and wellness, acute care, and chronic due to time constraints, physicians may not be able
care. Providing comprehensive care requires a team to utilize these opportunities effectively.
of care providers. This team might include physi- Occupational therapists providing services in
cians, advanced practice nurses, physician assistants, primary care settings need to recognize that health
nurses, pharmacists, nutritionists, social workers, promotion and prevention interventions do not
educators, and care coordinators. Although some immediately resolve health problems, and that in-
medical home practices may bring together large dividuals will progress in their own incremental
and diverse teams of care providers to meet the and idiosyncratic ways. Appropriate theoretical
needs of their patients, many others, including perspectives for health promotion practice in these
smaller practices, will build virtual teams linking settings are the PRECEDE-PROCEED Model
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Table 27-1 Healthy People 2020 Objectives Related to Health Promotion in Primary Care
Area Objective
AHS-3 Increase the proportion of persons with a usual primary care provider
AHS-5 (Developmental) Increase the proportion of persons who receive appropriate evidence-
based clinical preventive services
AOCBC-7 Increase the proportion of adults with doctor-diagnosed arthritis who receive health care
provider counseling
C-18 Increase the proportion of adults who were counseled about cancer screening consistent
with current guidelines
D- 16 Increase prevention behaviors in persons at high risk for diabetes with pre-diabetes
HC/HIT-1 (Developmental) Improve the health literacy of the population
HC/HIT-4 (Developmental) Increase the proportion of patients whose doctor recommends
personalized health information resources to help them manage their health
MHMD-5 Increase the proportion of primary care facilities that provide mental health treatment
on-site or by paid referral
MHMD-11 Increase depression screening by primary care providers
MICH-12 Increase abstinence from alcohol, cigarettes, and illicit drugs among pregnant women
MICH-30 Increase the proportion of children, including those with special health care needs, who
have access to a medical home
NWA-5 Increase the proportion of primary care physicians who regularly measure body mass
index of their patients
NWS-6 Increase the proportion of physician office visits that include counseling or education
related to nutrition or weight
OA-7 Increase the proportion of health care workforce with geriatric certification
PA-11 Increase the proportion of physician office visits that include counseling or education
related to physical activity
RD-6 Increase the proportion of persons with current asthma who receive formal patient
education
SA-10 Increase the number of Level I and Level II trauma centers and primary care settings that
implement evidence-based alcohol screening and brief intervention
TU-9 Increase tobacco screening in health care settings
TU-10 Increase tobacco cessation counseling in health care settings
Data from: USDHHS (2011). Healthy people 2020. Retrieved from http://healthypeople.gov/2020/about/
default.aspx
(Green & Kreuter, 2004) and the Transtheoretical TTM can be utilized to identify the individual’s
(or Stages of Change) Model (TTM) by Prochaska, readiness to change. The health program strategies
DiClemente, and Norcross (1992) described in used should correspond with the stage of readiness,
Chapter 3. whether precontemplation, contemplation, prepa-
Assessing the person’s health promotion needs ration, action, or maintenance. Acquiring the skills,
includes identifying his or her readiness to change habits, and lifestyle behaviors that promote health
and the predisposing, reinforcing, and enabling fac- provides individuals with a sense of self-efficacy
tors that impact the targeted health behavior. The regarding their health, that may lead to better and
2580_Ch27_390-408 16/07/13 3:15 PM Page 395
longer lasting results, and can be generalized to King, 2003). Most of these deaths are attributed
other health issues. to complications of obesity, such as heart disease,
Applying the stages of change to prevention and stroke, and diabetes.
health promotion involves: The American Heart Association (AHA) guide-
lines for the prevention of cardiovascular disease rec-
• bringing the risky behavior(s) to the person’s
ommend a target body mass index (BMI) between
attention,
18.5 and 24.9 regardless of age (Pearson, Blair,
• helping the person to determine the need to
Daniels, et al., 2002). Of the approximately 65% of
change these risky behaviors,
all adults who are above normal weight, 30% are
• facilitating the decision to change and select-
overweight (BMI 25–29.9), 30% are obese (BMI
ing strategies for change,
30–39.9), and 5% are extremely obese (BMI 40 and
• maintaining the new healthy behaviors, and
over) (Purnell, 2005). Several studies have indicated
• reinstituting the healthy behaviors when laps-
that abdominal obesity, regardless of overall weight,
ing into old habit patterns and behaviors
is a significant predictor of metabolic disturbances
(Moyers & Stoffel, 2001, p. 329).
and disease risk. Even persons with a BMI in the
The health promotion process in primary care con- normal range can be at higher risk if they have a
sists of assessing the person’s health promotion needs; large waist circumference. Therefore, waist circum-
providing appropriate, culturally sensitive health ference measurements are recommended as part
education; collaboratively setting realistic health goals; of a routine physical examination (Dobbelsteyn,
facilitating the person’s acquisition and development Joffres, Mac Lean, & Flowerdew, 2001). A waist
of skills needed to implement health behaviors; assist- circumference of more than 36–40 inches in men
ing individuals and their families to integrate health and more than 32–35 inches in women is highly
behavior change into their daily lives; facilitating ac- correlated with obesity-related conditions, such
cess and use of community resources; and follow-up as hypertension, sleep apnea, diabetes, and heart
monitoring and evaluating the outcomes (Goel & disease (Dobbelsteyn et al., 2001; Mosley, Jedlicka,
McIsaac, 2000). This approach is consistent with LeQuieu, & Taylor, 2008).
occupational therapy’s emphasis on client-centered The medical approach to weight management
care. Occupational therapists can offer a wide variety combines healthy nutrition, appropriate physical
of prevention, health promotion, evaluation, and activity, behavior modification, psychotherapy,
intervention services in primary care settings. hypnosis, and stress reduction techniques, along
Some of the most common areas for lifestyle in- with fat-binding medications to block fat absorption
tervention in today’s primary care medical practice and anti-depressants to decrease cravings for food.
include weight loss, tobacco use and smoking ces- Diet support groups, such as Weight Watchers,
sation, low back pain, domestic violence, and men- self-help, and 12-step groups (Overeaters Anony-
tal health problems, including alcohol abuse (Zapka, mous), may also be useful. Stimulant-based weight-
2000). Several of these health problems and the role loss medications may have severe risks or unpleasant
of occupational therapy in the primary care setting side effects; thus, there is no safe, effective weight-
are discussed in the next section. loss drug for the general population.
Role of Occupational Therapy
Weight Loss Mosley, Jedlicka, LeQuieu, and Taylor (2008) pro-
Obesity has been a well-recognized concern even vide a succinct overview of the role of occupational
before the Surgeon General’s Call to Action on therapy in prevention and intervention for obesity
Obesity (U.S. Public Health Service [USPHS], in children and adults. They address the importance
2001) stated that reducing obesity was a national of occupation weight reduction and the prevention
priority. As many as 300,000 deaths per year of obesity. In addition, they describe adaptations
are related to obesity caused by unhealthy diet and and modifications that can be made to facilitate
insufficient physical exercise, although this num- bariatric clients’ abilities to perform and participate
ber is probably an underestimate (Ganiats & in daily life activities. Occupational therapists can
2580_Ch27_390-408 16/07/13 3:15 PM Page 396
assess an individual’s overall pattern of daily activity quit, helping them develop practical problem-solving
and make recommendations for occupational skills and a support system, utilizing meditation and
participation in instrumental activities of daily breathing techniques, teaching stress management,
living (IADLs), work, and leisure that increase the encouraging exercise, and prescribing appropriate
level of physical activity in which the person engages medications (USPHS, 2000). Medications include
and thereby enable a person to maintain or lose first-line agents like nicotine, in forms such as gum,
weight more easily. lozenge, skin patch, nasal spray, or oral inhaler. Pre-
Moderate intensity physical activity, such as a brisk scription medications used as adjuncts include those
walk for 30 minutes daily, is the level recommended with anti-craving effects, such as the antidepressant
by the American Heart Association (AHA) for raising bupropion hydrochloride (Wellbutrin, Zyban) and
the heart rate from 40% at baseline to 60% of vareniclidine (Chantix), a partial nicotine agonist.
its maximal capacity. Regular exercise, sports, yard Some contraindications to pharmacotherapy in-
work, and job activities may confer the benefits as clude unstable medical conditions, drug interactions
well (Pearson et al., 2002). For the less active, even (i.e., seizure disorder and use of buproprion), med-
10 minutes of daily walking improves stamina. ication side effects, pregnancy, and breastfeeding
Occupational therapists can provide guidance to (Ganiats & King, 2003).
patients regarding incorporating physical activity Relapse prevention involves the continuation of
into their daily routines. Integrating a variety of stress management and behavioral modification
occupations into one’s routine can provide needed techniques and support from health care providers,
physical activity, for example, washing and waxing including encouragement to remain abstinent,
a car, housework, gardening, pushing a stroller, positive reminders of the benefits of smoking cessa-
raking leaves, and climbing stairs. Occupational tion, and congratulations on continuing successes.
therapists can introduce and encourage active leisure Encouragement and re-motivation for slips may
pursuits such as bicycling, volleyball, dancing, and help the return to a tobacco-free lifestyle, along
swimming. Providing interventions that are devel- with examining the triggers to smoking that can be
opmentally appropriate and addressing safety issues changed to avoid further relapse. More intensive
are important considerations (Reitz, 2010). treatment may be necessary for those with persisting
symptoms of depressed mood, anxiety, insomnia,
weight gain, and difficulty maintaining motivation,
Tobacco Use and Smoking Cessation and for those with withdrawal symptoms or med-
Cigarette smoking has gradually declined over the ication side effects (Ganiats & King, 2003).
years, but nearly one in five adults and one in four Role of Occupational Therapy
high school students still smoke (Centers for Disease
The smoking cessation program sponsored by
Control and Prevention, 2011a). The National
the Department of Occupational Science and Oc-
Cancer Institute (NCI, 2003) concluded the follow-
cupational Therapy at the University of Southern
ing: tobacco smoking is the leading cause of lung
California (2011) assists smokers to:
cancer, secondhand smoke is a risk factor for lung
cancer, and smoking cessation reduces the likeli- • Identify and manage physical, emotional, and
hood of death from primary lung cancer. Cigarette social triggers
smoking is a risk factor for several other cancers • Modify work and home environments to
as well, including mouth, pharynx, larynx, esopha- decrease cues to smoking
gus, pancreas, kidney, bladder, and uterine cervix • Address psychosocial and emotional issues
(American Cancer Society [ACS], 2002). Smoking related to smoking
is also a significant contributor to heart disease, • Prevent and control chronic conditions that
arterial vascular disease, stroke, and chronic obstruc- are the result of smoking
tive lung disease (USDHHS, 2011). • Discover healthy pleasures and non-tobacco
Most smokers attempting to quit need a combi- rewards
nation of pharmacotherapy and behavior modifica- • Learn and practice stress management and
tion, which includes supporting their decision to relaxation techniques
2580_Ch27_390-408 16/07/13 3:15 PM Page 397
• Incorporate exercise and physical activity into Role of Occupational Therapy

their weekly routines According to Karjalainen, Malmiraara, van Tulder,
• Develop healthy eating habits Roine, Jauhiainen, Hurri, & Koes, (2003, p. 4),
• Increase their energy and improve overall health “prolonged low back pain can lead to a combination
• Achieve occupational balance in work, rest, of physical, psychological, occupational and social
and play impairment.” Therefore, a biopsychosocial approach,
This occupation-based smoking cessation program including psychological, behavioral, and educational
uses the theoretical premises and evidence-based prac- interventions, is likely to produce the best results.
tices of Lifestyle Redesign that are discussed more Rosenwax, Semmens, and Holman (2001) provide
fully in Chapter 26. examples of how occupational therapists can adapt
and apply clinical guidelines for LBP from evidence-
based reviews to occupational therapy practice.
Low Back Pain For example, strong evidence exists that bed rest
Low back pain (LBP) is the most common muscu- is counterproductive in the management of LBP.
loskeletal complaint seen in primary care medical Occupational therapists can assess clients’ functional
practice and is a major source of activity limitation limitations and lifestyles and modify activities to
and disability. LBP is experienced by one in five achieve a tolerable comfort level (not necessarily
adults each year and affects 60%–80% of adults pain-free) that enables a person to maintain partic-
at some time in their lives. It is often persistent or ipation in a variety of occupations.
recurrent and is a significant cost to individuals, For persons with subacute LBP, grading of activ-
businesses, and society. It is the fifth most com- ities as the client progresses can enable a return to
mon reason to seek health care. LBP can be due to work more quickly with less disability. In addition,
a single event resulting in acute injury or to a there is moderate evidence to support workplace in-
cumulative process of stress and strain (Gaunt, tervention involving the worker, medical team, and
Herring, & O’Connor, 2008; Rosenwax, Semmens, employer to facilitate a prompt return to work.
& Holman, 2001). Occupational therapists can make recommenda-
The longer a person is out of work due to tions for workstation design and modification of
chronic pain, the more disabling the condition work tasks, provide instruction on appropriate
becomes and the less likely the person is to recover body mechanics in job performance, and address
and return to work. A work absence of 1–3 months psychosocial risk factors in the work environment
puts the worker at a 10%–40% risk of remaining (Rosenwax, Semmens, & Holman, 2001). For more
unemployed at 1 year. Returning to work after a information on ergonomics and prevention of
1- to 2-year absence is highly unlikely even with work-related injury, see Chapter 16.
further treatment (Waddell & Burton, 2001).
Therefore, the primary goal of intervention is to re-
turn the worker to the job as soon as possible. Family and Intimate Partner Violence
Strong epidemiological evidence indicates that Intimate partner violence is an abusive pattern of
most workers with LBP can continue working or behavior one uses to gain power and control over an
return to work within a few days or weeks of injury. intimate partner whether married, living together,
There is no need for a person with LBP to wait for or dating. Abuse comes in many forms, including
complete resolution of pain prior to returning to verbal, emotional, psychological, physical, sexual,
work, as this does not increase risk of reinjury and religious, and economic. Domestic violence can
actually reduces recurrences and missed workdays happen to anyone regardless of race, ethnicity, age,
during the next year. Due to the recurrent and gender, sexual orientation, religion, socioeconomic
persistent nature of LBP, a complete cure is an status, or educational level. Typically, domestic
unrealistic expectation regardless of work status. violence continues for a long period of time and
Job reassessment, modified work, and employer escalates in frequency and severity (Nelson, Nygren,
support increase the likelihood of successful job McInerney, & Klein, 2004). Victims and abusers
reentry (Waddell & Burton, 2001). are from all age and social groups, and women
2580_Ch27_390-408 16/07/13 3:15 PM Page 398
are much more (seven to 14 times) likely to be abused also face obstacles obtaining and maintain-
seriously injured by their partners than men are. ing employment.
One-third of women are abused in their lifetime Occupational therapy services for this population
(USPSTF, 2004). “may include working on the development of a
Each year at the hands of intimate partners, realistic budget; facilitating the use of effective
women experience 4.8 million physical assaults decision-making skills regarding employment op-
and rapes, and men experience 2.9 million physical portunities; learning parenting skills and calming
assaults. These result in more than 2,300 deaths techniques to use with their children; encouraging
overall (Centers for Disease Control and Prevention, and supporting efforts to attain further education;
2011b). Psychological and emotional abuse is much learning assertiveness skills; and teaching stress man-
higher in numbers and frequency but is much more agement and relaxation techniques to improve sleep
difficult to identify and track than physical and patterns” (American Occupational Therapy Associ-
sexual abuse is. Fifty percent of men who abuse ation [AOTA], 2011, p. 6).
their female partners also abuse their children. For Occupational therapy practitioners may also work
victims, awareness of the abuse of their children is with children who have witnessed domestic violence.
another way they may be abused. Child abuse also These interventions may include the facilitation of
pertains to the trauma endured by children who age-appropriate developmental skills, social skills
witness abuse and violence (Nelson et al., 2004). training, improving attention and concentration for
Long-term effects on victims are many and in- school tasks, stress management, and coping strate-
clude: denial, self neglect, self injury, depression, gies. In addition, occupational therapy practitioners
anxiety and panic disorders, alcohol and drug abuse have a professional and ethical responsibility to fa-
and other addictions, chronic pain syndromes, sleep cilitate the health and ensure the safety of victims of
and eating disorders, sexual dysfunction, aggression domestic violence. This may involve reporting to
toward themselves and others, and suicide attempts local and state authorities and assisting survivors
(USPSTF, 2004). Many of these symptoms are also to find temporary shelter, housing, work, and edu-
found in people with post-traumatic stress disorder cational opportunities (AOTA, 2011).
(PTSD) (American Psychiatric Association [APA],
2000). Children who witness abuse also develop
many of the same symptoms. Mental Health
Physicians and health professionals suspect abuse According to the World Health Organization
when there are: repeated or unusual injuries, persist- UK Collaborating Centre (WHO, 2004), at least
ing or worsening depression or other problems 25% of the patients who visit primary care physi-
noted above, unexplained physical and psychologi- cians have significant mental health problems. Men-
cal symptoms (e.g., fear of the abuser or of being at tal health problems in primary health care settings
home alone with the abuser), and absences from are frequently manifested by physical symptoms
school or work (USPSTF, 2004). Abusers are not such as chronic pain, insomnia, gastrointestinal
likely to seek or obtain help unless mandated by disturbance, headaches, and difficulty breathing,
their employer or the courts, so victims must usually among others. The most common mental health
initiate intervention. It is paramount that health problems encountered in primary care are depres-
professionals identify the abuse and encourage and sion, anxiety, substance abuse, eating disorders, and
support victims in getting help. PTSD (WHO, 2004).
Excessive alcohol use is a concern because it is
Role of Occupational Therapy associated with a high rate of injuries and deaths,
Survivors of intimate partner violence often experi- as well as liver disease, ischemic heart disease, car-
ence difficulty with IADLs, including money diomyopathy, and hemorrhagic stroke (Jaen, 2003).
management, community mobility, home manage- The primary care office is an important setting for
ment, and parenting. In addition, they may struggle screening and brief interventions aimed at reducing
with concentration, problem solving, decision alcohol use (Jaen, 2003). When screening reveals
making, and coping skills. Women who have been at-risk drinking, the four-item CAGE questionnaire
2580_Ch27_390-408 16/07/13 3:15 PM Page 399
is very reliable in diagnosing problem drinking anxiety, stress, obsessions, tranquilizer dependence,
(NIAAA, 2003). See Chapter 20 for more informa- depression, post-natal depression, bereavement, mar-
tion about this assessment and potential occupa- ital disharmony, loneliness, child abuse, and lack
tional therapy interventions for substance abuse of self-confidence. Some of the positive aspects of
disorders. the service were:
Mental health problems, particularly major
• People needed fewer visits than in a hospital-
depressive disorder, impose a significant burden on
based program because they were identified
society in terms of lost work productivity, increased
at an earlier stage, and
use of health services, and increased morbidity and
• Patients were more likely to accept the services
mortality from chronic illnesses, and as a leading
provided in the primary care setting because
cause of disability. In addition, mental disorders
the stigma of going to a mental health setting
have adverse effects on adherence to medical regi-
was eliminated (Creek et al., 2002).
mens and health habits, including poor diet, in-
creased alcohol consumption and smoking, and The second model involved occupational thera-
sedentary lifestyle (National Institute of Mental pists working for a home health–like agency that
Health, 2010). Therefore, it is of critical importance marketed their mental health services to physicians.
to screen primary care patients for mental health They provided individual and group interventions
problems. in homes, physician offices, and other community
settings. Several group interventions were run on a
Role of Occupational Therapy regular basis, including groups addressing anger
Although the United Kingdom has a much different management, anxiety management, and assertive-
health-care system than the United States has, there ness skills. The types of client problems seen were
is much to be learned from occupational therapists similar to the first model, but there were some ad-
in the UK regarding providing mental health ser- ditional psychosocial issues, including women going
vices in primary care venues. Several models have through menopause, chronic fatigue syndrome,
been used, including: myocardial infarction (for stress management
and lifestyle changes), PTSD, and employment/
1. providing services in primary care offices,
unemployment issues. A biopsychosocial approach
2. direct referrals from physicians to a service
was used, with access to psychiatrists and primary
provided at a community site, and
care physicians readily available. Referring physi-
3. a collaboration between a mental health
cians noted that patients were requesting referral to
service and primary care physicians (Creek,
the occupational therapy services because a friend,
Beynon, Cook, & Tulloch, 2002).
family member, or neighbor recommended it
In the first model, two occupational therapists (Creek et al., 2002).
working on an inpatient psychiatric unit of a hospital The third model utilized the services of a multi-
decided to pilot mental health services in a local gen- disciplinary Community Mental Health Team
eral practice. They discussed the role of occupational (CMHT) that provided services to eight primary
therapy in mental health with the physicians and care practices. The CMHT comprised an occupa-
provided them with a written description of the tional therapist, psychiatric nurse, and social worker.
services that could be provided and referral criteria. A pilot project was set up at one of the practice sites.
The potential benefits to the physician included: The goals of the project were to: increase access to
“reduced time seeing patients with social and emo- mental health services, offer services within the famil-
tional problems, reduced prescriptions for anxiolytics iar surroundings of a primary care office, provide
and antidepressants, and status in offering an extra timely and effective brief interventions, and develop
service to patients” (Creek et al., 2002, p. 457). The stronger relationships with primary care providers.
physicians agreed and the occupational therapists During the 6 months of the pilot program, referrals
began providing evaluations and individual and increased dramatically and a waiting list had to be
group interventions. The patients (aged 21–76) developed. Patients expressed a need for evening
presented with a variety of problems, including: hours due to work and school schedules, and stated
2580_Ch27_390-408 16/07/13 3:15 PM Page 400
that attending mental health services provided in Brief Office Interventions

the primary care setting was convenient and less
Brief office interventions are short, targeted inter-
stressful than traveling to another location (Creek
actions between patients and health care professionals
et al., 2002).
for the purpose of changing health behaviors. They
These models individually, or the development
are practical and cost-effective and can be imple-
of a hybrid model, could be useful to occupational
mented by a variety of health care professionals, in-
therapists in the United States as a starting point for
cluding occupational therapists (Moyers & Stoffel,
establishing mental health services in primary care
2001). The Counseling and Behavioral Interven-
settings. The benefits of this type of program are
tions Work Group of the U.S. Preventative Services
impressive, including identifying clients with psy-
Task Force (USPSTF) evaluated the features of
chosocial problems earlier before the problem
six models of behavior change and recommended
becomes severe and chronic, reducing the need for
an adaptation for brief office interventions in pri-
psychotropic medication prescriptions, and increas-
mary care settings. The model, briefly described in
ing quality of life.
Table 27-2, is based on 5As: Assess, Advise, Agree,
Assist, and Arrange (Jaen, 2003).
Integrating Health Promotion Medication adherence is a significant concern in
primary care practice that can be addressed by oc-
Practices Into Routine cupational therapists through brief office interven-
Primary Care tions. Barriers to medication compliance, which are
magnified with advancing age and increased medical
Specific populations and the health promotion and psychiatric problems, include multiple drugs,
services they could benefit from were just described. multiple doses per day, problematic side effects
In this next section three evidence-based, health pro- or interactions, and lack of family/social support.
motion approaches that can be used by occupational Effective motivational strategies to improve medica-
therapists will be introduced: brief office intervention adherence include daily reminder charts, use of
tions, health literacy interventions, and chronic daily pill holders, packaging medications in combi-
disease self-management. nation, training in self-determination, social/family
Table 27-2 Brief Office Intervention Model: The 5 As

Step Description
1. Assess • Target a risky behavior identified by patient complaint, and/or medical and social history
2. Advise • Emphasize the importance of discontinuing the risky behavior, the improvements that can
be gained in health status, and the willingness of the health care provider to assist the
patient in making the needed changes
• Clear, simple, and personalized advice provided in a warm, empathic, non-judgmental way
3. Agree • Collaboratively design and agree upon a course of action to change the target risk behavior
• Assess the patient’s readiness to change and design interventions accordingly
4. Assist • Provide specific behavioral interventions
• Encourage and facilitate follow-up counseling and health education sessions
• Assess the effectiveness of physician-provided medications in assisting behavior change
5. Arrange • Reinforce positive changes
• Revise intervention plans if necessary
• Provide ongoing follow-up and support by telephone, electronic communication, or office
visits
Data from: Jaen, C. R. (2003). Integrating Health Behavior Counseling into Routine Primary Care. AAFP CME
Bulletin, (2)7, pp. 1–5. Leawood, KS: AAFP.
2580_Ch27_390-408 16/07/13 3:15 PM Page 401
support, phone calls from nurses, and phone-linked • Facilitating in-person and online self-help and
computer counseling (Domino, 2005). support groups,
• Educating patients on how to prepare for and
Health Literacy Interventions participate in health care interactions with
providers,
Health literacy refers to “the degree to which indi- • Assisting patients with medication manage-
viduals have the capacity to obtain, process, and ment, and
understand basic health information and services • Teaching patients to assess the relevance,
needed to make appropriate health decisions” quality, and credibility of health information,
(USDHHS, 2000, pp. 11–20). Osborne (2005) be- particularly on the Internet.
lieves health literacy goes beyond the individual and
it is the mutual responsibility of the health care
provider to communicate information in ways that Chronic Disease Self-Management
can be understood and applied. The national em- In the elderly population over 70 years of age, ap-
phasis on health literacy is based, in part, on research proximately 80% have at least one of the following
that demonstrates relationships among health liter- chronic diseases or conditions: arthritis, cancer,
acy, health disparities, and health outcomes. Ac- diabetes mellitus, heart disease, hypertension, respi-
cording to the National Center for Education ratory disease, and cerebrovascular accident (CVA)
Statistics, “adults with low literacy levels are more (Chodosh, Morton, Mojica, Maglione, Suttorp,
likely than those with high literacy levels to be poor Hilton, Rhodes, & Shekelle, 2005). In addition,
and to have health conditions which limit their ac- chronic diseases are often accompanied by depres-
tivities” (National Network of Libraries of Medi- sion and other mental health problems. As a result
cine, 2006, p. 3). Low health literacy is also linked of rising health care costs, patient self-management
to higher hospitalization rates, more frequent use of of chronic disease is being increasingly emphasized.
emergency room services, less compliance with There are varying definitions in the literature, but
health recommendations, and more frequent errors essentially chronic disease self-management in-
with medication management. Studies on health volves individuals and families actively participating
literacy and health outcomes have elucidated the in the health care process, self-monitoring symp-
connections between low health literacy and cancer toms or physiological processes, making informed
incidence, mortality and quality of life (Merriman, decisions about their health, and managing the
Ades, & Seffrin, 2002), glycemic control and rates impact of the disease on their daily lives. Chronic
of retinopathy in persons with type 2 diabetes disease self-management programs are designed to
(Schillinger, Grumbach, Piette, Wang, et al., 2002), enable individuals to prevent, control, and manage
and other health conditions (Williams, Baker, complications of their conditions, including the
Parker, & Nurss, 1998; Williams, Baker, Honig, mental health sequelae (Chodosh et al., 2005).
Lee, & Nowlan, 1998). Several recent reviews have been published re-
Primary health care settings provide an excellent garding the nature and efficacy of chronic disease
opportunity for occupational therapists to promote self-management programs with mixed results. Pro-
health literacy, thereby enhancing health outcomes. gram elements vary, but generally they feature:
Health literacy services may include:
• tailoring the program and messages to specific
• Informal assessment of health literacy, individual needs and circumstances,
• Creation and provision of culturally relevant, • grouping interventions in order to facilitate
“plain language” health communications for peer support,
persons with limited health literacy, • giving frequent feedback to the patient regard-
• Health information sessions on a variety of ing his or her progress in meeting his or her
topics, self-management goals,
• Training office staff in effective communica- • addressing psychosocial concerns, and
tion with patients, • involving the health care provider in program
• Health counseling, delivery (Chodosh et al., 2005).
2580_Ch27_390-408 16/07/13 3:15 PM Page 402
It is important to note that the Lifestyle Re- Box 27-2 Stanford University’s Chronic
design program includes all of these elements, Disease Self-Management
and incorporates occupational therapy principles Program
and practices.
Stanford University’s School of Medicine Participants in Stanford University’s Chronic Disease
(2006) has developed a model chronic disease self- Self-Management Program (2006) demonstrated
improvements in the following.
management program (CDSMP). The program
is provided in a workshop format for a total of Health status:
15 hours over several sessions and is facilitated by • Disability
two trained leaders, one a health care professional • Social/role limitations
and the other a person with a chronic disease. The • Energy/fatigue
content of the program was derived from informa- • Health distress
• Self-reported general health
tion provided by focus groups of people with
chronic disease. The topics covered include: Health care utilization:
• Fewer hospitalizations
• techniques to deal with problems such as • Fewer days in the hospital
frustration, fatigue, pain, and isolation, • Fewer outpatient visits
• appropriate exercise for maintaining and im-
Self-management behaviors:
proving strength, flexibility, and endurance,
• Exercise
• appropriate use of medications,
• Cognitive symptom management
• communicating effectively with family, • Communication with physician
friends, and health professionals,
• nutrition and meal planning, and Data from: Stanford University (2006). Chronic disease self-
• evaluating new treatments and making management program. Retrieved from http://patienteducation.
stanford.edu/programs/cdsmp.html
informed treatment decisions (Stanford
University, 2006, para. 2)
More than 1,000 people participated in a ran- occupational therapists could market to primary
domized controlled evaluation of the program. care providers.
Participants were followed for up to 3 years. Those
who participated in the program, as compared to
those who did not, demonstrated significant im- Developing Health Promotion
provements in a number of areas, as described in Programs for Primary Care
Box 27-2. Many of the improvements noted per-
sisted for as long as 3 years. The study showed The nature of primary care is such that practitioners
that for every dollar spent on the self-management follow a panel of patients intermittently over an ex-
program, 10 dollars were saved in health care costs tended period, providing health promotion, preven-
(Stanford University, 2006). Replication of the tion, and treatment services at times of need. This
study in 21 community primary care sites with is much different than typical occupational therapy
489 patients yielded similar results (Lorig, Sobel, services, which are often provided continuously
Ritter, Laurent, & Hobbs, 2001). and intensely over a short period. However, patients
Occupational therapists have knowledge of may need fewer visits for intervention because they
chronic diseases and their effects on daily life func- are seen at an earlier stage of the health problem.
tioning, which enables them to develop chronic Therefore, occupational therapists working in
disease self-management programs in primary care primary care settings must be flexible, adaptive, and
settings, train persons with chronic diseases to in- readily available when the physician refers a patient
struct and lead groups, and evaluate the outcomes. with a particular need. Allowing the patient to
The research available supports the efficacy of leave the office and attempting to schedule a
generic chronic disease self-management programs follow-up appointment for occupational therapy is
and their cost-effectiveness. This is a service that likely to be unsuccessful.
2580_Ch27_390-408 16/07/13 3:15 PM Page 403
A comprehensive health promotion program in Pilot the program and collect efficacy data
a primary care setting would include:
• Health risk appraisals, including mental
health screenings, Institute a tracking and documentation system
• Patient health education and counseling,
• Caregiver education and training,
Identify reimbursement and funding sources
• Phone call follow-up,
• Home visits, and
• Brief office interventions.
Establish a protocol for health promotion services
Health risk appraisals (HRAs) are assessments
that profile an individual’s risk factors and estimate
the probabilities of manifesting certain diseases. Conduct needs assessment
HRAs ask the participant a number of questions
related to health behaviors and thereby raise awareness
about the impact of lifestyle on health. In addition, Gather evidence for program planning
some HRAs provide suggestions for improving Fig. 27•1 Developing a Health Promotion Program
one’s health status. These assessments are a useful for Primary Care Settings.
tool for initiating dialogue about lifestyle concerns
and may motivate the individual to action. Educating
patients regarding their health status is the next logical The first step is to be well informed and gather
step. Information tailored to the individual’s needs evidence for program planning. As is true in all areas
can enable and empower the individual to assume of practice, preventive interventions should be based
more responsibility for his or her health. on the best research evidence available. Evidence on
Caregivers are also in need of health education and appropriate assessment strategies, early detection
counseling regarding the needs of the care recipient procedures, and effectiveness of known interven-
and their own health needs as caregivers. Providing tions is essential.
support, information about community resources, The second step is to conduct a needs assessment
and training to prevent caregiver injury can reduce of the primary care physician’s patient panel. This
caregiver burden and improve caregiver well-being. can be done in a variety of ways using surveys, focus
Follow-up phone calls to patients and caregivers can groups, epidemiological data, and chart reviews
reinforce plans made during a health promotion visit, (Scaffa, 2001). The choice of targets for health pro-
encourage compliance with medical recommenda- motion interventions should be based on current
tions, and identify barriers to health behavior change. morbidity and mortality profiles of the community
Home visits to assess safety, support systems, psy- in which the primary care practice is situated
chosocial issues, and home modification can also be (Zapka, 2000). Health promotion approaches are
helpful. Home visits are particularly beneficial for complex and must be flexible, adaptable, and tai-
those who have a difficult time getting to health care lored to the individual or group to be effective.
facilities and who might otherwise need to move to a The third step is to establish a protocol that
long-term care facility (Devereaux & Walker, 1995). outlines how patients will be evaluated, potential in-
Brief office interventions, as described earlier, should terventions that may be used, and community re-
be used routinely to address tobacco use, alcohol sources that are available as support services. The
abuse, mental health, physical fitness, obesity, risky protocol should include clear referral criteria and
sexual behavior, and other health behaviors. describe the services the occupational therapist can
Developing a health promotion program for a provide. Administering the Canadian Occupational
primary care setting is much like developing other Performance Measure (COPM) provides an excel-
community-based health initiatives, with a few ad- lent opportunity for the occupational therapist to
ditional considerations. The basic steps are outlined gain an understanding of the patient’s needs, desires,
in Figure 27.1. and priorities as a basis for individualized health
2580_Ch27_390-408 16/07/13 3:15 PM Page 404
promotion planning (Law, Baptiste, Carswell, survey collected demographic information, reasons
McColl, Polatajko, & Pollock, 2005). Health be- for referral, and knowledge of occupational therapy.
havior contracts that specify the number of sessions, The results of this pilot study indicated that physi-
goals, and strategies may enhance patient motiva- cians with 17 years or more of practice experience
tion and commitment to long-term change. were more likely to refer for occupational therapy
The fourth step is to identify reimbursement services than their less experienced counterparts.
and funding sources for the program. In addition Physicians practicing in specialty areas referred at a
to private health insurance, Medicare, Medicaid, rate 10% higher than the primary care physicians did.
and other reimbursement mechanisms for billable Among all physicians, the services most referred for
services, sources of revenue may include grants, included: range of motion (74%), gross motor skills
fee-for-service, and foundation funding. Next is (71%), fine motor skills (71%), mobility (68%),
establishing a tracking and documentation system. home assessment (68%), environmental modification
Tracking may involve creating flow sheets, check- (68%), grooming (65%), dressing (62%), and
lists, and other strategies for monitoring the pro- bathing (62%). Other services referred for demon-
vision of screenings and other health promotion strate a need for expansion of occupational therapy
services. Documentation style and content are services into settings other than rehabilitation and
often dictated by the funding source. offer support for the notion of occupational therapy
Finally, the health promotion program is ready services in primary care. For example, a significant
to be piloted and evaluated. Quarterly process as- percentage of physicians referred to occupational
sessments of services provided, patient satisfaction, therapy for the following services: safety issues (50%),
and outcome measures are needed to document the meal preparation (44%), work/job performance
efficacy and cost-effectiveness of the program. Data (44%), lifestyle modifications (38%), assessment of
is collected and used to modify and enhance pro- supports (32%), and emergency response (21%).
gram components. Although program evaluation Clearly, if occupational therapy is to have a role
is the last step in this sequence, it must be systemat- in primary care, educating physicians about occu-
ically planned throughout the earlier stages of pational therapy practitioners’ contributions to
program development. health promotion and prevention, as well as their
evaluation and intervention skills, is paramount.
Working With Primary Care Physicians
Marketing Occupational
Primary care physicians are generally unaccustomed
to working directly with occupational therapists.
Therapy Services to Physicians
Therefore, physicians may need to be informed in Primary Care
regarding the potential benefits of offering occupa- Attitudes, personal beliefs, and lifestyle habits of
tional therapy services to their patients. In addition, physicians have a major impact on the likelihood of
the benefits to the physicians themselves should be implementing prevention and health promotion
stressed, for example, increased physician efficiency, strategies in their practices. Primary care physicians
enhanced patient adherence to treatment recom- tend to be more prevention- and health promotion–
mendations, and improved outcomes. It is impor- focused than physicians in other specialties. In ad-
tant to assess primary care physicians’ knowledge dition, reimbursement issues and energy, time, and
and attitudes toward occupational therapy in order resource constraints also limit physicians’ participa-
to market services effectively. tion in patient-centered health promotion (Goel &
An unpublished pilot study conducted by one of McIsaac, 2000). Employing or collaborating with
the authors was designed to examine physicians’ re- other professionals, such as occupational therapists,
ferral patterns regarding occupational therapy and who have the expertise and time to address lifestyle
the possible effects that experience and specialty modifications and health literacy can enhance
area may have on referral rates. Questionnaires were the health outcomes in primary care settings. The
distributed to rehabilitation and medical facilities physician can then focus on treating illness and
along the Mississippi and Alabama Gulf Coast. The preventing disease, identifying patients in need of
2580_Ch27_390-408 16/07/13 3:15 PM Page 405
specific prevention and health promotion interven- Occupational therapy evaluation and treatment
tions, and referring these individuals to an occupa- is a billable service under Medicare and many private
tional therapist for follow-up services. health insurance plans. Many preventive interven-
The benefits to primary care physicians of utiliz- tions, such as energy conservation, work simplifi-
ing occupational therapists (as an employee or a cation, and safety awareness, are already being
contractor) to provide health promotion and pre- reimbursed through these mechanisms. However,
vention services in their practice settings potentially before developing a health promotion program, it
include: is essential that occupational therapists are cognizant
of, and adhere to, state licensure laws that define the
• availability of high-quality prevention and
scope of occupational therapy practice.
health promotion services on-site, thus in-
Other revenue sources may be foundation grants,
creasing the physician’s time to focus on
fees-for-service, health maintenance organizations
medical interventions,
(HMOs), workers’ compensation, and other gov-
• better patient health outcomes as a result of
ernment programs. Physicians can also use billing
comprehensive health promotion services,
codes for health counseling. In addition, many peo-
• less need for medications and better compli-
ple may be able and willing to pay for occupational
ance with self-management regimens,
therapy services, as is evidenced by the amount
• identification of patients who have mental
spent for complementary and alternative medical
health needs not readily recognizable in a
care, which typically is not reimbursed by insurance
short medical office visit, including alcohol
(National Center for Complementary and Alterna-
and drug abuse problems, domestic violence,
tive Medicine, 2006).
depression, anxiety, bereavement, etc.,
• detection of performance deficits that may
impact the safe participation in everyday
activities, and Conclusion
• prevention of secondary complications of
medical conditions. Health promotion and the medical model can be
effectively blended in primary care office practice.
In addition, it has been noted that providing Physicians and other primary health providers are
occupational therapy and other services in-house in a position to identify their patients’ risky behav-
can enhance a physician’s earnings. Out of 11 iors and health practices, determine patients’ will-
factors that are associated with high-earning ingness to change, and encourage changes for better
family physicians (those earning $160,000 or health. Brief visits in the office are a good way to
more as compared with those earning $100,000 carry out these interventions. More extensive health
or less), provision of adjunctive services ranks counseling also could ideally be provided in the
fourth (Carter, 2005). office setting. Occupational therapists may be able
The benefits to patients include more time with to establish a niche on the primary health care team
staff, immediate access to occupational therapy ser- by assisting primary care physicians with the provi-
vices without the need to leave the physician’s office, sion of health education, prevention, health promo-
opportunities to learn to manage their own health tion, and intervention services in the physician office
problems, and improved quality of life. environment and elsewhere.
Integrating occupational therapy and health pro-
motion services into primary care practice is an op-
Funding Occupational Therapy portunity and challenge worth pursuing. According
Services in Primary Care to Devereaux and Walker (1995), “occupational ther-
Funding for health promotion services can come apy can be a major force in the delivery of primary
from a number of sources. There are office visit and health care” (p. 393). Occupational therapy’s focus
procedural codes for time spent in health counseling on physical, cognitive, emotional, social, and spiritual
that can be billed to insurance, for either individual well-being provides a useful, and increasingly neces-
or group sessions. sary, adjunct to primary care medical services.
2580_Ch27_390-408 16/07/13 3:15 PM Page 406
CASE STUDIES
CASE STUDY 27•1 Doris
Doris is a recently widowed 68-year-old African American woman with diabetes who presents to her
family physician with complaints of fatigue, poor concentration, insomnia, and binge eating. She has
gained 20 pounds in the 6 months since the death of her husband. The physician, a member of a multi-
disciplinary practice, diagnoses depression, prescribes an antidepressant medication, and refers the patient
to an occupational therapist who works in the office. The occupational therapist conducts an interview,
administers several assessments including the COPM, and develops an occupational profile. Prior to her
retirement, Doris worked as a middle school teacher. Doris lives alone and has two grown children and
six grandchildren who live approximately two hours from her home. She enjoys movies, reading, garden-
ing, and walking her dog. In the past, Doris was very active in her church, but over the past two years
while caring for her ill husband, her participation diminished significantly. She has a limited income,
but her home mortgage is paid off and she has good health insurance coverage as a benefit of her teacher’s
retirement plan.
In collaboration with Doris, the occupational therapist develops an intervention plan that includes the
following:
• chronic disease self-management and health literacy to address the client’s diabetes
• Lifestyle Redesign for weight management to increase the client’s level of physical activity and to improve
the quality of her sleep, and
• mental health services to facilitate the grief process and re-establish life goals.

1. What types of occupational therapy services could be provided to Doris in the primary care physician’s
office? How would the occupational therapy services be unique and different from services provided
by other health care professionals in this setting?
2. What intervention strategies would you use to improve Doris’s health literacy and chronic disease
self-management? To help Doris achieve her weight loss goals?
3. What intervention strategies would you use to facilitate the grief process and improve her mental health?
4. How would the provision of occupational therapy services in this case benefit the primary care physician?
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Chapter 28
Health Promotion Initiatives

Within Academic Communities
Jenna Yeager, PhD, OTR/L, S. Maggie Reitz, PhD, OTR/L, FAOTA, M. Beth Merryman, PhD, OTR/L,
FAOTA, and Sonia Lawson, PhD, OTR/L
The result of the educative process is capacity for further education.

—John Dewey
Learning Objectives
• Engage in community health promotion activities in partnership with local primary and secondary schools,
community colleges, colleges, and universities.
• Develop community-based programs that address knowledge obtainment and skill development to assist in the
selection of healthy occupations and lifestyle choices that promote well-being.
• Articulate the benefits of offering health promotion services to an academic community.
Key Terms
Academic community Healthy Campus 2010: Making It Happen
Flow Leisure ethic
Health promotion Well-being
Introduction that promote health and well-being (American

College Health Association [ACHA], 2002).
As early as the 1930s, in an article in Occupational The developers of the Jakarta Declaration on
Therapy and Rehabilitation, the forerunner of the Leading Health Promotion into the 21st Century doc-
American Journal of Occupational Therapy, con- ument (World Health Organization [WHO],
cerns were raised regarding the health and well- 1997) declare that there is clear evidence that
being of college students. In this article, Shaffer schools and the workplace are ideal locations to
(1938) criticized colleges for commercializing col- provide comprehensive health promotion strategies.
lege sports and abandoning the original goals of Health Promotion is defined in the Jakarta Decla-
such programs, which were to enhance social and ration as “a process of enabling people to increase
health benefits of individual student participants. control over, and to improve, their health” and is
Shaffer commended Johns Hopkins University’s considered an “essential element of health develop-
decision to make available “organized play activi- ment” (WHO, 1997, p. 1). Academic communities
ties to all students instead of concentrating on the are one of many possible settings where occupa-
development of a special skill in a very limited tional therapy practitioners (i.e., occupational ther-
group” (Shaffer, 1938, p. 102). Discussions con- apists and occupational therapy assistants) can
tinue today regarding the appropriate role of col- become change agents, preferably within an inter-
legiate athletics in campus life (Sperber, 1990, disciplinary team, to meet the challenges of the
2000) and access of all students to environments Jakarta Declaration.
409
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Academic occupational therapy departments • involvement with a university’s Healthy

have ready access to a population in need of health Campus Task Force,
promotion services: the faculty, staff, and students • provision of education and training services
at their home institution and the surrounding to faculty, staff, and students to promote an
community (e.g., Campbell, Rhynders, Riley, inclusive environment for individuals with
Merryman, & Scaffa, 2010). In addition, occupa- mental illness,
tional therapy faculty members have knowledge • facilitation of a stroke support group, and
of human development and the use of occupation • development and provision of college
as a preventive and a healing tool, expertise in courses.
group process, and appreciation for issues such
as transition to college life, college athletics, stu-
dent drinking, and safety that can be used to sig- Policy Support for
nificantly contribute to the health of academic
communities. Occupational therapy and occupa- Occupational Therapy
tional therapy assistant faculty and their respective Involvement in Health
students can favorably impact the health and well-
being of their own and other local academic com- Promotion in Academic
munities (i.e., primary schools, secondary schools, Communities
community colleges, colleges, and universities) in
many ways. The U.S. government has used an interdisciplinary
For the purposes of this chapter, an academic approach to develop policies and documents that
community is defined as the participants in a com- can assist occupational therapy practitioners in
munity that includes faculty, staff, students, and developing or joining health promotion initiatives.
parents who have a shared focus and value of edu- One of these documents is Healthy People 2020
cation. Well-being is defined as the outcome of a (USDHHS/ODPHP, 2010). Many of the national
proactive lifestyle, which includes both active health objectives identified in this document relate
engagement in life and reflection on life choices to academic settings along the educational contin-
that impact the health, safety, and welfare of self uum (i.e., primary through post-baccalaureate edu-
and others. Active engagement is not limited to the cation). A sampling of objectives from Healthy
pursuit of physically active or challenging occupa- People 2020 (USDHHS/ODPHP, 2010) that could
tions, and the state of well-being is not precluded be the target of a health promotion initiative in an
by the occurrence of illness or disability. Access to academic community is provided in Table 28-1.
health information, health services, and the pre- Healthy Campus 2010: Making It Happen
requisites to health identified by the Ottawa Char- (ACHA, 2002) is a document designed to support
ter (WHO, 1986) are, however, required to reach colleges and universities as they assess the health sta-
this state. tus of their campuses in order to make informed
Four types of health promotion initiatives that decisions regarding priorities and interventions. This
can be replicated at any academic campus—with or document can be instrumental in identifying possi-
without an occupational therapy department or ble opportunities for occupational therapy students
major—will be described. Ideas regarding adapting and faculty to contribute to their community’s
these initiatives to primary and secondary educa- health and well-being. Occupational therapy prac-
tional settings as well as new avenues to consider for titioners can be valuable additions to interdiscipli-
future program development also will be shared. nary task forces or committees seeking to improve
Prior to describing these initiatives, two public the quality of life and well-being for students, staff,
health reports will be reviewed that provide support and faculty.
and a context for these and other potential initiatives Data collected and reported by the ACHA
directed at promoting health and well-being of fac- through the National College Health Assessment
ulty, staff, and students in academic communities. (NCHA) can also be helpful to both programming
The initiatives to be discussed include: and policy decision making. The NCHA collects
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Chapter 28 | Health Promotion Initiatives Within Academic Communities 411
Table 28-1 Examples of Healthy People 2020 Objectives for Academic Community Interventions
Objective Number Objective
AH-1 Increase the proportion of adolescents who have had a wellness checkup in the past
12 months
FP-7 Increase the proportion of sexually active persons who received reproductive health
services
IID-11 Increase routine vaccination coverage levels for adolescents
IVP-34 Reduce physical fighting among adolescents
IVP-35 Reduce bullying among adolescents
MHMD-2 Reduce suicide attempts by adolescents
MHMD-3 Reduce the proportion of adolescents who engage in disordered eating behaviors in
an attempt to control their weight
MICH-4 Reduce the rate of adolescent and young adult deaths
NWS-10 Reduce the proportion of children and adolescents who are considered obese
PA-1 Reduce the proportion of adults who engage in no leisure-time physical activity
PA-3 Increase the proportion of adolescents who meet current Federal physical activity
guidelines for aerobic physical activity and for muscle-strengthening activity
PA-13 Increase the proportion of trips made by walking
PA-14 Increase the proportion of trips made by bicycling
SA-14 Reduce the proportion of persons engaging in binge drinking of alcoholic beverages
STD-1 Reduce the proportion of adolescents and young adults with Chlamydia trachomatis
infections
STD-10 Reduce the proportion of young adults with genital herpes infection due to herpes
simplex type 2
TU-3 Reduce the initiation of tobacco use among children, adolescents, and young adults
TU-15 Increase tobacco-free environments in schools, including all school facilities, property,
vehicles, and school events
Adapted from: “Healthy People 2020: Topics and Objectives,” by U. S. Department of Health and Human
Services (n.d.a.).
data nationally on college and university students’ Healthy Campus Task Force
health behaviors and perceptions on a variety of oc-
cupations, including alcohol, tobacco, other drug The president of a large metropolitan university
use, sexual intimacy, and physical activity (ACHA, appointed a Healthy Campus Task Force during his
2004, ¶2). first year in office. This team was charged with
In addition to data gathered specific to the health developing a comprehensive, long-term, campus-
topics listed above, data on the perceptions of factors wide health plan (Towson University, 2003).
that impact academic success are also collected. Specifically, the Task Force was charged with com-
With time to degree completion and student grad- pleting an environmental scan as the basis for the
uation becoming important outcome measures for development of recommendations. These recom-
colleges and universities, this data translates general mendations were to address modifications or addi-
health issues into real-life impacts on student tions to current programs as well as strategies to
achievement (ACHA, 2004). improve the health and health-enhancing behaviors
2580_Ch28_409-420 16/07/13 3:16 PM Page 412
of students, faculty, and staff. The university health students can directly contribute to the health and
center medical director and the chairperson of the well-being of the university, and the university
Department of Occupational Therapy and Occupa- community gains an appreciation for the health
tional Science (DOTOS) were named task force promotion and healing powers of occupation
co-chairs. This shared leadership role helped blend
the perspectives of the academic and student affairs
divisions, and was further augmented via the ap- Promoting a More Inclusive
pointment of representatives from both divisions.
The task force was an interdisciplinary team and Environment for Individuals
included faculty as well as the police chief, safety With Psychiatric Disabilities
officer, head of campus recreation, students, and
other university officials. The interdisciplinary na- According to Healthy People 2020, mental health
ture of the task force was one of its strengths and is conditions are a result of complex interaction
a key to successful health promotion activities. between social, emotional, and genetic factors
The report Healthy Campuses: Making it Happen (USDHHS, n.d.b). An overarching goal involves the
(ACHA, 2002) was the foundation for the work of creation of a social environment that promotes the
the task force. Each member received and reviewed health of all. Specific objectives address improved ac-
a copy of the report prior to conducting the next cess to treatment for persons with mental health dis-
step, the environmental scan. The task force took orders. A reduction in stigma toward mental illness
approximately 1 year to complete the environmental by focused education initiatives aimed at knowledge,
scan. The scan included documenting current uni- attitudes, and behavior would support the develop-
versity services, programs, and opportunities for stu- ment of an inclusive environment that promotes the
dents, staff, and faculty to promote their health and health of all and facilitates treatment access by those
well-being. This process included inviting key uni- who may otherwise avoid it (Mechanic, 2002).
versity personnel and service providers to meet with Wilcock (2006) argues that occupational thera-
the task force and discuss their particular unit or pists support health beyond the individual level by
service. Two of these services were offered by faculty intervening socially to support community and eco-
members from the DOTOS: (a) ergonomic consul- logical well-being. According to Sinclair (2004),
tations (Scaffa, Chromiak, Reitz, Blair-Newton, occupational therapists possess the skills to support
Murphy, & Wallis, 2010) and (b) an awareness pro- community workers and individuals with disabili-
gram designed to increase others’ understanding of ties to actively participate in valued activities that
people with mental illness (National Empowerment support occupational performance in environments
Center, 2010; Merryman & Uhland, 2005). The of choice. In addition the Occupational Therapy
awareness program will be discussed next in this Practice Framework (AOTA, 2008) and the Inter-
chapter. national Classification of Functioning, Disability and
During the fact-finding phase of the task force, Health (WHO, 2001) provide language to describe
the ACHA–National College Health Assessment this advancement in occupational therapy service
(ACHA, 2005) survey was administered to a ran- provision.
dom sample of undergraduate students. The task The evolution of collaboration between the Of-
force reviewed the survey data as well as reference fice of Disability Support Services (ODSS) and the
group data from the ACHA-NCHA survey and DOTOS was sparked by an increase in students
other survey data available at the university. This with serious mental health issues enrolling at the
data, combined with discussions and results of the university. The occupational therapy faculty’s
year-long fact-finding process, served as the founda- knowledge of the impact of serious mental illness
tion for the development of the task force recom- on healthy role execution, as well as their skills in
mendations. The Healthy Campus 2010 (ACHA, group facilitation and active advocacy with the
2002) document was referenced frequently during local National Alliance on Mental Illness (NAMI)
the Task Force’s deliberations. chapter, were valued and needed. This expertise
Through the provision of services and participa- was used to assist the campus as it sought to ac-
tion in the Healthy Campus Task Force, faculty and commodate a growing number of students with
2580_Ch28_409-420 16/07/13 3:16 PM Page 413
mental health needs. Of particular concern was the on their own struggles and use of coping skills during
need for faculty and staff to develop knowledge the activity and share observations in a structured
and understanding about mental illnesses and their group setting that encourages potential applications
impact on daily life. The goal was to improve to daily life.
knowledge and attitudinal response toward indi- A mixed methods study was conducted to assess
viduals with serious mental illnesses to support a effects of this simulation experience on students’
more inclusive campus community. understanding of mental illness (Merryman, 2010).
It is well documented that social stigma negatively Students completed a pretest including the Mental
impacts the recovery process of individuals with Illness Disorder Understanding Scale (MIDUS)
serious mental illnesses (Corrigan & Penn, 1999; developed by Tanaka (2003) prior to the exercise
Smart, 2009). When asked what they wanted most and again at the end of the semester. In addition,
from providers, people with disabilities revealed that student qualitative comments during the debriefing
a sense of hopefulness and an understanding of the and at the end of the semester were systematically
prejudice and discrimination that they faced were collected and analyzed. T-test results were statisti-
among the top priorities (Marrone, 1997). In an cally significant on two of three factors. These were
effort to more fully understand the challenges that that mental illness was treatable and that medica-
individuals with mental illnesses face, a consumer tions were effective. Student qualitative comments
advocacy group called the National Empowerment revealed a new awareness of the challenges that
Center offers an educational kit that involves partic- hearing voices presents in daily life.
ipants experiencing simulated auditory hallucina- The training has involved a variety of student
tions (Deegan, 1992). This experience, called Hearing groups from various disciplines, faculty, counseling
Voices That Are Distressing, has been adopted by fac- center staff, and campus police. Students often com-
ulty from the DOTOS and the Towson University ment that it is the most powerful aspect of their men-
ODSS as a key component of an education and tal health course experiences. Staff members have
training opportunity to make the campus more in- commented on the value of the experience to
clusive for individuals with disabilities that involve broaden their understanding of the challenges stu-
hearing voices. dents face in navigating the campus and fulfilling
Participants use an individual headset with a cas- their student roles (Merryman & Uhland, 2005).
sette tape reflecting content typical of what individ- According to Baum and Baptiste (2002), occupa-
uals who hear voices experience. The tapes have tional therapy practitioners are reframing practice by
been made by people who actually experience au- intervening beyond the individual level to impact
ditory hallucinations (i.e., hear voices). While the communities through attention to the environment
tape is playing, participants visit four stations and and contextual factors that support or impede social
are asked to perform tasks typical of that setting. participation. An intervention that promotes knowl-
These stations include a psychiatric day hospital edge and understanding of a marginalized popula-
task room, a hospital emergency room, a vocational tion supports a more inclusive atmosphere for all. In
testing center, and the broader campus. this manner, such an intervention promotes com-
At the end of the visits to the four stations, par- munity health and occupational justice (Wilcock,
ticipants are asked to discuss the experience. This 1998, 2003, 2006; Wilcock & Whiteford, 2003).
facilitated discussion includes, when possible, an in-
dividual or family member of an individual who is a
consumer of mental health services. Having a first- Stroke Support Group
person account during the discussion reinforces the
philosophy of inclusion and empowerment by hav- Health promotion programs for stroke survivors and
ing people speak for themselves. It also supports the their caregivers, such as support groups, are fre-
work of Kolodzei and Johnson (1996), who found quently offered through a health care facility or
that interpersonal contact between students and peo- health system. These programs may or may not open
ple with mental illness was associated with improved their programs to members of the immediate com-
attitudes toward persons with mental disorders. The munity. Community-based health promotion pro-
facilitation aspect encourages participants to reflect grams that target individuals who have disabilities,
2580_Ch28_409-420 16/07/13 3:16 PM Page 414
such as stroke, and their families can be offered candidates to target to serve as leaders of the sup-
through academic institutions as well. port group; however, this additional responsibility
Academic campuses that have health-related ma- would need to be evaluated for its impact on the
jors are in an excellent position to offer a commu- faculty member’s workload. In addition, due to the
nity support group for stroke survivors and their typical semester organization of classes on academic
caregivers. There are several benefits of this type of campuses, there may be breaks in the meeting
program for students, stroke survivors, and care- schedule that can impact the continuity of the
givers. Students benefit from the opportunities to group and group process. Care should be taken to
interact with stroke survivors and caregivers and to have some kind of “bridge” activity during semester
develop and deliver presentations on health-related breaks. Classroom or meeting room space must be
topics, such as yoga for relaxation or driving after a allocated for the group meetings, and this space
stroke. This enables the students to develop their must be fully accessible. With the changing course
presentation skills and also benefits the stroke sur- schedules from semester to semester, finding a per-
vivor in gaining valuable information to optimize manent meeting space may prove difficult.
participation in health-promoting activities. The Stroke Survivors Group at Towson University
Stroke survivors benefit from an academic has been in existence for approximately 8 years with
institution–based support group as they are able to 10–20 participants in attendance for each monthly
engage with stroke survivors who have received meeting. The group was initially co-led by faculty
services from varying rehabilitation facilities; re- from nursing and speech language pathology with a
ceive unbiased valuable information on commu- faculty member from occupational therapy added
nity resources in the area that are not associated in the second year. More recently, the group has
with a particular health care system; and partici- been lead by faculty from occupational therapy and
pate in activities held during the meetings with speech language pathology.
the extra support of students and faculty who lead The Stroke Survivors Group runs during the fall
the group. Another benefit that stroke survivors and spring semesters with a break over the summer.
receive is current information related to research Because participants verbalized their desire to con-
studies in which the survivor may participate to tinue meetings over the summer, a summer activity-
gain additional physical or speech-related rehabil- based meeting is planned, with the participants
itation. Many academic institutions have access to taking the lead for planning this event. This sum-
this kind of information, perhaps more readily mer event serves as a bridge between the spring and
than programs offered in non-academic settings. fall semester meetings. A database of participants
Caregivers of stroke survivors, a group that typ- and their contact information is kept by one of the
ically is not targeted for support group interven- faculty leaders. Students from the academic disci-
tion, benefit from a community-based support plines mentioned assist in maintaining the database
group located within an academic institution. and sending out information about meeting times,
Studies have shown that caregivers report fewer topics, and announcements.
negative feelings and believe they gain valuable in- Both participants and students have reported
formation and support the more support group enjoying and benefitting from their experiences
sessions they attend (Brereton, Carroll, & Barnston, attending the group meetings. Because students
2007; Franzen-Dahlin, Larson, Murray, Wredling, are required to assist participants as needed, help
& Billing, 2008). For caregivers, support groups set up materials for meetings, and reflect on their
can be a primary prevention strategy, helping experiences, they become deeply engaged, and this
them cope with emotions by sharing with other promotes future professional activities of this type.
caregivers and obtaining information that can help Participants enjoy engaging with the students and
relieve the stress associated with caring for a stroke assisting them in their learning. It proves to be a
survivor. very meaningful activity for the participants, and
When planning a support group to be offered they take their role as educators very seriously.
on an academic campus, faculty, student, and space Many participants are very willing to participate
resources are important considerations. Faculty in classroom activities to help train future health
members in health-related disciplines are ideal professionals.
2580_Ch28_409-420 16/07/13 3:16 PM Page 415
Overall, academic campuses provide an excellent friends and activities and acquire new occupations
environment to offer community-based support and habits (Towson, 2011). This course is marketed
groups for stroke survivors and for individuals with to students who are not occupational therapy
other types of disabilities. It provides a wonderful majors. Sometimes students who take the course
learning opportunity for all involved: faculty, students, decide to switch their major to pre-occupational
stroke survivors, and their caregivers. therapy. After a review of the history and philosophy
of leisure and leisure studies, the course addresses
health promotion via content related to healthy
General Education/Core (e.g., moderate physical activity) and unhealthy
Curriculum Courses (e.g., unsafe sexual activity, substance use and abuse)
habits of this population, as indicated by national
Occupational therapy faculty and graduate students surveillance data. The role of leisure in promoting
possess the expertise to develop and provide under- health and well-being across the life span is discussed
graduate courses that focus on prevention and and reinforced throughout the course. Examples
health promotion using an occupation-based ap- of course topics include leisure theories, health
proach. Learning activities from one of three courses behaviors, consumerism, and leisure occupations.
offered by an academic occupational therapy depart-
ment will be described. The course was approved as Leisure and Health Course:
meeting the university’s General Education Re- Philosophical and Theoretical
quirements, which were “designed to help students
gain the essential intellectual skills and knowledge
Foundation
that will be important throughout life” (Towson Teaching methodologies for this course are con-
University, 2010, p. 4). sistent with the occupational therapy principle
Offering college courses to address students’ of learning through activity engagement (Fidler &
health, quality of life, and academic success is consis- Fidler, 1978; Wilcock, 1998). The course is based
tent with occupational therapy practice as described on the importance and value of a leisure ethic
in the Occupational Therapy Practice Framework: Do- (Kelly, 1982), Csikszentmihayli’s construct and
main and Process [Framework] (American Occupa- theory of flow (Csikszentmihayli, 1990), the Model
tional Therapy Association [AOTA], 2008). Course of Human Occupation (MOHO) developed by
content is directly related to instrumental activities of Kielhofner and Burke (Kielhofner, 2002; Kielhofner
daily living (IADL) categories of health management & Burke, 1980; Rosenfeld, 1993), and the Health
and maintenance, care of others, and child rearing Belief Model, a health behavior model (Becker,
(AOTA, 2008). As noted in the Framework (AOTA, 1974; Rosenstock, Strecher, & Becker, 1994). Con-
2008), health promotion and other health care service structs from social norms theory (Perkins, 2003) also
provision must be considered in relation to con- have been incorporated into the theoretical base of
textual features, such as health care advances, societal the course.
beliefs, cultural factors, and financial constraints. A primary goal of the course is the facilitation of
Accordingly, these university courses provide an the development of a healthy leisure ethic and
enhanced awareness of health care contexts and issues engagement in healthy leisure occupations. The term
in order to enhance students’ abilities to make in- leisure ethic has been described by Kelly as “the
formed decisions regarding health promotion activi- process of stressing the quality of life’s experience and
ties, which is a component of health management environment rather than occupational prestige”
and health maintenance. (1982, p. 10). It is noted that social and internal pres-
sures to pursue power or financial success may result
in the abandonment of the value of leisure to enhance
Leisure and Health Course: quality of life. Accordingly, the course invites students
Overview to engage in reflection and discussion regarding
This 100-level course targets first- and second-year the influence of values on lifestyle choice, with an
undergraduate students as they transition to univer- emphasis on the health benefits of an occupationally
sity life, a time when they leave family and old balanced life (Wilcock, 1998, 2006).
2580_Ch28_409-420 16/07/13 3:16 PM Page 416
Flow Theory health screenings for later life span periods are also
identified.
Csikszentmihayli (1990) articulated an inherent qual-
Peer educators are used to provide course ses-
ity of leisure activities, flow, that renders health bene-
sions on topics including healthy eating habits,
fits in various dimensions of wellness. Flow is defined
alcohol abuse, and safer sex practices. A novel use
as the way in which people “describe their state of
of campus resources was illustrated via the involve-
mind when consciousness is harmoniously ordered,
ment of the social action campus theater group to
and they want to pursue whatever they are doing
provide theater-based experiential class activities.
for its own sake” (Csikszentmihayli, 1990, p. 6). Al-
Student actors perform scenarios pertaining to
though flow can be reached through engagement in a
health issues, such as date rape, eating disorders,
physical activity, it also can be experienced when play-
and suicide. These scenarios are followed by inter-
ing an instrument, when writing a poem, or through
active class discussion exploring perspectives of the
participating in a variety of other skilled leisure or
various portrayed characters.
work occupations (Godbey, 1994). This notion is
useful in the college classroom as a means of expand-
ing students’ awareness of the benefits associated Leisure and Health Course:
with participation in creative and expressive activities Assignments
in addition to the more commonly acknowledged
health benefits gained through physical activities. Course assignments are designed to engage students
in experiential learning. The goal of the assignments
is to establish habits consistent with healthy living.
Model of Human Occupation (MOHO) Examples of such assignments include the Activity
The Leisure and Health course is conceptualized as an Analysis and Leisure History and Plan.
avenue to favorably impact the volitional and habit- Fundamental principles of occupational therapy
uation subsystems described in the MOHO by (Fidler & Fidler, 1978; Ludwig, 1993) are evident
improving the performance subsystem through en- in the Activity Analysis assignment. Students are re-
hanced knowledge and skills. It is theorized that a quired to select two leisure occupations in which to
solid foundation for a lifetime of healthy leisure engage for purposes of analysis, one on a favorite
choices, including a balance of physical, social, cre- familiar activity and one on a new activity. Invoking
ative, and reflective occupations, will be established the notion that positive gains arise from engagement
by enhancing the performance subsystem through in creative and expressive pursuits as well as physical
experiential learning. The rationale behind this asser- activities, students are urged to try something new
tion is that “volition is reflected in the wide range of as a means of expanding the repertoire of occupa-
thoughts and feelings people have about the things tions available for their health and leisure engage-
they have done, are doing, or might do” (Kielhofner, ment. A structure is provided to assist them in
2002, p. 15). Experiential activities and assignments articulating aspects of activity engagement that typ-
in this course promote student reflection regarding ically remain tacit. The analysis includes a description
values and interests as well as the resultant choices of the preparation needed, materials, and costs of the
that impact health and future health through patterns activity. Potential and existing barriers are identified,
reflected in the habituation subsystem. as well as health benefits and risks of the activity.
Deconstructing their favorite activities provides
students with an opportunity to identify the healthy
Health Belief Model and unhealthy aspects of their own leisure engage-
The Health Belief Model (see Chapter 3 of this ment. Furthermore, some students use the assign-
text for an introduction to this model) was used to ment as a catalyst to engage in an activity that they
provide the basis for the delivery of health educa- “have always wanted to try.” For example, students
tion to maximize adoption or continuation of often use the assignment as incentive to “work out”
health screening habits, such as testicular and in campus recreational facilities, or attempt a novel
breast self-examination. These habits were targeted activity such as meditation. Students are encouraged
due to the students’ average age and recommended to involve friends in these activities, and they often
age-appropriate health screenings. Age-specific report interest in the assignment among their peers.
2580_Ch28_409-420 16/07/13 3:16 PM Page 417
In this way, course activities have the potential to Thus, the course offers a unique opportunity for oc-
make an impact on the health of students beyond cupational therapy practitioners to engage in health
those enrolled in the course. promotion with college students.
The Leisure History and Plan is a culminating With the exception of the course evaluation
paper, which requires the integration and applica- process described above, no formal evaluation
tion of principles learned. In this assignment, stu- or long-term follow-up on the impact of this course
dents describe their history of leisure and detail a has been conducted. However, the work of Dermody,
plan for future health-promoting leisure activities. Volkins, and Heater (1996) and Hilton, Ackermann,
Students engage in a developmental analysis of their and Smith (2011) may serve as a model for future
occupational engagement since birth, identifying research into the impact of Leisure and Health and
factors that contribute to their current pattern of other such courses. Dermody et al. investigated the
healthy and unhealthy habits. Integrating constructs impact of instruction during a course addressing
gained throughout the course, students devise a plan health promotion, prevention, and occupation as a
for leisure that incorporates principles of health pro- health promotion tool for a group of occupational
motion and demonstrates an increased awareness of therapy graduate students. Results indicated that
the health risks and health benefits associated with occupation-based health promotion instruction
leisure and other occupations. appears to broaden students’ perceptions of health
promotion and the power of occupation to enhance
health and well-being. In addition, the researchers
Leisure and Health Course: concluded that study participants had achieved per-
Assessment spective transformation, which is a step in behavior
Student course evaluations have been used through change.
the years to assess and adjust course delivery and Hilton et al. explored the outcomes of a wellness
content. The course has been offered for more than assignment provided to 58 undergraduate occupa-
30 years, and since that time there has been a long- tional science students. The goal of the assignment
standing positive trend in qualitative and quantita- was to instill healthy habits, while the objective of
tive student feedback for this course (Reitz, 1994; the study was to determine the barriers and supports
Reitz & Castaneda, 1995). A total of 699 students for students’ success with the assignment. Follow-
took the course from fall 2005 through spring 2010. up data was collected 6 months and 1 year after
Student course evaluations were examined for this completion of the course assignment. Continued
time period; the mean overall score was 4.52 on a engagement in healthy habit goals appeared to be
5-point scale, with 5 being “excellent.” Student sustained, with 86% of the students still working
comments frequently reflect interest in the material “on at least one goal and almost half still working
and appreciation of experiential and personally rel- on two goals a year after completion of the course”
evant activities. A representative comment was made (Hilton et al., 2011, p. 70).
by one student who noted that the course was fun,
interesting, and “made a difference in my life.”
Other comments included, “all the information was
Leisure and Health Course:
relevant,” “[I] learned about society and myself at Replicability
the same time,” and “good class to take in college; This course has been easily adapted for various
had a lot of valuable information that could actually formats of delivery, suggesting a wider application
be used.” to other academic communities and community
Additionally, students’ integration and applica- settings. Although originally taught in a tradi-
tion of course content to their individual health tional semester structure, the course has success-
development is assessed in the culminating assign- fully been offered once a week for a 3-hour time
ment, the Leisure History and Plan, described ear- block, as well as in a 7-week format over summer.
lier. The engaging nature of class activities and the Therefore, the course serves as a potential model
personal relevance of topics addressed create a con- for the development of Leisure and Health Work-
text where students actively participate to apply shops that could be targeted for populations
constructs learned to personal lifestyle redesign. such as teens or elders in community settings.
2580_Ch28_409-420 16/07/13 3:16 PM Page 418
In addition, it may be taught at a community col- Learning Activities

lege as a non-credit life enrichment course or a
for-credit health course. Many of the assignments 1. Determine, through an investigation of campus
also can be adapted for use in middle and high resources, the persons on your campus who are
school courses or programs. responsible for monitoring and facilitating a
healthy campus environment. Request a meet-
ing to collect data on an area of health that you
Conclusion are concerned about (e.g., current rates of sui-
cides, accidents/injuries, hate crimes) and infor-
Occupational therapy practitioners can enhance mation about current programming to reduce
personal health and healing for individuals and those rates. Write a thank-you letter including
groups within academic communities. While any suggestions you have for the potential con-
occupational therapy practitioners may be most tribution of occupational therapy faculty and
familiar with occupational therapy service delivery students to enhance the academic community
in the primary school setting, occupational ther- through current or additional programs.
apy health promotion interventions also can be 2. Review the course catalog at your college or
delivered at community colleges, colleges, and university. Write a course description for a
universities. The populations served in these set- possible new elective course that could be
tings can greatly benefit from occupation-based developed and taught by occupational therapy
health education initiatives to influence choices or occupational science faculty.
of life habits and activity patterns. These benefits 3. Request an appointment with a member of the
can be achieved through a variety of recommen- campus police to discuss the possible replica-
dations and programs, such as pedestrian safety tion of the Hearing Voices That Are Distressing
for grade school students, backpack awareness program. Before your meeting, develop a
programs (Jacobs et al., 2010), advocating for one-page fact sheet explaining the program.
appropriate size and type of classroom furniture
(Wingrat & Exner, 2005a, 2005b), dating eti-
Acknowledgment: The authors would like to thank
quette for middle school students, and healthy
Stacey Schilling, Shira N. Zapinsky, and Hollie Hatt
transitions to university life. Programs can be
for their assistance with this manuscript while they
aimed at healthy individuals and groups or indi-
were occupational therapy graduate students at
viduals with a specific diagnosis. One such pro-
Towson University.
gram that focuses on the needs of college students
with depression, anxiety, and other similar disor-
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SECTION IX
Looking Ahead
Chapter 29
Future Directions in
Community-Based Practice
Marjorie E. Scaffa, PhD, OTR/L, FAOTA, Erin Guillory Caraway, MS, OTR, and Shun Takehara, OTR
What we see depends on how we look.

—Capra and Steindl-Rast (1991)
Only people who see the big picture ... are the ones who step out of the frame.
—S. Rushdie (1999, p. 43)
Learning Objectives
• Discuss the principles of futurist thinking.
• Describe the characteristics of an ecological worldview, applying it to community-based practice.
• Identify strategies that occupational therapy practitioners can use to develop ideas for community-based practice.
• Describe the role of occupational therapy in emerging community-based practice areas.
• Discuss potential curricular and fieldwork options for teaching community-based practice concepts.
• Describe the role of community-based participatory action research in occupational therapy practice and scholarship.
Key Terms
Community-based participatory action research (CBPAR) Obesity
Community service learning (CSL) Occupational justice
Ecological worldview Self-assertion
Innovation Telehealth
Integration Telerehabilitation
Mixed methods research Transition services
421
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422 SECTION IX | Looking Ahead
Introduction • An increased focus on the consumer as the

driving force in health care
In ancient Greece and Rome, an oracle was a place • Changing demographics, including increased
where, or a medium by which, deities were consulted cultural diversity of the population, requiring
for advice or prophecy about the future. The modern a need for increased cultural competence
futurist movement, which began in the 1960s, was among practitioners
fueled by the desire to understand and shape the • Increased numbers of elderly with a full range
future and is guided by three basic principles of health, illness, and disability
(Cornish, 1980). The first principle, or conviction, • Health care reform that includes increased
is the unity or interrelatedness of reality. It is the emphasis on mental health and quality of life
perception that the whole is greater than the sum of • A developing role for occupational therapy in
its parts, an insistence on the interconnectedness preventing and addressing social problems such
of everything in the universe (Cornish, 1980). as violence, crime, and alcohol and drug abuse
The second principle that directs futurist think- What occupational therapy needs most to move
ing is the crucial importance of time. The world of forward in the 21st century are creative ideas and
the future is shaped by the decisions made today and thoughtful decisions put into action. Only in this
the determinations made in the past (Cornish, way can the profession fulfill its destiny as “health
1980). Futurists believe that almost anything can be agent” (Finn, 1972), enhance community health,
accomplished in a period of 20 years. and facilitate “community occupational develop-
The third principle on which futurists rely is ment” (Bockhoven, 1968).
the importance and power of ideas, particularly
ideas about the future. The future is created out
of ideas, the tools of thought. Without them, An Ecological Worldview
change is not possible. Futurists believe that
human achievement is constrained more by con- To become health agents, occupational therapy
ceptual restrictions or limitations in our ideas than practitioners must make a paradigm shift from a
by our access to material resources (Cornish, 1980). holistic perspective to an ecological worldview.
Some advocate that the profession should re-create “An ecological worldview is holistic, but it’s more
or re-invent itself. However, this is not the only avail- than that. It looks not only at something as a whole,
able choice of action. An alternative is to embrace a but also how this whole is embedded into larger
vision that incorporates the fundamental principles wholes” (Capra & Steindl-Rast, 1991, p. 69). Eco-
of the profession, with its focus on occupation and logical awareness recognizes the interrelatedness and
one that expands the scope of practice to include interdependence of all phenomena.
populations not typically served in settings not The root of the word “ecological” comes from the
commonly utilized. The profession would not be Greek “oikos,” which means house. In a broader
where it is today if it had not survived the chal- context, it refers to “the inhabited world, the house
lenges of the past century. Thus, it is not possible of humanity” (Capra & Steindl-Rast, 1991, p. 70).
or desirable to discard what has been part of the The house of humanity includes the biological, psy-
profession’s heritage. chological, and spiritual aspects of life embedded in
Some predictions can be made about the future a physical, social, and cultural reality. The shift to an
of occupational therapy based on current trends. ecological paradigm reflects not only a change in
The following statements reflect the authors’ beliefs thinking but also a change in values. Overall, the
regarding the future of occupational therapy and are shift in values is characterized by a shift from self-
offered as “food for thought.” We anticipate: assertion to integration (Capra & Steindl-Rast,
1991). Self-assertion is a living system’s tendency
• An increased role for occupational therapy in toward domination in an effort to preserve and pro-
prevention and health promotion tect itself, while integration is the tendency to part-
• A significant shift in services from medical ner with other systems in order to fulfill the greater
institutions to decentralized, coordinated, good. Table 29-1 provides a synopsis of the changes
community-based settings in values required by the ecological paradigm.
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Chapter 29 | Future Directions in Community-Based Practice 423
Table 29-1 Change in Paradigm, Change in Creating Opportunities in

Values
the Community
From a Holistic To an Ecological
Perspective With Paradigm With To develop creative ideas for community-based prac-
an Emphasis on an Emphasis on tice, one must simply be observant, open-minded, and
Self-assertion Integration reflective. Opportunities are abundant, but one must
Rational thought Intuitiveness know where to look and how to see potential. Getting
to know the community and becoming involved in
Analysis Synthesis community affairs are necessary first steps. Volunteer-
Competition Cooperation ing one’s time and talents begins the networking
Expansion Conservation process. Communities typically have a variety of
Quantity Quality groups, organizations, and agencies that need volun-
teers and may be potential recipients of occupational
Domination Partnership therapy services.
Individuality Community To be successful in community-based practice
settings, practitioners must see themselves providing
a wide range of interventions. Direct service to indi-
Self-assertion is not completely lost in the ecolog- viduals is only a small part of what occupational ther-
ical paradigm because it is essential for survival. How- apy has to offer. In community-based practice, the
ever, left unchecked, self-assertion can become client is often not an individual but rather a group,
destructive, evidenced by the variety of community organization, agency, or collective. Potential interven-
health problems experienced today, such as violence, tions may include case management, training, con-
poverty, racism, homelessness, substance abuse, and sulting, program coordination, policy development,
destruction of the environment. Self-assertion must and advocacy. These levels of intervention and their
be tempered with integration to be useful and healthy. strategies and goals are described in Table 29-2.
Koestler (1978) speaks of this dichotomy as the Janus Effective community-based interventions share
nature. A living system is an integrated whole that as- some characteristics in common with effective occu-
serts itself to protect its individuality. However, as part pational therapy interventions for individuals. Both
of a larger whole, the living system is required to inte- are client-centered, involve the recipient of services in
grate itself into the larger system. According to Capra the planning and implementation of the intervention,
and Steindl-Rast (1991), “it is important to realize that utilize existing environmental resources, and prepare
those are opposite and contradictory tendencies. We clients to become self-managers and self-advocates.
need a dynamic balance between them, and that’s Occupational therapy practitioners can learn much
essential for physical and mental health” (p. 74). from the professional literature in health education
Table 29-2 Strategies, Goals, and Levels of Occupational Therapy Intervention

Intervention Type Strategy or Process Goals/Outcomes Target/Level
Direct service Providing occupational Improved occupational Individual
therapy intervention performance
Counseling Helping people learn Goal attainment, healthy Individual, interpersonal
how to achieve personal behaviors, empowerment
goals, resolve problems,
make decisions, or
change behaviors
Case management Coordinating care plans Improved client out- Individual, interpersonal,
comes, comprehensive, organizational
coordinated care
Continued
2580_Ch29_421-440 16/07/13 3:17 PM Page 424
Table 29-2 Strategies, Goals, and Levels of Occupational Therapy Intervention—cont’d

Intervention Type Strategy or Process Goals/Outcomes Target/Level
Education Providing information and Positive change in Individual, interpersonal,
employing the methods, knowledge, attitude, organizational,
strategies, and tools that or behavior societal/community,
facilitate learning governmental/policy
Training Providing information Competence in targeted Individual, interpersonal,
to enhance a skill or skills, processes, organizational
process techniques
Consulting Using the knowledge Problem solving in area Individual, interpersonal,
and experience of an of concern organizational,
“expert” to help a per- societal/community,
son or organizational governmental/policy
leaders make better
decisions or deal more
effectively with situations
Program Assessing the need for, Improved services/care Organizational,
development planning, and evaluating for target population societal/community
programs and services
Program Managing the resources Effective and efficient use Organizational,
coordination (e.g., staff, materials, of resources societal/community,
space, finances, etc.) to governmental/policy
accomplish the objec-
tives of a program
Policy development Formulating rules, laws, Laws, rules, policies, and Governmental/policy
policies, procedures procedures that are favor-
able to area of concern
Advocacy Using the power of per- Favorable change in poli- Organizational,
suasion to alter public cies, regulations, resource societal/community,
opinion and mobilize allocation governmental/policy
resources in favor of a
policy or issue
Research Building knowledge Improved practice, Organizational,
through systematic study evidence-based practice governmental/policy
Data from: Washington University Community Practice Model.
and public health regarding the design and imple- actions expand the scope of practice. Each of these
mentation of community health interventions. Basic examples, taken from recent literature, is described
principles of effective community interventions are briefly. Some involve expansion of professional roles,
listed in Box 29-1. some include populations not typically served, and oth-
ers describe practice in settings not typically utilized.
Innovative Ideas Put
Transition Services for Youth With
Into Action Disabilities
Occupational therapy practitioners have begun to put The Individuals With Disabilities Education
some innovative ideas into action. These ideas and Act (IDEA) of 2004 requires schools to provide
2580_Ch29_421-440 16/07/13 3:17 PM Page 425
Box 29-1 Principles of Effective Community Interventions
• Tailor to a specific population within a particular setting.

• Involve the participants in planning, implementation, and evaluation.
• Integrate efforts aimed at changing individuals, social and physical environments, communities, and policies.
• Link participants’ concerns about health to broader life concerns and to a vision of a better society.
• Use existing resources within the environment.
• Build on strengths found among participants and their social networks and communities.
• Advocate for the resources and policy changes needed to achieve the desired health objectives.
• Prepare participants to become self-managers and self-advocates.
• Support the diffusion of innovation to a wider population.
• Seek to “institutionalize” successful components and to replicate them in other settings.
Data from: Freudenberg, N., Eng, E., Flay, B., Parcel, G., Rogers, I., and Wallerstein, N., (1995). Strengthening
individual and community capacity to prevent disease and promote health: In search of relevant theories
and principles. Health Education Quarterly, 22(3), 290–306.
individual transition plans (ITPs) for youth with disabilities are important, there is a growing need
disabilities age 16 to 21. Transition services are for these services for individuals with autism spec-
specifically designed to “facilitate the child’s trum disorder. The Southwest Autism Research &
movement from school to post-school activities, Resource Center (SARRC) of Phoenix, Arizona,
including postsecondary education, vocational has made an effort to support people with autism
education, integrated employment (including spectrum disorder (ASD) throughout the life span.
supported employment), continuing and adult In its vocational and life skills training program,
education, adult services, independent living, or the Center seeks to advocate for independence in
community participation” (U.S. Department of individuals aged 13 and older with ASD. The
Education (USDE), 2006, p. 46762). ITPs are Center provides opportunities to learn skills required
based on the “individual child’s needs, taking into for various jobs and/or independence, including art,
account the child’s strengths, preferences, and job and social skills training, cooking, entrepreneur-
interests; and include: ial skills, landscaping/gardening, and basic life
skills. Internships and job coaches are offered for
• Instruction;
individuals interested in obtaining employment
• Related services;
(SARRC, 2012).
• Community experiences;
Similarly, the Hussman Center for Adults with
• The development of employment and other
Autism at Towson University in Maryland, estab-
post-school adult living objectives; and
lished in 2008, provides mutual learning opportu-
• If appropriate, acquisition of daily living skills
nities for students at the university, professionals in
and provision of a functional vocational evalu-
the community, families of people with autism, and
ation” (USDE, 2006, p. 46762).
transitioning youth/adults aged 18 years and older
In addition to transition services mandated by with autism spectrum disorders. Six to 15 transi-
IDEA, young adults with disabilities can receive tioning youth/adults with autism are paired with
transition-planning services in the community university students and participate in 4- to 12-week-
through adult disability services’ community-based long programs. Some programs include recreation
long-term care services funded by Medicaid Home and fitness classes; introduction to college and peer
and Community-Based services (HCBS) waivers support; social experience classes; and arts, music,
(Orentlicher & Dougan, 2011). and dance classes. These programs utilize university
Occupational therapy involvement in transition students in various majors, including occupational
planning for youth can extend beyond the school therapy, kinesiology, the arts, and family studies
system to community-based programs. Although to address language, fitness, social, self-advocacy,
transition services for individuals with all types of problem-solving, communication, leadership, and
2580_Ch29_421-440 16/07/13 3:17 PM Page 426
relational skills with individuals with autism with children, adolescents, and adults. Primary
(Crabtree, 2011). prevention involves the implementation of health
As occupational therapists begin to provide tran- education and health promotion intervention
sition services for individuals with autism, critical strategies with healthy people to decrease the inci-
deficits must be targeted to increase independence dence of obesity and decrease its prevalence. Sec-
and occupational participation in transitioning ondary prevention involves the early detection and
youths/adults. Although deficits associated with implementation of strategies to prevent or diminish
autism are on a spectrum from higher to lower func- the negative health effects in individuals who are
tioning, self-determination, self-advocacy, commu- already overweight. Finally, tertiary prevention in-
nity participation, relationship development, career volves treatment of obesity to prevent disability and
and employment preparation, and independent liv- to promote engagement in occupation despite the
ing are common areas of concern (Crabtree, 2011). presence of severe obesity (Scaffa, Van Slyke, &
It is important to maintain a client-centered ap- Brownson, 2008).
proach, building on the strengths of the individual In building a community-based program for
to foster success and independence during transition health promotion and obesity prevention, occupa-
into adulthood (Kotler & Koenig, 2012). Finally, tional therapists consider the OT Practice Framework
when helping a transitioning youth/adult integrate and the functional implications of obesity. Occupa-
into a particular community/role, it is important to tional therapists address areas of need relevant to
educate the people he or she will encounter about the framework (Clark, Reingold, & Salles-Jordan,
autism, behaviors associated with the disorder, and 2007). In children’s programs some of the areas
specific strategies to overcome any associated barri- addressed include arousal, concentration, family
ers in order to foster a smooth transition (Baugher education on community resources, safety aware-
& Pyne, 2012). ness, nutrition and meal preparation, leisure/play,
flexibility, strength, activity level, goal setting, and
self-efficacy (Cahill, Daniel, Nelson-Stitt, Brager,
Obesity Prevention and Intervention Dostal, & Hirter, 2009; Kugel, 2010; Lau, 2011).
Health management and maintenance is categorized Similarly, programs geared toward adults focus on
as an instrumental activity of daily living (IADL) and establishing and enhancing a client’s environment;
is within the scope of practice for occupational ther- independence in activities of daily living (ADLs)
apists (American Occupational Therapy Association and IADLs; activity tolerance; range of motion; and
[AOTA], 2008). It incorporates development, man- performance patterns, habits, and rituals for weight
agement, and maintenance of performance patterns reduction and/or maintenance (Mosley, Jedlika,
for health and wellness promotion. Interventions Lequieu, & Taylor, 2008). These programs may also
focusing on fitness, nutrition, behaviors, and med- include education on use of adaptive equipment,
ication routines are appropriate strategies to address stress management, community resources, leisure/
health management and maintenance (AOTA, physical activity, and compensatory strategies (Mosley,
2008). As a result, there is an increasing awareness Jedlika, Lequieu, & Taylor, 2008).
in occupational therapy of the need to address com- In response to the nation’s increased incidence
munity health and wellness, especially regarding the of obesity and its limiting effects on occupational
issue of obesity (Clark, Reingold, & Salles-Jordan, performance, occupational therapists can make
2007). Obesity is defined as body mass index greater a difference through prevention and promotion
than or equal to 30 in adults and greater than or of health within the community. A number
equal to the 95th percentile on age- and sex-specific of community-based programs have been estab-
growth charts in children. In 2009–2010, 35.7% of lished to address both childhood and adult obe-
U.S. adults and 16.9% of U.S. children were obese sity, including: The Healthy Lifestyle Initiative, by
(Odgen, Carroll, Kit, & Flegal, 2012). LaGrange Area Department of Special Education
Occupational therapists have begun to address and University of Illinois at Chicago (Cahill et al.,
this nationwide health concern with the use of pri- 2009); Healthy Choices for Me, a partnership be-
mary, secondary, and tertiary prevention approaches tween Henderson, Nevada, Recreation and Touro
2580_Ch29_421-440 16/07/13 3:17 PM Page 427
University Nevada OT School (Lau, 2011); and proprioception, muscle power, joint mobility, mus-
Madonna ProActive at Madonna Rehabilitation cle endurance, muscle tone, motor reflexes, control
Hospital in Lincoln, Nebraska (as cited in Mosley of voluntary and involuntary movements, cardio-
et al., 2008). In addition to these sources, the vascular functions, and respiratory functions.
AOTA position paper on obesity can guide practi- Specifically, driving programs may focus on:
tioners in establishing community-based obesity
• independence in car transfers with loading
programs (Clark, Reingold, & Salles-Jordan,
of assistive devices,
2007).
• orientation to environment and following
directions,
Driving Across the Life Span • emotional regulation,
• reaction time,
Community mobility involves use of private
• bilateral coordination,
and/or public transportation to move within one’s
• visual perception, processing, and scanning,
geographic neighborhood. It includes walking;
• multitasking, attention, decision making,
driving automobiles; and riding bicycles, buses,
problem solving, and
taxicabs, or other forms of transportation (AOTA,
• recommendation and operation of vehicle
2008). Driving is an IADL, which contributes to
modifications (Stern, Prudencio, & Sadler,
increased independence. Impairments leading to
2011; Strzelecki, 2011).
loss of ability to drive can limit a client’s occupa-
tional performance and participation, especially Some community-based driving programs are
in locations with limited public transportation specific to older adults, while others are geared to the
options. Driving and community mobility can be needs of young adults or war veterans (McKenna,
addressed through occupational therapy interven- 2011; Stern, Prudencio, & Sadler, 2011; Strzelecki,
tion. Both non-specialized occupational therapists 2011). The AOTA has many resources on its Web
and those practicing as driving rehabilitation spe- site to support the development of a driver rehabili-
cialists can and should address this area of occupa- tation program. In addition, the Association for
tion to provide needed services for maximization Driver Rehab Specialists (ADED) provides certifica-
of occupational independence and client well- tion courses and continuing education to increase
being (McKenna, 2011). competence in driving rehabilitation. Finally, the
Many different types of clients can benefit from National Highway Traffic Safety Administration
driving rehabilitation services. Older adults with (NHTSA) and state departments of transportation
age-related decline are particularly vulnerable to are important resources to increase familiarity with
deficits that may prevent them from driving the laws of the road and legal issues regarding adap-
(McKenna, 2011). Additionally, clients diagnosed tive equipment and license restrictions. Driving as
with traumatic brain injury, post-traumatic stress an IADL is an enabler of occupational participation
disorder (Stern, Prudencio, & Sadler, 2011), vision and independence and should be addressed in all
deficits, amputation, and limited mobility due to clients of driving age to ensure safe, effective, and
cerebral vascular accidents or orthopedic conditions client-centered care.
may have decreased safety and independence during
driving. Because occupational therapists not only
work to restore lost occupations but also create and Aging-in-Place Home Modifications
promote skills for new occupations (AOTA, 2008), In the United States in 2009, 12.8% of the popula-
young people with disabilities can also benefit from tion was over age 65, and by 2025 the percentage
driving rehabilitation programs (Strzelecki, 2011). of older adults is expected to climb to 17.9%
Driving programs focus on evaluation and inter- (Shrestha & Heisler, 2011). The vast majority of
vention to improve skills related to safe driving for older adults desire to remain in their homes as they
clients, passengers, and other motorists. Some skills age. With aging, natural decline occurs, creating new
important for safe and independent driving in- barriers to living in an environment that was once
clude: higher-level cognition, attention, vision, functional. To address these barriers, occupational
2580_Ch29_421-440 16/07/13 3:17 PM Page 428
therapists work to modify home environments to In addition to the AOTA and the NAHB, there
promote successful aging in place. are other resources that can facilitate the achievement
Occupational therapists are teaming with build- of aging-in-place goals. Non-profit organizations
ing contractors in communities to increase awareness such as Rebuilding Together, the National Aging in
about the role of occupational therapy in home mod- Place Council, and AARP can provide information
ification and the creation of accessible environments. and potential funding to assist in providing safe
Through the National Association of Home Builders home environments promoting occupational per-
(NAHB), occupational therapists can be trained as formance for productive aging (Waite, 2011; Young,
Certified Aging in Place Specialists (CAPS). Addi- 2011). It appears that this area of practice will con-
tionally, AOTA offers a course for a Specialty Certi- tinue to grow in the years ahead due to the aging
fication in Environmental Modifications (SCEM) baby boomer generation.
(Waite, 2011). Through these courses, therapists can
network with contractors, architects, interior design-
ers, and others who advocate for accessible environ- Telerehabilitation
ments for productive aging. Occupational therapists Jana Cason, an early intervention occupational
like Lizzette Davis, OTR, CAPS, from San Antonio, therapy practitioner, uses the emerging telehealth
Texas; Carolyn Sithong, OTR/L, CAPS, SCEM, model of practice to provide services to clients who
from Orlando, Florida; and Marnie Redna, MEd, would otherwise not receive occupational therapy.
OTR/L, CAPS from Cincinnati, Ohio, all began Long distances and hours on the road characterize
home modification businesses by partnering with the jobs of many in-home occupational therapy
contractors after recognizing that their recommen- practitioners (Cason, 2011). Rather than serving
dations to clients often were not implemented. They more clients, these practitioners exhaust their re-
noticed that often the modifications were not com- sources traveling between clients. Despite their
pleted due to lack of professional guidance from efforts, therapists remain unable to provide needed
occupational therapists to properly implement the services due to provider shortages or lack of
recommendations (Waite, 2011). specialized knowledge, creating health disparities
Considering the functional declines common in in many geographic areas. In an effort to be more
the aging population, there are many different rec- cost effective, a new practice model is emerging.
ommendations that can be made to increase acces- Telehealth is the use of technology and electronic
sibility of a home and thus enhance occupational information to support health care, health admin-
participation. The addition of ramps for easy entry, istration, or health education delivery across a
and grab bars to improve safety are commonly rec- distance (Health Resources and Services Adminis-
ommended modifications. Home lighting and or- tration, n.d.). From an occupational therapy
ganization of the environment are also important as perspective, telerehabilitation is the use of com-
aging residents’ vision and balance decline. In many munication technology to provide clients with
homes, kitchens and bathrooms are inaccessible due evaluative, preventative, diagnostic, and therapeu-
to lack of space to access sinks, stoves, showers, and tic services (AOTA, 2010). Telehealth is used to
toilets from a wheelchair or walker. Bathroom provide health care in underserved areas, homes,
tub/shower barriers are often renovated to curbless hospitals, nursing homes, schools, and workplaces
showers to increase independence in performance (Cason, 2012). Telerehabilitation has been effec-
of ADLs. Multiple-level houses may require instal- tive for consultative purposes in situations when
lation of elevators or chairlifts to access upper levels therapists can seek advice from expert therapists,
(Fagan & Sabata, 2011; Waite, 2011; Chase & or across disciplines for collaborative efforts. Ad-
Roche, 2011; Morris, 2009). Although many differ- ditionally, it has been used successfully to educate
ent recommendations can improve ease of access to caregivers and serve clients with many diagnoses,
home environments and improved independence, including traumatic brain injuries, cerebral vascu-
it is important to develop a strong network of qual- lar accidents, multiple sclerosis, cerebral palsy,
ified contractors to support construction and instal- polytrauma, post-traumatic stress disorder, and
lation of accessible environments (Morris, 2009). chronic diseases (Cason, 2012).
2580_Ch29_421-440 16/07/13 3:17 PM Page 429
Before using the telehealth model, some concerns/ occupational injustice persists, occupational dysfunc-
barriers must be considered. Funding of services is tion is often the result.
limited, so practitioners must be knowledgeable Risk factors that cause occupational dysfunction
about reimbursement sources and advocate for due to occupational injustice include occupational
their clients (U.S. Department of Health and imbalance, deprivation, and alienation (Wilcock,
Human Services, n.d.). Research regarding the 1998). Occupational imbalance is a lack of balance
effective use of assessment and intervention tools between self-sustaining, productive, and leisure oc-
is also limited, so care must be taken to ensure cupations that fails to meet an individual’s physical
services are efficacious (Cason, 2012). Practitioners or psychosocial needs, thereby resulting in decreased
must be aware of appropriate technology and be health and well-being. Occupational deprivation is
competent in its use. This is especially important, the result of external circumstances or limitations
as there is an increased risk for a breach in patient that prevent a person from participating in necessary
privacy due to the use of technology. Care must be and meaningful occupations. Conditions that lead
taken to ensure the use of protected systems, espe- to occupational deprivation may include poor health,
cially when the Internet is involved (Cason, 2012). disability, poverty, isolation, and homelessness. Oc-
Ethical principles must be adhered to just as in any cupational alienation is a lack of satisfaction in one’s
other practice model (AOTA, 2010). Additionally, occupations that leads to experiencing life as pur-
practitioners are expected to abide by all state poseless and meaningless. Tasks that are perceived
licensure laws when performing services across as stressful, meaningless, or boring may result in an
state lines; this may require licensure in more than experience of occupational alienation.
one state (American Telemedicine Association, Occupational therapy practitioners are ethically
2011). As researchers continue to discover the bound to address occupational injustice wherever it
effective use and benefits of telerehabilitation, exists, in health care institutions, communities, or
opportunities expand for occupational therapists social and political policies and practices. A case
to incorporate advanced communication technol- study at the end of this chapter illustrates the ideas,
ogy into practice to achieve a globally connected beliefs, and principles associated with occupational
and widely recognized workforce meeting society’s justice as they relate to a Japanese woman, Yuriko,
occupational needs (AOTA, 2006). who lives in a nursing home.
The Influence of Implications for Professional

Occupational Justice: An Preparation and Education
International Example As occupational therapy services continue to in-
crease in a diverse array of community-based set-
Many of the emerging areas of community-based tings, it is imperative to prepare students for
practice are predicated on the construct of occupa- community practice (Fagan, Van Oss, Cabrera,
tional justice. The next section briefly describes the Olivas De La O, & Vance, 2008). In order to re-
construct and the implications for practice, and pro- spond to changes in practice settings and to fulfill
vides a case study submitted by an occupational its mission to produce competent practitioners for
therapist in Japan. the future, professional education must develop
Occupational justice is based on the belief that new curricular and fieldwork models. A primary
humans are occupational beings and that participa- challenge will be to balance the need to prepare stu-
tion in occupation is essential for health, well-being, dents for traditional biomedical practice with the
and quality of life. Therefore, all persons should have new demands of community health roles. McColl
the right to engage in meaningful occupation; this (1998) identifies the knowledge needed by occupa-
is their occupational right. Occupational injustice tional therapy students and practitioners in order
exists when this right is violated or goes unfulfilled to participate effectively in community programs
(Stadnyk, Townsend, & Wilcock, 2010). When (Box 29-2).
2580_Ch29_421-440 16/07/13 3:17 PM Page 430
Box 29-2 What Students and Practitioners new standards for occupational therapy assistant and
Need to Know to Participate occupational therapist (master’s and doctoral level)
Effectively in Community preparation programs to be implemented by July 31,
Programs 2013. One entire section of the accreditation stan-
dards (the minimum essential requirements for
• What a community is accreditation of educational programs) is devoted
• How organizations and communities form
to the context of service delivery. This section
• How organizations and communities are governed
• How to identify community resources
describes, in some detail, the competencies required
• How to identify community needs for practicing in a variety of environments, with
• How to facilitate change a major emphasis on community and social systems.
• How persons with disabilities live in the community Community-related competencies also can be found
• How persons develop and pursue occupations in as minor components in other sections of the stan-
the community dards, including:
• What supports and barriers to participation in
occupation exist in the community • Foundational content requirements
• Basic tenets of occupational therapy
Data from: McColl, M. A. (1998). What do we need to know to • Occupational therapy theoretical perspectives
practice occupational therapy in the community? American • Intervention plan formulation and
Journal of Occupational Therapy, 52(1), 11–18.
implementation
• Management of occupational therapy services
• Professional ethics, values, and responsibilities
In December 2011, the Accreditation Council for
• Fieldwork education.
Occupational Therapy Education (ACOTE), the or-
ganization responsible for accrediting entry-level oc- Box 29-3 provides examples of standards that
cupational therapy educational programs, adopted emphasize community and social systems from the
Box 29-3 ACOTE Standards Related to Community-Based Practice
SECTION B: CONTENT REQUIREMENTS

1.0 Foundational Content Requirements
1.4 Demonstrate knowledge and appreciation of the role of sociocultural, socioeconomic, and diversity
factors and lifestyle choices in contemporary society.
1.5 Demonstrate an understanding of the ethical and practical considerations that affect the health and
wellness needs of those who are experiencing or are at risk for social injustice, occupational deprivation,
and disparity in the receipt of services.
1.6 Demonstrate knowledge of global social issues and prevailing health and welfare needs of populations
with or at risk for disabilities and chronic health conditions.
2.0 Basic Tenets of Occupational Therapy
2.5 Explain the role of occupation in the promotion of health and the prevention of disease and disability for
the individual, family, and society.
2.9 Express support for the quality of life, well-being, and occupation of the individual, group, or population
to promote physical and mental health and prevention of injury and disease considering the context
(e.g., cultural, personal, temporal, virtual) and environment.
3.0 Occupational Therapy Theoretical Perspectives
3.5 Apply theoretical constructs to evaluation and intervention with various types of clients in a variety
of practice contexts and environments to analyze and effect meaningful occupation outcomes.
5.0 Intervention Plan: Formulation and Implementation
5.4 Design and implement group interventions based on principles of group development and group
dynamics across the life span.
5.5 Provide training in self-care, self-management, health management and maintenance, home management,
and community and work integration.
5.9 Evaluate and adapt processes or environments (e.g., home, work, school, community) applying
ergonomic principles and principles of environmental modification.
2580_Ch29_421-440 16/07/13 3:17 PM Page 431
Box 29-3 ACOTE Standards Related to Community-Based Practice—cont’d
5.13 Provide recommendations and training in techniques to enhance community mobility, including public
transportation, community access, and issues related to driver rehabilitation.
5.17 Develop and promote the use of appropriate home and community programming to support perfor-
mance in the client’s natural environment and participation in all contexts relevant to the client.
5.18 Demonstrate an understanding of health literacy and the ability to educate and train the client, caregiver,
family and significant others, and communities to facilitate skills in areas of occupation as well as
prevention, health maintenance, health promotion, and safety.
5.21 Effectively communicate and work interprofessionally with those who provide services to individuals, organi-
zations, and/or populations in order to clarify each member’s responsibility in executing an intervention plan.
5.26 Understand when and how to use the consultative process with groups, programs, organizations, or
communities.
5.27 Describe the role of the occupational therapist in care coordination, case management, and transition
services in traditional and emerging practice environments.
5.29 Plan for discharge, in collaboration with the client, by reviewing the needs of client, caregiver, family, and
significant others; available resources; and discharge environment. This process includes, but is not lim-
ited to, identification of client’s current status within the continuum of care; identification of community,
human, and fiscal resources; recommendations for environmental adaptations; and home programming
to facilitate the client’s progression along the continuum toward outcome goals.
5.33 Provide population-based occupational therapy intervention that addresses occupational needs as
identified by a community. (Doctoral degree level only)
6.0 Context of Service Delivery
6.1 Evaluate and address the various contexts of health care, education, community, political, and social
systems as they relate to the practice of occupational therapy.
6.2 Analyze the current policy issues and the social, economic, political, geographic, and demographic factors
that influence the various contexts for practice of occupational therapy.
6.3 Integrate current social, economic, political, geographic, and demographic factors to promote policy
development and the provision of occupational therapy services.
6.4 Articulate the role and responsibility of the practitioner to advocate for changes in service delivery
policies, to effect changes in the system, and to identify opportunities in emerging practice areas.
6.5 Analyze the trends in models of service delivery, including, but not limited to, medical, educational,
community, and social models, and their potential effect on the practice of occupational therapy.
7.0 Management of Occupational Therapy Services
7.1 Describe and discuss the impact of contextual factors on the management and delivery of occupational
therapy services.
7.5 Demonstrate the ability to plan, develop, organize, and market the delivery of services to include the
determination of programmatic needs and service delivery options and formulation and management
of staffing for effective service provision.
7.9 Demonstrate knowledge of and the ability to write program development plans for provision of
occupational therapy services to individuals and populations. (Doctoral degree level only)
7.11 Identify and develop strategies to enable occupational therapy to respond to society’s changing needs.
(Doctoral degree level only)
9.0 Professional Ethics, Values, and Responsibilities
9.12 Describe and discuss strategies to assist the consumer in gaining access to occupational therapy services.
SECTION C: FIELDWORK EDUCATION
1.12 Provide Level II fieldwork in traditional and/or emerging settings, consistent with the curriculum design.
In all settings, psychosocial factors influencing engagement in occupation must be understood and inte-
grated for the development of client-centered, meaningful, occupation-based outcomes. The student can
complete Level II fieldwork in a minimum of one setting if it is reflective of more than one practice area,
or in a maximum of four different settings.
Data from: American Occupational Therapy Association. (2011). Accreditation Council for Occupational
Therapy Education (ACOTE) Standards and Interpretative Guide (effective July 31, 2013). Retrieved from
http://aota.org/Educate/Accredit/Draft-Standards/50146.aspx?FT=.pdf
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Standards for an Accredited Educational Program effort, and talents to a need or cause they value out
for the Occupational Therapist (AOTA, 2011). of a sense of social responsibility. In high-quality
A number of educational approaches can be de- community service learning programs, students are
veloped, implemented, and evaluated for their effec- involved in identifying community needs, planning
tiveness in meeting the demands of emerging and implementing a service project, and structured
practice arenas. The accreditation standards allow reflection on what was learned through the service
the flexibility to create a variety of curricular models experience. CSL is designed to meet a community
that qualify for accreditation. As every community need while facilitating the development of skills in
is different, so too may educational programs differ the learner.
in how they meet the need to produce a new type Much research has been conducted on the effects
of occupational therapy practitioner. of community service learning. The effects appear
Some educational programs are meeting the chal- to be broad based and enduring, many of which
lenge by infusing community practice content are congruent with occupational therapy’s history
throughout the curriculum, while others are creating and philosophical base. Regardless of the discipline,
new courses that focus entirely on community health service-based learning appears to:
concerns. Some programs are using community-
based sites in creative ways for level I fieldwork. • Develop open-mindedness
Other programs place students in community pro- • Increase awareness of one’s own values,
grams for both level I and level II fieldwork. In ad- beliefs, and attitudes (an essential aspect of
dition, community service learning has become an therapeutic use of self)
attractive educational methodology within occupa- • Increase problem-solving ability
tional therapy programs to address the competencies • Increase empathy
needed for effective community-based practice. In- • Be as effective as traditional instruction in
tegrating community service learning opportunities conveying knowledge
in occupational therapy curricula can facilitate stu- • Increase self-efficacy and enhance a belief that
dents’ understanding and appreciation of social, eco- a person can make a difference in other
nomic, and environmental factors and their impact people’s lives
on occupational participation, health, and quality of • Increase social and personal responsibility
life (Horowitz, 2012). (an important aspect of ethical behavior)
• Enhance communication skills
Community Service Learning • Reinforce the development of professional
behaviors (good practice for students early
Community service learning (CSL) is defined as “a in their academic program)
teaching and learning strategy that integrates mean- • Instill a healthy work ethic
ingful community service with instruction and • Enable students to assess their strengths and
reflection to enrich the learning experience, teach weaknesses (Conrad and Hedin, 1991; Giles
civic responsibility, and strengthen communities” and Eyler, 1994; Markus, Howard, & King,
(National Service Learning Clearinghouse, 2012, 1993; Sankaran, Cinelli, McConatha, &
para. 1). Through CSL, occupational therapy stu- Carson, 1995)
dents not only have the opportunity for practical
application of what they have learned in the class- In addition, several potential benefits specific
room to a real world problem but also increase the to the discipline of occupational therapy are
awareness of occupational therapy in the community evident. CSL can increase the students’ under-
and provide much-needed services to underserved standing of the role of occupational therapy in
populations. community-based settings, providing an opportu-
CSL has several characteristics that distinguish it nity to integrate theory with practice and net-
from volunteerism. Volunteerism, although a highly working opportunities with professionals in a
valued occupation, is not an educational pedagogy. variety of disciplines. CSL also allows community-
The purpose of volunteerism is to serve one’s based organizations, which currently may not have
neighbors and communities in order to enhance the occupational therapy services, to experience occu-
quality of life for all. Volunteers donate their time, pational therapy firsthand, thereby increasing the
2580_Ch29_421-440 16/07/13 3:17 PM Page 433
potential development of new job opportunities their families, schools, work settings, and
for occupational therapy practitioners in community- community.
based programs. • Identify the personal, social, and environ-
CSL also increases the probability that students mental circumstances that promote
might choose a community-based setting for future acceptance and use of assistive devices.
practice. It has been demonstrated that practition- • Investigate how the interaction of biopsy-
ers who are trained in institutions want to work in chosocial and environmental factors con-
institutions (Weissert, Knott, & Steiber, 1993). What tribute to the development of functional
students learn in school is most likely how they will limitations, disabilities, and impairments.
practice. Providing students, early in their academic • Identify the personal, developmental, and
career, with opportunities to experience the potential environmental attributes that contribute to
for community-based practice is one of the goals of successful community living.
this community service-learning approach to level I
Traditional approaches to quantitative research
fieldwork.
may not be the most effective ways of investigating
The overall goal of a CSL program is to develop
the impact of occupational therapy in community
students’ skills and competencies in the provision of
settings or the impact of occupational therapy on
community-based occupational therapy services to
community health. Typically, quantitative studies
agencies and organizations in the local community,
do not capture the unique experiences of commu-
which have typically been underserved. An effective
nity members nor the complex interactions that im-
program is designed to:
pact health (Christiansen & Matuska, 2010). As a
• Respond to actual community needs result, researchers in public and community health
• Provide community-based organizations with have advocated for the use of community-based par-
the opportunity to experience occupational ticipatory action approaches and mixed methods re-
therapy services firsthand search. Kielhofner (2005) eloquently argues that
• Increase the potential for the development of participatory action research may be one strategy for
new job opportunities in community-based bridging the divide between scholarship and practice
programs in occupational therapy.
• Increase the probability that students will Community-based participatory action re-
choose a community-based setting for future search (CBPAR) takes place in real-world contexts
practice and is client-centered and collaborative, action-ori-
ented, and designed to solve a community health
According to Horowitz (2012), “service learning
problem. In CBPAR, participants are involved in a
provides occupational therapy education with a flexi-
collaborative relationship with the researcher to
ble, relatively low-cost pedagogy that advances the
identify the problem to be addressed, determine the
Centennial Vision and provides opportunities to com-
research questions, design the research methods,
munity practice through reflective, active learning
conduct data collection and analysis, and interpret
experiences” (p. 3).
and apply the results. CBPAR often involves the use
of a mixed methods approach combining quantita-
Implications for Research in tive and qualitative methods.
Although there are few examples of CBPAR in the
Community-Based Practice occupational therapy literature, Letts (2003) argues
that participatory research is an approach that is
Baum and Law (1998) outlined a number of
consistent with the values of the profession and can
research areas relevant for community practice.
make significant contributions to the knowledge base
Occupational therapy researchers need to:
in occupational therapy. Taylor, Braveman, and
• Identify the factors that contribute to suc- Hammel (2004) describe two case examples of how
cessful employment, self-sufficiency, and community-based services, for persons with AIDS and
social integration. individuals with chronic fatigue syndrome, were
• Determine the conditions that enable persons developed and evaluated using participatory action re-
with chronic disabilities to participate fully in search. One CBPAR project, involving occupational
2580_Ch29_421-440 16/07/13 3:17 PM Page 434
therapy faculty and students, was based on the prin- produces changes, both planned and unplanned,
ciples of occupational justice and addressed the im- in the structure and function of a social system.
portance of clean water in the ability of persons in Time is a factor in the diffusion process. Some
Appalachian Kentucky to carry out the necessary and individuals are early adopters of innovation, while
desired occupations of family and community life others tend to lag behind. Some innovations are
(Blakeney & Marshall, 2009). In each of these studies, adopted very quickly. Others may take significantly
mixed methods research strategies were employed. longer periods of time. In a profession, diffusion of
Mixed methods research combines elements innovation requires a “critical mass” of adopters
of both the quantitative and qualitative research tra- before the innovation becomes the standard.
ditions in an attempt to expand our understanding The occupational therapy profession is at an im-
of a phenomenon and confirm findings from a portant crossroads in its history. Do we re-adopt the
variety of data sources. Using mixed methods helps innovation of community practice and all that it en-
to neutralize the inherent biases and draw on the tails and move ahead quickly and deliberately, or do
respective strengths of each, thereby increasing the we reinforce the status quo and work within the ex-
validity and usefulness of the information obtained. isting parameters of practice? While some practition-
Researchers intentionally combine the quantitative ers are losing their jobs in the managed-care arena,
and qualitative data in order to gain a larger perspec- other opportunities are becoming available in com-
tive on the phenomenon of interest. Mixed methods munity settings. These emerging practice areas are
studies incorporate both deductive and inductive very much in harmony with the founders’ visions of
reasoning. Depending on the research questions, the profession. Will we respond quickly and enthu-
mixing quantitative and qualitative methods may be siastically to these challenges? Fidler (2000) clearly
done sequentially with one method following the supports change and suggests moving “beyond the
other, or concurrently where both methods are used therapy model.” She advocates that practitioners be-
simultaneously. Mixed methods research provides come “occupationalists,” who have the capability to
multiple perspectives on a problem, contextualizes practice and conduct research in a variety of areas,
the information obtained, and allows the examina- including but not limited to (Fidler, p. 101):
tion of the relationships between processes and out-
• services and programs of wellness, of preven-
comes (Office of Behavioral and Social Sciences
tion, of learning enhancement, and lifestyle
Research, National Institutes of Health, 2011).
counseling;
• community planning and design;
Diffusion of Innovations • organizational, agency, and institutional
design and operations; and
Through research, publication, and entry-level and • treatment, restorative interventions, and
continuing education, innovations are disseminated rehabilitation.
for implementation into practice. These innovations
and changes are diffused and perpetuated in profes-
sions through a variety of communication channels. Conclusion
An innovation is an idea, method, practice, or
object that is perceived to be new or novel. Some “We envision that occupational therapy is a power-
innovations are not really new from an objective his- ful, widely recognized, science-driven, and evidence-
torical perspective but are new to the perceiver by based profession with a globally connected and
virtue of a lapse of time since their initial discovery diverse workforce meeting society’s occupational
or introduction (Rogers, 1995). needs.” (AOTA, 2006)
Innovations often require a significant period To paraphrase Barker (1992) in Future Edge: Dis-
of time for diffusion before being adopted by covering the New Paradigms of Success, the three keys
practitioners, academics, and researchers in a dis- to the successful achievement of the AOTA Centen-
cipline. Diffusion refers to “the process by which nial Vision are excellence, innovation, and anticipa-
an innovation is communicated through certain tion. Excellence refers to the ability to do whatever it
channels over time among the members of a social is one does with the utmost quality, in a cost-effective
system” (Rogers, 1995, p. 5). Diffusion of innovation manner, while seeking continuous improvement.
2580_Ch29_421-440 16/07/13 3:17 PM Page 435
Innovation is the ability to initiate or introduce some- • Perspective on the role of occupational
thing new and different, and in unison with excel- therapy
lence is a powerful combination. Anticipation is the • View of the profession
ability to be in the right place at the right time with • Identification of potential opportunities
an excellent, innovative product or service. Anticipa- • Capabilities as program planners,
tion allows one to predict or foresee future needs, consultants, advocates, and grant writers
trends, and priorities. If, in some small way, one can
The only real barriers are the limits of one’s cre-
anticipate the future, then there is no need to fear it.
ativity. Occupation is fundamental to human life.
The future can be embraced as an opportunity for
It improves physical and mental health, contributes
growth and revitalization.
to a sense of well-being, enhances life satisfaction,
The ideas presented in this chapter serve as a cat-
and provides meaning to everyday existence. Op-
alyst to stimulate further dialogue and the dissemi-
portunities for professionals with expertise in occu-
nation of community practice models in these
pational performance are evident in all spheres of
emerging practice areas. Successful entry into com-
human endeavor. One need only look with fresh
munity practice will require occupational therapy
eyes and an open mind.
practitioners to expand their:
“Do not follow where the path leads, rather go
• Conceptualization of the usefulness of where there is no path and leave a trail” (Author
occupation unknown).
CASE STUDIES
CASE STUDY 29•1 YURIKO
Occupational Justice: An International Case Study

Yuriko is an 85-year-old female who resides in a nursing home in Japan. Twenty years ago, she sustained
a cerebrovascular accident (CVA), with right hemiplegia and flaccidity of the right upper and lower
extremities. She does not exhibit any cognitive or perceptual deficits. She has right knee pain due to
osteoarthritis. She is ADL independent but uses a wheelchair for mobility due to fear of falling.
Yuriko’s typical daily pattern was as follows:
• She gets out of bed at 6 a.m. and eats breakfast at 7:30 a.m.
• During the day, she often sleeps in bed or watches some TV in her room.
• At 4 p.m., she watches a TV program with samurai dramas and sumo wrestling in the multipurpose hall.
• At 6 p.m. Yuriko eats supper and then goes to bed.
Yuriko shares a room with three other residents, and has little living space and only a curtain for
privacy. She participates in functional rehabilitation that includes stair-climbing exercises and outdoor
gardening with a care-worker and other clients once a week. She does not have any opportunities to go
out into the community. Her daughter has been able to visit Yuriko only once in three months.
Occupational Therapy Evaluation
Yuriko was evaluated using the occupational justice checklist designed for older adults. The checklist
consists of 10 items. For instance, one item reads: “sitting alone in nursing homes or other confined
settings with nothing to do except to watch others in the same situation or television programs that they
did not choose.”
The checklist results suggested that Yuriko was experiencing occupational injustice in the following areas:
1. Occupational imbalance: She had few occupations in the facility except for self-care, and reported
boredom in her free time.
2. Occupational deprivation: She had few opportunities for new role acquisition.
3. Occupational alienation: She did only the activities that had been offered in the facility.
Continued
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CASE STUDY 29•1 YURIKO cont’d
She reported that every day was monotonous because she did not have meaningful occupation.
The occupational therapist at the facility developed an intervention blending Occupational Science,
Person-Occupation-Environment Model, and the Model of Human Occupation.
Occupational Therapy Goals
The first step was for the occupational therapist to understand Yuriko’s occupational history narrative in
order to improve her motivation and adjustment to the environment. Yuriko and her occupational thera-
pist collaborated in the identification of meaningful occupations and valued roles, and in the determination
of her occupational goals.
Yuriko said, “I was gardening and found value in growing vegetables,” before the CVA. “I want to do
anything that I am able to do, but what opportunities do I have in the facility?” For Yuriko, her internal
expectancies of maximal independence and choice in roles and activities conflicted with the rules and
routines of the facility. In choosing to follow the nursing home’s rules and routines, she increasingly
experienced occupational imbalance, occupational deprivation, and occupational alienation.
Occupational Therapy Intervention
The occupational therapist learned that Yuriko had been a farmer prior to her CVA, so she took Yuriko
to the campus of a local university where Yuriko was given the opportunity to teach agriculture
to the students. She lectured the students on how to plant a potato crop and sometimes went out to the
field to observe. Although she only taught the students the skills and did not manage the crops herself,
she enjoyed the challenge of teaching farming skills, which gave her a sense of accomplishment and
satisfaction and provided an experience of flow. Yuriko’s occupational role as a farmer was expanded
to include the role of teacher, and this was very meaningful to her.
Afterwards, the students sent Yuriko photographs of the crop growth and their work in the fields.
They wrote about how Yuriko taught them to plant and farm, and they invited her to the campus
festival. By this time, the students had already become practicing occupational therapists. In addition
to learning how to farm, the students also learned some important occupational therapy principles. The
occupational therapist from the nursing home explained the meaning that growing crops had for Yuriko
and how motivation is improved when a client is able to enact a chosen role. The students also learned
clinical reasoning skills and the meaning of improvised occupational therapy.
Yuriko said that after her stroke she did not know if she would ever be able to work to raise farm
products like this again. So she wrote a heartfelt letter of thanks to the students using her non-dominant
hand. In the letter, she shared her feelings and thanked them for the photographs they sent and the
memories. She said “when I met you one year ago, I was embarrassed and uncertain of what needed to
be done. However, I can enjoy the results of the planting thanks to you this year. The potatoes and green
soybeans appear to be growing well. I think that this is because 21 students’ minds united into one. This
experience has become one of the happiest memories of my life, and I am thankful to you every day. I
hope to live long, and look forward to the time when we meet again.” She also encouraged them to
work hard when they graduated from the university and become independent. Then she invited them
to the summer festival at the nursing home.
Conclusion
According to Wilcock (1998), occupation is a synthesis of being, doing, and becoming and occupational
participation enhances health and well-being. The case of Yuriko is instructive in three ways. First,
through being, doing, and becoming, Yuriko emerged as a new occupational being. Prior to occupational
therapy intervention, “being” for Yuriko was egocentric and anxiety-producing, with a very limited
perspective of the future; “doing” was the once-a-week recreational activity of gardening. As a result of
2580_Ch29_421-440 16/07/13 3:17 PM Page 437
minimal occupational participation, “becoming” was occupational dysfunction, occupational injustice,

loss of role, and decreased motivation. After occupational therapy intervention, using an occupational
narrative approach, “being” for Yuriko became consideration of the students’ needs, a calm and soft
manner, and a future perspective; “doing” became a meaningful occupation (teaching) based on her
previous role as a farmer. As a result, “becoming” developed into occupational function, occupational
justice, role acquisition, and improvement of motivation.
Secondly, Yuriko’s activity participation in the nursing home might be considered an unstable occu-
pation. Occupational therapy intervention can transform unstable occupation into occupation with
energies. As a result, vitalized unstable occupation becomes “true” occupation and can have the health-
enhancing power of occupation. Finally, occupation gives color to the client’s daily life and changes the
facility environment in which the client lives. As this process is repeated for others, the positive outcomes
spread and produce a wonderful, healthier community and region.

1. What aspects of occupational justice are illustrated in this case study?
2. How might culture impact Yuriko’s daily routine? How might Yuriko’s culture have impacted the
practice of occupational therapy in this case study?
3. What strengths does Yuriko demonstrate? How might these strengths be incorporated into future
therapy sessions?
4. Why were Yuriko’s interactions with the occupational therapy students significant for her and for the
students?
5. What strategies could be employed in the nursing home to facilitate occupational participation and
enhance occupational justice?
REFERENCES
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Index
Page numbers followed by “f” denote figures, “t” denotes tables, and “b” denotes boxes
A Age-related macular degeneration, Archival data, 67

Abuse, 397–398 192, 197 Area health education centers (AHECs),
Academic communities Aging. See also Older adults 201–202
core curriculum courses, 415–418 health and, 214–217, 215t Arena-style evaluation, 135
general education courses, 415 productive, 180, 210 Articles of incorporation, 122, 122b
health promotion in, 410–411 successful, 180 Assertive community treatment (ACT),
Healthy Campus Task Force, 411–412 Aging in place 276t, 280–281
leisure and health courses, 415–418 community support for, 210–211 Assisted living facilities (ALFs)
overview of, 409–410 definition of, 210 accreditation of, 181
populations in, 418 home modifications for, 427–428 client-centered care, 186
psychiatric disabilities, inclusive in naturally occurring retirement goal of, 181
environment for, 412–413 community, 212, 214 individualized services care plan, 183
stroke support group, 413–415 occupational therapy roles in, 214–217 level of care in, 183, 184f
summary of, 418 societal trends that affect, 211–213 regulation of, 181
Accessibility Aging in Place Initiative, 205–207 services provided in, 183
community, 323–324 Aging-friendly communities, 212 Assistive Technology Act of 2004, 57, 346
definition of, 322 Aid for Families with Dependent Assistive technology devices, 346–347
home, 323, 428 Children (AFDC), 258 Assistive technology services, 346–347
Accommodation, 327 Alcohol dependency, 296 Association for Driving Rehabilitation
Accountability, 97 Alcohol use, excessive, 398 Specialists (ADED), 173, 427
Accountability structures, 384 Alcoholics Anonymous (AA), 302, 303b Association for Prevention Teaching and
Accreditation, of assisted living facilities, Alzheimer’s disease, 187 Research (APTR), 28
181 American Association of Children’s Attachment theory, 153, 158
Accreditation Council for Occupational Residential Centers, 155 Attention-deficit/hyperactivity disorder
Therapy Education (ACOTE), 62, 430, American Heart Association BMI (ADHD), 149, 149t, 155
430b–431b guidelines, 395 Audiovisual aids, 75t
Active duty, transitioning to, 249–251 American Occupational Therapy Augmentative and alternative communication
Active engagement, 410 Association (AOTA) (AAC) intervention, 351, 352t
Activities of daily living (ADLs) CARF International and, 181
ergonomics of, 225 Centennial Vision, 2, 12, 31, 387,
evaluation of, 284–285 434 B
examples of, 286t entrepreneur as defined by, 115 Balanced Budget Refinement Act of 1999,
independent living and, 341 Environmental Modification Specialty 193
low vision effects on completion of, 192 Certification, 356 Bariatric surgery, 384–385
Ticket to Work Programs and, 267 Evidence-Based Literature Review Behavior change, for strength development,
Adaptive cycle, 43 Project, 298 14–15
Administrative assessment, 41 history of, 2 Behavior Rating Inventory of Executive
Administrative objectives, 203 Occupational Therapy Code of Ethics Functioning (BRIEF), 152
Adolescents, 391b–392b. See also Children and Ethics Standard, 109–110, Behavioral assessment, 41
and youth 110t–111t, 112, 313, 370 Behavioral objectives, 203
Adult day services centers (ADCs) Occupational Therapy Practice Behavioral rehearsal, 302
care provided by, 182 Framework, 243–244, 415 Benefits analysis, 100
client-centered care, 186 Standards for Continuing Competence, 8 Biopsychosocial approach, 397
goal of, 181 Task Force on Target Populations, 4 Blindness, 192t
health-related model, 183 Americans with Disabilities Act of 1990, Body language, 140
medical model, 183 56–57, 175, 248, 282, 333t, 336 Body mass index (BMI), 395, 426
models of, 182–183 Americans with Disabilities Act Bridge employment, 251–252
social model, 182–183 Amendments Act of 2008, 325 Brief interventions, 298–299
specialized care model, 183 Amplification, 139 Brief office interventions, 400t, 400–401
in United States, 182 Anticipatory principle, 105 Broker-advocate role, in Welfare to Work
Advisory board, 91 Antisocial personality disorder, 314 programs, 262
Advocacy, 58, 75t, 144, 328, 367t, 369 Appreciative inquiry approach, to program Budgeting, 88–89, 128
After school programs (ASPs), 156–159, evaluation, 105 Business concept, 123
157b Architectural barriers, 323 Business goals, 123
Aftercare programs, 297 Architectural Barriers Act, 56, 323 Business plan, 120, 123–124
441
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442 Index
C Client-centered care, 185–186 conceptual models, 273–275

CAGE questionnaire, 301, 398 Client-centered model, 12–13 funding for, 286–287
Canadian Center for Occupational Health Client-centered practice, 341 occupational therapists in, 273, 284,
and Safety (CCOHS), 225 Clinical Prevention and Population Health 285t
Canadian Occupational Performance Curriculum, 28 occupational therapy in
Measure (COPM), 235, 355, 403 Closed-circuit televisions, 195, 198 evaluations, 284–285
Capacity assessment, 67 Cognitive workload, 226, 228 interventions, 285–286, 286t
Capacity building, 212 Cognitive-behavioral therapy, 301 occupation-based approach, 275
Caregivers, 144–145, 187 Collaboration, 90 overview of, 272–273
CARF International, 181 Commission on Social Determinants of psychiatric/psychosocial rehabilitation
CarFit, 37, 176 Health (CSDH), 25 models, 274–275
Carpal tunnel syndrome, 232, 239 Commitment, 39t recovery model, 275, 275b
Carrying, 237b Communication for serious mental illness. See Serious
Case management, 283 interpersonal, 118 mental illness, community-based
Case manager, 7, 283, 285t of program evaluation results, 109 services for
Catalog of Federal Domestic Assistance, 127 technology and environmental stress-vulnerability model, 274
Cataracts, 191–192 interventions for, 351, 352t theoretical models, 273–275
Centennial Vision, 2, 12, 31, 387, 434 Community, 21 Community mental health team, 399
Centers for Independent Living programs, accessibility issues, 323–324 Community mobility
337, 337t aging in place, 215 case study of, 330
Certified aging in place specialist (CAPS), capacity assessment of, 67 consequences of not engaging in, 169
356, 428 definition of, 5 definition of, 168, 324
Certified low vision therapist (CLVT), 193, profiling of, 66–67 description of, 427
194t Community assets, 34 funding for, 173
Challenge grants, 127b Community awareness campaign, 84 interventions for, 174–177
Children and youth Community block development grants organization interventions for, 175–176
evaluation of, 151–152 (CBDGs), 356 personal transportation, 324–325
in foster care system, 340 Community capacity, 34b summary of, 177
health promotion in, occupational Community coalitions, 75t Community model paradigm
therapy contributions to, 391b Community consultation-liaison service, characteristics of, 12–15
independent living services for, 340 316–317 client-centered approach of, 12–13
interventions for Community development, 34b dynamic systems theory, 13–14
case studies of, 160–161 Community empowerment, 75t ecological approach, 14
community-based planning, 153–156 Community ergonomics evidence support, 13
designing of, 152–153 definition of, 225 medical model paradigm versus, 11, 11t
family-based, 155–156 home, 229 occupation-based, 13, 13b
self-regulation, 154 program development for, 239 strength-based, 14–15
social competence, 154–155 recreation sites, 229–230 summary of, 15
task competence, 154–155 sites for, 228–230 Community organization
mental health disorders in, 149t–150t, workplace, 230, 231b, 248 definition of, 33, 75t
149–151 Community forum, 70t models used in, 34–35
after school programs for, 156–159, 157b Community health principles of, 34
summer camps for, 158–159 description of, 21–22 steps of, 35f
temperament in, 150–151, 151b practitioner roles in, 27 strengths-based approach to, 34
transition services for, 424–426 Community health advocate, 6 terms associated with, 34b
wheeled mobility for, 349–350 Community health interventions, 22 Community partnerships, 90–91
Chronic conditions and diseases Community health promotion, 5. See also Community reintegration
description of, 186, 211, 377 Health promotion definition of, 325
mental health comorbidities, 401 Community integration after disability, 322
self-management of, 401–402, 402b case study of, 329 of forensic clients, 311–312
types of, 401 components of, 326b Community service learning, 432–433
Chronic headaches, Lifestyle Redesign definition of, 325 Community support programs (CSPs), 272
program for, 385 description of, 273 Community-based participatory action
Cigarette smoking, 396 leisure, 327 research (CBPAR), 433
CIPP model, 101–102 post-injury or illness, 326–327 Community-based practice
Citizen participation, 34b recreation, 327 Accreditation Council for Occupational
Civic development, 157 work, 327–328 Therapy Education standards for,
Civic engagement, 212 Community integration specialist, 285 430, 430b–431b
Civil Rights Act of 1964, 333, 333b Community Mental Health Act, 272 advocacy activities that support, 58
Civil rights referenced legislation, 56 Community mental health services. See also client’s role in, 112
Civilian employment, transitioning to, Mental health; Mental health disorders definition of, 5
249–251 case study of, 287–288 historical perspective of, 2–4, 3t
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Index 443
obstacles to implementation of, 3–4 Cost-benefit analysis, 93, 100 Driving

paradigm of, 2 Countering, 39t alternatives to, 169–171, 324
research in, 433–434 Courts, 310–311 as instrumental activity of daily living,
roles in, 6–7 Credentialing, of driving rehabilitation 168–169
team-based approach to, 47, 89–90 programs, 173–174 cessation of, 324
theories related to, 33 Criminal justice system contributions of, 168–169
timeline of, 3t cultural dynamics of, 314–315 definition of, 168
trends in, 6–7 description of, 310–311, 311 jobsite analysis, 237b
Community-based practitioners Crisis intervention, 295–296 medical fitness for, 174
characteristics of effective, 7–8 Critical reasoning competencies, 9b statistics regarding, 171
functions of, 11–12 Cues to action, 37 Driving rehabilitation
roles of, 6 Culturally inclusive climates, 156 case studies of, 177–178
Community-centered definition of, 171
initiatives/interventions, 5–6 D interventions for, 174–177, 427
Community-level interventions Daily occupations, 303 organization interventions for, 175–176
definition of, 5 Data analysis and interpretation, 71 populations benefiting from, 427
purpose of, 22 Data collection, 67, 68t–70t, 70–71, 107f Driving rehabilitation program
Competencies, 8, 9b Deficit Reduction Act of 2005, 55 credentialing of, 173–174
Comprehensive Assessment and Solution Deinstitutionalization, 272, 333 development of, 171–174
Process for Aging Residents (CASPAR), Demedicalization, 334 funding of, 173
355 Demographic data, 77 personnel involved in, 173–174
Computers Demographics referral pathways, 171–173, 172b
adaptations for, 353–354 population, 28, 66 Dynamic systems theory, 13–14
equipment and accessories, 238–239 social, 66 Dynamical systems approach, 14
input devices for, 353–354 Denomination, 360 Dysfunctional teams, 90
output devices for, 353 Dental care, 142–143 Dysphoria, 151b
technology and environmental Determinants of health, 23
interventions for accessing of, Developer of support groups role, of health E
352–354 minister, 364b Early intervention programs
universal design in, 353 Developmental delay, 135 components of, 135–136
Concept, 32 Developmental Disabilities Act, 57, 333b definition of, 134
Conceptual model of practice, 33, 33b Developmentally appropriate play, 279 eligibility determination, 135
Conceptual use, 109 Diabetes mellitus evaluation, 135–136
Conduct disorder, 149, 149t description of, 186 identification, 135
Conference grants, 127b Lifestyle Redesign program for, 385 individualized family service plan, 136,
Consciousness-raising, 39t Diabetic retinopathy, 192 136b
Constraint, 151b Diagnostic and Statistical Manual of Mental neuromotor status, 140
Constructivist principle, 105 Disorders, Fifth Edition, 293 occupational therapy evaluations in
Construct, 32 Didactic presentation, 381 description of, 137–138
Consultant, 6–7, 285t Diet support groups, 395 ecological evaluation, 139
Consultant-educator role, in Welfare to Diffusion, 118–119, 434 observations, 138–139
Work programs, 262 Diffusion of innovations, 41–42, 42t, 434 parent interview, 138
Consultation, 6, 367t, 368 Direct care provider role play, 139–140
Consulting grants, 127b in community mental health, 285t occupational therapy interventions
Consumer control, 334, 341 in Welfare to Work programs, 261–262 dental care, 142–143
Consumer referenced legislation, 57 Direct costs, 88–89 description of, 140–141
Consumerism, 334 Direct experience, 381 dressing, 143
Consumer-run businesses, 278 Disability family involvement in, 144
Contingency perspective, 101 age of onset, 267 feeding, 141–142
Continuing care retirement community in aging patients, 168 parent instruction, 144–145
(CCRC), 182, 187–188 employment rates, 243, 264, 327 toilet training, 143–144
Continuing disability reviews (CDRs), 265 Healthy People 2020 health objectives sensory processing status, 140
Continuing support grants, 127b for, 24, 25b societal trends that affect, 134
Contracts, 127 legislation and, 53–57 summary of, 145
Control, of theory, 32 statistics regarding, 322 teams involved in, 135–137
Coping, 151 work transition after, 248–249 transition planning, 137
Coping skills Disability ministry, 366t, 367 Eccentric viewing, 195
spirituality effects on, 361 Disability rights movement, 332 Ecological approach, 14
training in, 304 Domestic violence, 397–398 Ecological assessment, 41
Coping Skills Inventory, 152 Donations, 87 Ecological evaluation, 139
Core curriculum courses, 415–418 Dressing, 143 Ecological health promotion model,
Corporations, 123, 126 Drinker’s check-up (DCU), 301 73–74, 74t
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444 Index
Ecological worldview, 422–423 Environmental Modification Specialty Faith-based interventions, 363, 364t–367t
Ecology of Human Performance Model, Certification, 356 Faith-based organizations
44–46, 45f, 203 Environmental objectives, 203 advocate for, 368–369
Education for All Handicapped Children Environmental referenced legislation, 56–57 board member for, 368–369
Act of 1975, 56, 244, 333b Environmental scan, 125 case study of, 371–372
Education for the Handicapped Act Environmental scanning, 62–63 communications about, 369
Amendments, 54 Epidemiological assessment, 41 community-based occupational therapy
Educational and developmental referenced Epidemiological data, 77 roles in, 368–369
legislation, 54–55 Epidemiology, 20 consultation to, 367t, 368
Educational assessment, 41 Equipment, for program implementation, 86 future directions for, 370–371
Effectuation, 116 ErgoIntelligence Upper Extremity historical background, 360–361
Efficiency evaluations, 98 Assessment, 233 occupational therapy involvement in, 362
Effortful control, 151 Ergonomics types of, 360
Elective noninvolvement, 144 case study of, 239–241 Faith-community nursing
Electronic aid to daily living (EADL), cognitive workload, 226, 228 description of, 364
355 community. See Community ergonomics programs for, 370
Eligibility, 135 comprehensive work-related evaluation Faith-community occupational therapy,
Emotional arousal, 39t of, 235, 236b 364
Emotionality, 151 computer equipment and accessories, Fall prevention
Emotion-related self-regulation, 152 238–239 case studies of, 208–209
Employee assistance programs, 297b, definition of, 224 needs assessment for, 202
297–298 history of, 224–225 programs for
Employment at home, 229 evaluation of, 204–205
bridge, 251–252 in injury prevention, 233–235 implementation of, 204
civilian, transitioning to, 249–251 lifting, 225–226, 227f, 237b planning of, 202–204
legacy planning in, 252 online assessment tools for, 233 sample, 201–207
supported, 276t, 281–282 positioning, 225–226 Family. See also Parents
transitional, 278 posture, 225–226, 226f interventions involving, 155–156
Employment networks, 264–267 psychosocial factors, 228 after school program involvement,
Employment specialist role, 285t at recreation sites, 229–230 157–158
Empowered community, 34b sites for, 228–230 of serious mental illness patients,
Empowerment, 339 sitting, 225–226, 226f, 237b 283–284
Endowment, 127b workplace, 230, 231b, 248 substance abuse effects on, 293, 304
Entrepreneur(s) Erickson’s developmental stage of older Family violence, 397–398
as visionary, 119 adults, 252 Family-centered philosophy, 144
behaviors of, 116 Ethical issues and considerations Fear, 151b
characteristics of, 119–120 in health ministry, 370 Federal policy, 57–58
decision making by, 116 in program evaluation, 109–112, Feedback, 43, 81, 299
definition of, 114–115 110t–111t Feeding, 141–142
description of, 7 Ethical reasoning competencies, 9b Fees for service, 88
entrepreneurial process and, 118 Evaluation Financial planning, for retirement, 251
future oriented, 119 description of, 64 Financing of program. See Funding;
mind-set of, 115 early intervention programs, 135–136 Program financing
occupational therapy, 119–120 ecological, 139 Fit, of theory, 32, 71, 72b
persistence by, 120 levels of, 76, 76t Fixed-route transit systems, 170, 175
personality traits of, 115 program. See Program evaluation Flat fees, 88
research on, 115–118 Evaluation plan, 74, 76–77 Flow, 416
risk taking by, 120 Evaluation research. See Program Focus groups, 70t
skills of, 116 evaluation Food neophobia, 141
social, 117–118 Evidence, 77 Food selectivity, 142
Entrepreneurial events model, 116 Evidence-based decision making, 13 Forecasting, 8
Entrepreneurial mind-set, 115 Evidence-based planning for health, 77 Forensic clients
Entrepreneurial process, 115–118 Evidence-based practitioners, 13 case study of, 318–319
Entrepreneurship Exercise, 396 community agency context for, 315
innovation and, 118–119 Experimental designs, 107–108 community consultation-liaison service
occupational therapy, 119–120 Eye diseases, 191–192 for, 316–317
social, 117–118 community intervention challenges for,
summary of, 129 F 313b, 313–314
Environmental assessment, 41 Face-to-face interview, 68t–69t community reintegration of, 311–312
Environmental control, 39t Faith, Importance, Community, and criminal justice system, 310–311
Environmental modification, 286t, 304, Address assessment, 362 defendants, 311–312
348 Faith communities, 360–361 inmates, 311–312
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mental health recovery movement for, definition of, 4, 26 summary of, 405
315–316 determinants of, 23 teachable moments for, 393
not criminally responsible, 311–312 evidence-based planning for, 77 tobacco use cessation, 396–397
occupational community re-entry with, faith communities and, 360–361 weight loss, 395–396
312–313 national goals for, 22–25 Health risk appraisals, 403
overview of, 309–310 occupations and, 214–217 Health statistics, 20
public safety issues, 313–314 spirituality and, 361 Health-related model adult day services
Forensic mental health system, 311 Health advocate role, of health minister, centers, 183
Formative evaluation, 76, 97, 102 363b Health-related quality of life, 24, 361
For-profit business, 121–124 Health behavior, 36 Healthy Campus 2010: Making It Happen,
Foundations, 127 Health behavior interventions, 36 410, 412
4D Model, 105 Health belief model (HBM), 35, 37, 38f, Healthy Campus Task Force, 411–412
FRAMES model, for brief interventions, 299 202–203, 416 Healthy Generation Model, 187
Free appropriate public education, 134 Health care. See Primary health care Healthy People, 22–23
Funding Health Care Financing Administration, Healthy People 2000, 23
community mental health services, 193 Healthy People 2010, 23, 57
286–287 Health counselor role, of health minister, Healthy People 2020, 23–24, 24b–25b, 28,
driving rehabilitation programs, 173 363b 393, 394t, 410, 411t
grants for, 127 Health disparities, 23 Helping relationships, 39t
health promotion program, 404–405 Health educator role, of health minister, Hierarchy, 14
health promotion projects, 127 363b Home accessibility, 323, 428
home modification, 355–356 Health literacy, 401, 406 Home care agencies, 183
independent living centers, 336 Health ministers, 363b–364b, 363–364 H.O.M.E.-E Principle, 185
program. See Program financing Health ministry Home health care, for serious mental
Welfare to Work programs, 263 definition of, 362 illness, 276t, 277–278
Fund-raising, 93, 125–127 ethical considerations, 370 Home modification(s)
Futurists, 422 examples of, 366t aging-in-place, 427–428
self-care, 370 description of, 354–356
G training and experience for, 369–370
Health promotion and wellness
Home modification process, 354
Home modification product, 354
Games, 75t
in academic communities, 410–411 Homelessness, 279
General education courses, 415
assessment of, 394 Housing
Generality, of theory, 32
brief office interventions for, 400t, permanent supportive, 282–283
Generativity, 252
400–401 transitional, 276t, 279
Glaucoma, 191–192
chronic disease self-management, Howard County Office on Aging,
Goals
401–402, 402b 205–207
definition of, 72, 82
definition of, 21, 409 Hull House, 2
grant, 128b
development of programs for, 402–405, Human agency, 36
objectives for, 73t, 82–83
403f Human Capital approach, 259
setting of, 203
ecological model of, 73–74, 74t Human-factor concepts, 224
writing of, 83–84
family violence, 397–398
Grant
definition of, 127
health literacy interventions for, 401, I
406 Ikigai, 185
description of, 87, 93
Healthy People 2020 objectives related to, Illness management and recovery, 283
goals and objectives, 128b
394t Impact, 76, 76t
Lifestyle Redesign program funding
importance of, 371 Impact evaluations, 98, 100, 107–108
from, 386
independent living programs, 339–340 Impact theory logic model, 106
supporting material with, 129
intimate partner violence, 397–398 Implementation of program. See Program
types of, 127b
low back pain, 397 implementation
Grant application, 129
mental health, 398–400 Impulsivity, 151b
Grant proposals, 128–129
obesity prevention, 426–427 Incidence, 20
Grassroots participation, 34b
occupational therapy contributions to, in Incorporation, 122, 122b
Group processes, 67, 69t–70t
primary health-care settings, 391b– Independence, 185–186
Guilty but mentally ill (GBMI), 310
392b Independent living center (ILC)
occupation-based interventions, 28b budgets of, 342
H practitioner roles in, 27 case study of, 343–344
Habituation subsystems, 43 primary health-care settings, 391b–392b, core services of, 337–338
Headaches, Lifestyle Redesign program for, 393–402 definition of, 334–335
385 purpose of, 393 financial support for, 342
Health smoking cessation, 396–397 funding of, 336
aging and, 214, 215t stages of change applied to, 395 future of, 341–342
communities characteristics and, 214–217 stroke survivors, 413–415 occupational therapy’s role in, 338–341
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Independent living community (ILC), low vision effects on completion of, 192 Joint Commission on Accreditation of
181–183 Ticket to Work programs and, 267 Healthcare Organizations (JCAHO),
Independent living movement Instrumental use, 109 181, 311
advocates of, 334–336 Integration Joint Committee on Standards for
health promotion services, 339–340 community. See Community integration Educational Evaluation, 110
history of, 333–334 definition of, 422
leaders of, 334–336, 335b
legislative acts that influenced, 333b
Integrative health care, 187
Intensive outpatient programs
K
Kawa model of rehabilitation, 371
philosophy of, 334 serious mental illness treated with, 276t,
Key informants, 67, 69t
principles of, 332, 334b, 338–339, 342 276–277
Knowledge competencies, 9b
summary of, 342 substance abuse treated with, 296b,
Kohler’s Taxonomy for Transition
Independent living programs 296–298
Planning, 245
for brain-injured persons, 341 Intermediate-term impact measures, 106–
core services of, 337–338 107
description of, 336 International Classification of Functioning, L
health promotion services, 339–340 Disability and Health, 51 LaLonde Report, 22
for older adults, 340–341 Internet, 342 Laptops, 238–239
special populations-specific services, 340 Interpersonal abilities competencies, 9b Learning objectives, 203
for spinal cord-injured persons, 341 Interpersonal communication, 118 Lecture-discussions, 75t
tertiary prevention focus of, 339 Intervention alignment, 41 Legacy planning, 252
for youth, 340 Interventions Legislation
Independent living skills training, 339 adolescents. See Children and youth, civil rights referenced, 56
Indicators, 107 interventions for consumer referenced, 57
Indirect costs, 89 brief, 298–299 disabilities and, 53–57
Individual placement and support, 281 brief office, 400t, 400–401 educational and developmental
Individual transition plans, 424–425 children. See Children and youth, referenced, 54–55
Individual work plan (IWP), 265 interventions for environmental referenced, 56–57
Individualized education program (IEP), 244 community mobility, 174–177 medical rehabilitation referenced, 55–56
Individualized family service plan(IFSP), community-level, 5, 22 protection and care referenced, 54
136, 136b definition of, 62 summary of, 52b–53b
Individualized services care plan, 183 early. See Early intervention program Leisure, 327
Individualized written independent living effective, 425b Leisure and health courses, 415–418
plan (IWILP), 340 faith-based, 363, 364t–367t Leisure ethic, 415
Individuals with Disabilities Education Act family, 155–156 Lifestyle, 378
of 1990, 54–55, 244 health behavior, 36 Lifestyle Redesign programs
Individuals with Disabilities Education Act low vision, 195–196 case study of, 387
of 2004, 424 strategies, goals and levels of, 423t–424t chronic headaches, 385
Individuals with Disabilities Education technology and environmental. See college students, 385
Improvement Act, 134–135 Technology and environmental components of, 378, 378b
Industrial Revolution, 224 interventions definition of, 378
Infant Neurological International Battery work-related injuries, 236 development of, 379b, 379–380
(INFANIB), 140 youth. See Children and youth, diabetes mellitus, 385
Infant Toddler Sensory Profile, 140 interventions for mental health, 385–386
Infant-Toddler Symptom Checklist, 140 Interview overview of, 377–378
Information seeking, 144 face-to-face, 68t–69t philosophical influences on, 379b, 380
Inhibition, 151b with parents, 138 pressure ulcers, 386
Injury prevention, 233–235 telephone, 69t reimbursement for, 386
Inmates, 311–312 Intimate partner violence, 397–398 since the USC Well Elderly study,
Innovation Intrapreneur, 117 382–386
definition of, 118 Intrapreneurship, 116–117 summary of, 386–387
diffusion of, 434 Intrinsic motivation, 300, 300f theoretical influences on, 379b, 380
entrepreneurship and, 118–119 Introduction, of grant application, 129 for USC Well Elderly study, 381–382,
Insanity acquittees, 310 382b–383b
In-state psychiatric hospitals, 309 J weight management, 383–385
Institutional jail, 314–315 Jakarta Declaration on Leading Health Lifting, 225–226, 227f, 237b
Instrumental activities of daily living Promotion into the 21st Century, 409 Limited liability company(LLC), 121, 123
(IADLs) Job Accommodation Network, 248 Literacy, 401, 406
driving as. See Driving Job coach, 282 Locality development, 34
ergonomics of, 225 Job descriptions, 86 Location, for program implementation,
evaluation of, 284–285 Job Opportunities and Basic Skills (JOBS), 85–86
examples of, 185, 286t 258 Logic models, 97–98, 99f, 106
independent living and, 341 Job retention, 259–260 Longevity revolution, 211
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Low back pain, 232, 397 clinical manifestations of, 398 case studies of, 217t–218t, 217–219
Low vision employment rates affected by, 264 definition of, 212
case study of, 198–199 job retention affected by, 260 description of, 211
community support for, 197 medical comorbidities, 273 healthy, 214
emotional adaptation strategies for, 197 Mental Health Parity and Addiction Equity occupational therapy roles in, 214–217
environmental interventions for, 196 Act of 2008, 287 research evidence on, 214
eye diseases as cause of, 191 Mental Health Services Act (MHSA), 272 Naturally occurring retirement
ICD-9-CM definitions of, 192t Mental Illness Disorder Understanding community-supportive service programs
interventions for, 195–196 Scale (MIDUS), 413 (NORC-SSPs), 212–213
occupational performance and, 192–193 Mental Retardation Facilities and NBCOT Code of Conduct, 110, 110t–
occupational therapy for Community Mental Health Center 111t, 112
billing issues, 197–198 Construction Act of 1963, 55 Needs assessment
description of, 193 Michigan Alcohol Screening Test (MAST), community profiling, 66–67
funding of, 197–198 301 data collection, 67, 68t–70t, 70–71
practice settings, 193–194 Milestones-Outcomes payment system, 265 definition of, 66
referrals for, 194 Military life, 250–251 fall prevention, 202
occupation-specific interventions for, 196 Mission statement, 81–82, 123 health promotion use of, 403
personal interventions for, 195–196 Missionary work, 366t, 367–368 objective of, 98
prevalence of, 191 Mixed methods research, 434 population profiling, 66–67
psychosocial issues associated with, Mobility Neuromotor status, 140
196–197 community. See Community mobility New business, starting a
rehabilitation team for, 193, 194t limitations in, 349 benefits of, 121t
wheeled, 349–351 description of, 120–121
M Model(s) for-profit, 121–124
Macro practice, 34b client-centered, 12–13 incorporation of, 122, 122b
Major depressive disorder, 149–150, 150t, definition of, 32 non-profit. See Non-profit business
399 diffusion of innovations, 41–42, 42t obstacles of, 121t
Maladaptive cycle, 43 Ecology of Human Performance (EHP), steps for starting, 122b
Managerial approach, to program 44–46, 45f, 203 Newborn Behavioral Observations (NBO),
evaluation, 102–103 Health Belief Model (HBM), 35, 37, 140
Manual wheelchairs, 350 38f, 202–203, 416 Nominal group process, 70t
MAP-IT, 24 Person-Environment-Occupation Non-experimental designs, 107
Market assessment, 123 (PEO), 46–47, 47t Non-profit business
Marketing, 124, 404–405 PRECEDE-PROCEED, 35, 40f, 40–41, description of, 121–122
Marketing plan, 84–85 74, 393 fund-raising, 125–127
Mass media, 75t Transtheoretical Model of Health grant writing, 127
Matching grants, 127b Behavior Change, 37–40, 38f, 39t member-supported, 124
Maximum security hospital, 314–315 Model of Human Occupation (MOHO), private foundations, 124
Measurable outcomes, 64 42–44, 44f, 152, 416 public, 124
Mechanistic paradigm, 10 Moral development, 157 service, 124
Medicaid, 55, 58, 173, 258, 286–287, 356 Morningside Protocol, 187 strategic planning, 124–125
Medical model adult day services centers, Motivation, 299 tasks needed for setting up, 124, 125b
183 Motivational enhancement therapy (MET), types of, 124
Medical model paradigm, 11, 11t 301 Not criminally responsible, 311–312
Medical rehabilitation referenced Motivational interviewing, 299–300 Nursing homes, 184–185
legislation, 55–56 Multidisciplinary mental health team, 280
Medicare, 55, 173, 193, 197, 266, 277, Mutual support programs, 302 O
286, 336, 356 Obesity, 383, 395, 426–427
Medication adherence, 400 N Obesogenic, 384
Member-supported non-profit business, National Alliance on Mental Illness Objectives
124 (NAMI), 412 administrative, 203
Mental health. See also Community mental National Association of Home Builders, behavioral, 203
health services 428 environmental, 203
health promotion interventions for, National College Health Assessment, 410 grant, 128b
398–400 National Council on Aging (NCOA), learning, 203
Lifestyle Redesign program for, 385–386 211–212 measurement of, 101
Mental Health Court, 311 National Evaluation of Welfare to Work for program plan, 72, 73t
Mental health disorders. See also strategies, 259 setting of, 203
Community mental health services; Natural environments, 134 strategic, 125
Substance abuse Naturally occurring retirement community writing of, 84
in children and youth, 149t–150t, (NORC) Objectives approach, to program
149–151 aging in place in, 212, 214 evaluation, 101–102
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Observations, 108, 138–139 case study of, 188 parent-child activity group, 155–156
Occupation home care agencies, 183 after school program involvement,
daily, 303 independent living communities, 157–158
definition of, 10 181–183 Parish nurse, 362–363
health promotion interventions based nursing homes, 184–185 Partial hospitalization, for serious mental
on, 28b health promotion in, occupational illness, 276t, 276–277, 286
preventive, 26 therapy contributions to, 392b Participants
substance abuse effects on, 293–295, 294f independent living services for, 340–341 recruitment of, 84–85
therapeutic, 303 life transitions for, 211 space needs of, 85
Occupational alienation, 26b, 429 naturally occurring retirement Participation and relevance, 34b
Occupational delay, 26b community benefits for, 214. See also Participatory approach, to program
Occupational deprivation, 26b, 429 Naturally occurring retirement evaluation, 103–104
Occupational disparities, 26b community (NORC) Partnerships, 90–91, 123, 144
Occupational enablers, 169 population increases in, 211, 427 Pediatric Evaluation of Disability Inventory
Occupational imbalance, 26b, 429 program models for, 181–185 (PEDI), 143
Occupational injustice, 429 self-management for, 211 Peer exchange, 381
Occupational interruption, 26b Olmstead Act, 325 Peer groups, 75t
Occupational justice, 429, 435–437 Online fund-raising, 126 Peer support
Occupational performance, 294f Open-ended questions, 138 independent living programs and
Occupational performance analysis, 236 Operational plan, 125 centers, 338
Occupational profile, 216 Ophthalmologists, 193 for serious mental illness, 276t, 278
Occupational re-engagement, 326 Opportunities Peer support networks, 187
Occupational risks, 232t–234t, 232–233 creating of, in communities, 423–424 Peer-run programs, for serious mental
Occupational self-analysis, 380, 384 recognition of, 116 illness, 276t, 278
Occupational storytelling and story Oppositional defiant disorder (ODD), 149, Perceived barriers, 37
making, 382 150t Perceived benefits, 37
Occupational therapists Optical devices, 195 Perceived severity, 37
compensation for, 6, 115 Optimism, 120 Perceived susceptibility, 37
deinstitutionalization of, 15 Optometrists, 193, 194t Perceived threat, 37
goal of, 361 Ordained ministry, 369 Performance capacity subsystem, 43
role of, 3–4 Organizational development, 75t Performance skills competencies, 9b
salary of, 6, 115 Organizational processes logic model, 106 Permanent supportive housing, 282–283
school to work transition involvement Orientation and mobility specialists, 193, Persistence, 120
by, 244 194t Personal causation, 43
Occupational therapy Outcome evaluations, 98, 216 Personal exploration, 381
as medical discipline, 4 Outcome expectations, 36 Personal Responsibility and Individual
definition of, 4 Outcome indicators, 107 Development for Everyone (PRIDE)
description of, 2 Outcomes Act, 258
focus of, 3, 7–8 definition of, 76, 76t Personal Responsibility and Work
outcome of, 201 determining of, 217 Opportunity Reconciliation Act
paradigm shifts in, 8–11 variables that affect, 100 (PRWORA), 258
practitioners of. See Practitioners Outcomes-Only payment system, 265 Personal transportation, 324–325
process of, 65t Outreach, 367–368 Personality disorders, 314
terminology associated with, 4–6 Personality types, 228, 228t
Occupational Therapy and Rehabilitation, P Person-Environment-Occupational Model,
409 Parachurch organizations, 366t, 367 46–47, 47t, 230
Occupational Therapy Code of Ethics and Paradigm Personnel, 86–87
Ethics Standard (2010), 109–110, community practice, 11–15 Pharmacies, 324
110t–111t, 112, 313, 370 definition of, 8, 33 Physical activity, 396
Occupational therapy educator, 367t ecological, 422–423, 423t Physical Work Performance Evaluation
Occupational Therapy Framework: Domain mechanistic, 10 (PWPE), 235
and Process, 19, 243–244, 415 medical model, 11, 11t Physician extenders, 393
Occupation-based practice, 13, 13b reductionist, 10 Plan
Office of Disability Support Services Paradigm shifts program implementation, 82–84, 83t
(ODSS), 412 definition of, 8 sustainability, 93
Older adults historical examination of, 9–11, 10f Play, 139–140
capacity variations in, 216 in independent living movement, 334 Poetic principle, 105
continuum of care for Paratransit, 169, 175 Policy assessment, 41
adult day services centers. See Adult Parents. See also Family Policy development, 75t
day services centers (ADCs) early intervention program instruction Population
assisted living facilities. See Assisted given to, 144–145 assessment of, 12, 12b
living facilities (ALFs) interview with, 138 demographics of, 28, 66, 211
2580_Index_441-452 16/07/13 3:19 PM Page 449
Index 449
mobility interventions with, 176–177 Process use, 109 Program financing

profiling of, 66–67 Productive aging, See also Aging in place; budgeting, 88–89
service needs of, 66 Older adults fees for service, 88
transportation interventions with, continuum of care for, 181–185, funding sources, 87–88, 93
176–177 182f start-up costs, 87
Positioning, 225–226 definition of, 180, 210 Program grants, 127b
Positive affect/interest, 151b Program Program implementation
Positive play, 155 definition of, 62 equipment, 86
Positive principle, 105 flexibility of, 92 evaluation of, 99–100
Post-traumatic stress disorder (PTSD), management of, 91–92 fall prevention, 204
249, 250t, 328 participants in. See Participants location, 85–86
Posture, 225–226, 226f sustainability of, 92–93 overview of, 80–81
Potty training, 143–144 termination of, 92 participant recruitment, 84–85
Poverty, 134, 257, 263. See also Welfare to Program design personnel, 86–87
Work programs implementation. See Program plan for, 82–84, 83t
Powered wheelchairs, 350 implementation practice regulations, 87
Practice regulations, 87 mission statement, 81–82 space, 85–86
Practitioners Program development staffing, 86–87
community-based, 6–8, 11–12 community ergonomics, 239 supplies, 86
evidence-based, 13 cycle of, 66f Program managers, 7, 85
future challenges for, 15–16 definition of, 62 Program monitoring, 99–100
preparation of, 429–430, 430b, grants for, 87 Program plan
432–433 Program director, 285t development of, 71–77
requirements for, 435 Program efficiency evaluation, 100–101 evaluation plan, 74, 76–77
roles of, 6–7 Program evaluation goals, 72, 82–84
work settings for, 6 in aging in place communities, 216 objectives, 72, 73t, 82–84
PRECEDE-PROCEED model, 35, 40f, appreciative inquiry approach to, 105 strategies, 72–74, 74t
40–41, 74, 393 approaches to, 101–105 Program planning
Pre-feeding program, 142 communicating the results of, 109 client participation in, 63–64
Preplanning, 63, 65–66 data needs for, 106–107 data, 64
Prevalence, 20 definition of, 96 description of, 64–65
Prevention, 21, 339 efficiency-specific, 98, 100–101 evidence, 77
Preventive occupation, 26 ethical issues in, 109–112, 110t–111t fall prevention, 202–204
Primary care medical home, 393 fall prevention, 204–205 performance, 64
Primary care physicians focus of, 97–101 preplanning, 63
definition of, 393 formative, 76, 97, 102 principles of, 63–64
occupational therapy services marketed grant proposal and, 128 priorities, 64
to, 404–405 impact-specific, 98, 100 Program planning process
working with, 404 managerial approach to, 102–103 needs assessment. See Needs assessment
Primary health care methods for, 107–108 occupational therapy process versus,
case study of, 406 needs assessment, 97–98. See also Needs 65t
definition of, 391, 393 assessment overview of, 64–65
health promotion in objectives approach to, 101–102 preplanning, 65–66
development of programs for, outcome-specific, 98 Program qualifications, 82
402–405, 403f participatory approach to, 103–104 Program theory evaluations, 98–99
integration of practices, 400t, program impact, 100 Programs for Assertive Community
400–402 program implementation, 99–100 Treatment (PACT), 276t, 280, 281b
occupational therapy services in program theory, 98–99 Protection and care referenced legislation, 54
funding of, 405 purpose of, 96–97 Protective factors, 20–21
marketing of, 404–405 qualitative approaches to, 108 Psychiatric disabilities, 412–413
Primary health-care settings quantitative approaches to, 107–108 Psychiatric hospitals, 309
health promotion in, 391b–392b, questions used in, 106 Psychiatric nurses, 277
393–400 results, use of, 108–109 Psychiatric/psychosocial rehabilitation
occupational therapy contributions to stakeholders, 97–98, 103, 105–106, models, 274–275
health promotion in, 391b–392b 112 Psychoeducational methods, 155
overview of, 390–391 standards for, 110t–111t Public health
types of, 393 summary of, 112 definition of, 20
Primary prevention, 21, 426 summative, 76, 97 principles of, 20
Principle, 32 utilization-focused approach to, 104b, summary of, 27–28
Private foundations, 124 104–105 Public non-profit business, 124
Private practice owner, 7 utilizing the results of, 108–109 Public safety, 313–314
Process evaluation, 76, 102, 216 Program fidelity, 99 Public transportation, 175, 325
2580_Index_441-452 16/07/13 3:19 PM Page 450
450 Index
Q Self-help manuals, 298 Social competence, 154–155

Qualitative approaches, 102 Self-liberation, 39t Social demographics, 66
Qualitative evaluation, 108 Self-management, 211 Social engagement, 214
Quality of life, 186–187 Self-reevaluation, 39t Social entrepreneurship, 117–118
Quantitative approaches, 102 Self-regulation, 152–153, 159 Social liberation, 39t
Quantitative evaluation, 107–108 Seniors. See Older adults Social marketing, 124
Quasi-experimental designs, 107 Sensory modulation disorders, 154 Social model adult day services centers,
Questionnaires, 68t Sensory modulation programming, 154 182–183
Questions, for program evaluation, 106 Sensory processing, 140, 152 Social planning, 34
Serious and persistent mental illness Social Security Act of 1935, 54–55
(SPMI), 273 Social security disability insurance, 264
R Serious mental illness (SMI) Social stigma, 413
Reasonable accommodations, 282, 325, community-based services for Social support, 22
327–328 family support and education, Social ties, 75t
Reciprocal causation, 73 283–284 Societal levels, 73–74, 75t
Reciprocal determinism, 36 home health care, 276t, 277–278 Software, 353
Recovery model, 275, 275b illness management and recovery, Sole proprietorship, 122
Recreation, 327 283 Solution-focused questions, 138
Reductionism, 10 intensive outpatient programs, 276t, Space, for program implementation,
Reductionist paradigm, 10 276–277 85–86
Re-Entry After Prison/Jail (RAP), 312 overview of, 276t Special-interest groups, 52
Referral advisor role, of health minister, partial hospitalization, 276t, 276–277, Specialized care model adult day services
363b 286 centers, 183
Referral pathways, for driving peer support/peer-run programs, Specialty certification in environmental
rehabilitation, 171–173, 172b 276t, 278 modification (SCEM), 428
Rehabilitation and participation, See also supported education programs, Specialty certification in low vision
Accessibility; Independent living 278–279 (SCLV), 193
movement; Independent living transitional housing, 279 Specialty certified in driving and
programs; Technology and veterans support services, 276t, 279 community mobility (SCDCM), 174
environmental interventions criminal history and, 315 Specialty court, 310–311
Rehabilitation Act of 1973, 56, 333t, 342 description of, 272 Speech language pathologists, 351
Repetitive strain injuries, 232 evidence-based practices for Spinal cord injury clients
Research, 433–434 assertive community treatment, 276t, computer access adaptations for, 354
Research grants, 127b 280–281 independent living programs, 341
Resiliency factors, 20–21 description of, 280 Spirituality, 361–362
Restrooms, 170 permanent supportive housing, Staffing, 86–87
Retirement, transitioning to, 251–252 282–283 Stages of Change model, 37–38, 38f, 39t,
Revised Knox Preschool Play Scale, 140 supported employment, 276t, 299, 304, 305t, 395. See also
Rewards, 39t 281–282 Transtheoretical Model of Health
Risk factors, 20 morbidity rates, 273 Behavior Change (TMHBC)
Risk taking, 120 wellness recovery action plan for, 275 Stakeholders, 64, 97–98, 103, 105–106,
Rule of Rights, 126 Service coordinator, 136 112, 326, 328
Service learning, 87 Start-up costs, 87
S Service non-profit business, 124 Start-up grants, 127b
School to Work Opportunities Act of Service utilization logic model, 106 State-level policy, 57–58
1994, 245 Short Child Occupational Performance Statewide Independent Living Council
School to work transition Evaluation (SCOPE), 151 (SILC), 336
community-based programs for, 245 Short-term impact measures, 106 STEADY As You Go program, 204t, 204–
description of, 244 Simulations, 75t 205
occupational therapy’s role in, Simultaneity principle, 105 Stewardship, 363
244–245 Sitting, 225–226, 226f, 237b Strategic objectives, 125
School to Work Transitions Program, Skill development, 75t Strategic plan, 124–125
245–247, 246t Slagle, Eleanor Clarke, 2, 4 Strategic planning, 124–125
Scientific management, 224 Sliding scale fee, 88 Strategies, for program plan, 72–74, 74t
Secondary data, 67, 68t–69t Small business loans, 126 Strength, 14
Secondary prevention, 21, 426 SMART, 84 Strength-based model, 14–15
Secretaries Commission on Achieving Smoking cessation, 396–397 Stress management, 396
Necessary Skills (SCANS), 246 Sociability, 151b Stress process, 228
Self-assertion, 422–423 Social action, 34 Stress-vulnerability model, 274
Self-care, 140, 370 Social assessment, 41 Stroke support group, 413–415
Self-determination, 245 Social capital, 34b, 214 Student development, 245
Self-efficacy, 36, 155, 299 Social Cognitive Theory (SCT), 35–37, 205 Student-focused planning, 245
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Index 451
Subacute low back pain, 397 Taylorism, 224 instrumental activities of daily living
Substance abuse Teachable moments, 393 and, 267
aftercare programs for, 297 Team lack of awareness about, 266
case study of, 305–306 definition of, 89 limitations of, 266–267
community-based services for, 295b, development of, 89t, 89–90 occupational therapy implications of, 267
295–298 dysfunctional, 90 participation rates in, 266–267
comorbidity with, 292 early intervention programs, 135–137 payment systems, 265
crisis intervention for, 295–296 Technology and environmental summary of, 268
definition of, 293 interventions Tobacco use cessation, 396–397
employee assistance programs for, 297b, advanced-level, 347 Toilet training, 143–144
297–298 case study of, 357 Traits, qualities, and characteristics, 9b
evidence-based practices for communication, 351, 352t Trajectory of change, 43
brief interventions, 298–299 computer access, 352–354 Transdisciplinary Play Based Assessment,
cognitive-behavioral approaches, electronic aids to daily living, 355 Second Edition (TPBA2), 139
301–303 entry-level, 347 Transit systems, 169–170
description of, 298 environmental modification, 348 Transition(s)
motivational approaches, 299 home modifications, 354–356 to active duty, 249–251
motivational enhancement therapy, 301 outcomes of, 347–348 case study of, 253–254
motivational interviewing, 299–300 overview of, 346–347 to civilian employment, 249–251
12-step recovery programs, 302–303, summary of, 356 definition of, 243, 425
303b universal design, 348–349, 349t to retirement, 251–252
family effects of, 293, 304 wheeled mobility, 349–351 school to work. See School to work
high-risk populations for, 298 Technology Related Assistance Act of transition
intensive outpatient programs for, 296b, 1988, 56–57 summary of, 252–253
296–298 Telecommunications Act of 1996, 322 work. See Work transitions
medical crises caused by, 295–296 Telehealth, 323, 428–429 for youth with disabilities, 424–426
occupational therapy in programs for, Telephone interview, 69t Transition planning, 137, 247
303–304 Telerehabilitation, 428–429 Transitional employment, 278
occupations and, 293–295, 294f Temperament, 150–151, 151b Transitional housing, 276t, 279
overview of, 292–293 Temporary Assistance for Needy Families Transitional return to work model, 238
police intervention for, 295 (TANF), 258 Transportation
relapse prevention, 304 Tertiary prevention, 21, 339, 426 alternatives for, 169–170, 325
terminology associated with, 293 Test of Environmental Supports (TOES), personal, 324–325
Substance Abuse and Mental Health 140 public, 325
Services Administration (SAMHSA), Test of Playfulness (ToP), 140 Transportation safety, 325
282–283, 287 Theory Transtheoretical Model of Health Behavior
Substance use disorder, 293 community-based practice, 33 Change (TMHBC), 37–40, 38f, 39t,
Substantial Gainful Activity (SGA), 265 criteria for, 32–33 299, 394
“Success Story,” 109 definition of, 32, 71 Traumatic brain injury (TBI), 249, 250t,
Successful aging, 180 dynamic systems, 13–14 328, 341
Suicide, 149, 249 evaluation of, 98–99 Trend analysis, 63
Summative evaluation, 76, 97 overview of, 31–32 Trends
Summer camps, 158–159 in program plan development, 71–72 definition of, 63
Supervisor, 7, 285t social cognitive, 35–37, 205 identifying of, 119
Supplemental security income, 264, 282 terminology associated with, 32–33 Twelve Step Facilitation (TSF) Therapy,
Supplies, for program implementation, 86 Therapeutic occupations, 303 302
Supported education programs, 278–279 Third-party payers, 287 12-step recovery programs, 302–303, 303b
Supported employment, 276t, 281–282 Throughput, 43
Supportive parenting, 153
Surveys, 67, 68t
Ticket, 264, 266–267
Ticket holders, 264
U
Understanding, of theory, 32
Sustainability, 92–93 Ticket to Work and Work Incentives
Universal design, 230–231, 231t–232t,
SWOT analysis, 125, 126b Improvement Act (TWW/IIA), 248, 264
348–349, 349t, 353
Symbolic use, 109 Ticket to Work Programs
U.S. Department of Veterans Affairs, 279
Systematic reviews, 77, 78b activities of daily living and, 267
Utilization-focused approach, to program
Systems theory, 11, 13–14 background, 264
evaluation, 104b, 104–105
Systems utilization approach, 230 beneficiaries of, 265b, 265–267
benefits of, 265b, 265–266
case study of, 269 V
T employment networks, 264–267 Veterans Health Administration, 193–194,
Tactical Activity Planning (TAP), 251 focus areas for, 264 356
Talent, 14 goal of, 257, 267 Veterans support services, 276t, 279
Task competence, 154–155 implementation process for, 264–265 Vision, low. See Low vision
2580_Index_441-452 16/07/13 3:19 PM Page 452
452 Index
Vision statement, 81 occupational therapist roles in school to work. See School to work
Visual impairment, 192, 192t broker-advocate role, 262 transition
Vocational rehabilitation, 264, 340 consultant-educator role, 262 types of, 243
Volitional subsystem, 43 direct care provider role, 261–262 WorkFirst approach, 259
Volunteer coordinator role, of health occupational therapy in Workforce Investment Act, 55, 336
minister, 364b barriers to, 262–263 Workplace
Volunteerism, 432 description of, 260–261 ergonomics for, 230, 231b, 248
Volunteers, 86, 212, 252, 278 future of, 263–264 jobsite analysis, 237b
participant demographics, 258–259, Work-related injuries
259b case study of, 239–241
W recipient demographics, 258–259, 259b interventions for, 236
Warrior transition units (WTUs), 249 services offered by, 260b–261b, 260–261 objective assessment of, 235–236
Weight loss, 395–396 summary of, 267–268 occupational risks and, 232t–234t,
Weight management Well-being, 26, 180, 341, 410 232–233
Lifestyle Redesign program for, Wellness, 379 return to work, 237–238
383–385 Wellness recovery action plan (WRAP), work location assessment, 236, 237b
medical approach to, 395 275, 285 work modification, 237–238
Welfare Wheelchairs, 350 Work-related skill building, 286t
mothers on, 263 Wheeled mobility, 349–351 World Health Organization
reforms in, 258 Work and industry chronic diseases, 377
Welfare to Work programs community integration, 327–328 evidence evaluation criteria, 77
assessment of, 259 modifications at, 237–238 International Classification of
case study of, 268 Work and Careers Opportunities Program Functioning, Disability and Health, 51
enhancing success in, 260 (WCOP), 246–247 World Institute on Disability (WID), 335
funding of, 263 Work assessments, 285 Wounded Warrior Project, 328
goal of, 257 Work incentives planning assistance
issues related to, 259–260 (WIPA) providers, 265
job retention, 259–260 Work transitions Y
lack of awareness about, 262 after disability, 248–249 Youth. See Children and youth

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2580_FM_i-xxvi 16/07/13 3:18 PM Page i

Copyright © 2014 by F. A. Davis Company

Printed in the United States of America

Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1

Senior Acquisitions Editor: Christa Fratantoro

Library of Congress Cataloging-in-Publication Data

For all those special people

Introduction to the Foreword

Twenty-ﬁve years ago I collaborated on my ﬁrst publication with one of my mentors,

Abigail Baxter, PhD Erin Guillory Caraway, MS OTR

Rebecca I. Estes, PhD, OTR/L, CAPS Susan M. Nochajski, PhD, OTR/L

Theresa Marie Smith, PhD, OTR/L, CLVT Lynn M. Swedberg, MS, OT

Mariana D’Amico, EdD, OTR/L, BCP Catherine McNeil, MS, OTR/L

SECTION I Basic Principles and Relevant Issues 1

Theories Related To Community-Based Practice 33

Chapter 4 Legislation and Policy Issues 51

SECTION II Community-Based Program Development 61

Chapter 6 Program Design and Implementation 80

Chapter 8 Entrepreneurship and Innovation in Occupational Therapy 114

Considerations in Designing Interventions for Children and Youth 152

Chapter 13 Low Vision Services in the Community 191

Role of Occupational Therapy in Community Ergonomics 225

Occupational Therapy in Welfare to Work Programs 260

Chapter 20 Community-Based Approaches for Substance Use Disorders 292

SECTION VII Rehabilitation and Participation 321

Communication Technology 351

Chapter 25 Occupational Therapy in Faith-Based Organizations 359

Lifestyle Redesign for Mental Health 385

SECTION IX Looking Ahead 421

We know what we are, but we know not what we may be.

2 SECTION I | Basic Principles and Relevant Issues

Introduction violence and abuse, and social discrimination

Chapter 1 | Community-Based Practice: Occupation in Context 3

Table 1-1 Historical Timeline of Community Practice in Occupational Therapy

4 SECTION I | Basic Principles and Relevant Issues

Chapter 1 | Community-Based Practice: Occupation in Context 5

Community more appropriately referred to as “community out-

6 SECTION I | Basic Principles and Relevant Issues

Chapter 1 | Community-Based Practice: Occupation in Context 7

8 SECTION I | Basic Principles and Relevant Issues

(Robnett, 1997, p. 30). In addition to the typical • Networking skills

Chapter 1 | Community-Based Practice: Occupation in Context 9

Listed in order of importance ratings Think outside of the box

Kielhofner conducted an historical examination of a daily routine of occupations in a family-like atmos-

10 SECTION I | Basic Principles and Relevant Issues

Emerging Crisis occupational therapy educational programs. Occu-

Chapter 1 | Community-Based Practice: Occupation in Context 11

12 SECTION I | Basic Principles and Relevant Issues

Chapter 1 | Community-Based Practice: Occupation in Context 13

intervention planning, implementation, and Box 1-3 Characteristics of

14 SECTION I | Basic Principles and Relevant Issues

environment and through internal reorganization Ecologically Sound

Chapter 1 | Community-Based Practice: Occupation in Context 15

16 SECTION I | Basic Principles and Relevant Issues

issues follows. Occupational therapy practitioners Learning Activities

Chapter 1 | Community-Based Practice: Occupation in Context 17

18 SECTION I | Basic Principles and Relevant Issues

Public Health, Community Health,

20 SECTION I | Basic Principles and Relevant Issues