Abstract
The U.S. population is aging at an unprecedented rate, creating both opportunities and challenges for the overall health of the nation. Occupational therapy practitioners can inform important health policies by developing an understanding of the basis for relevant laws and programs and how occupational therapy principles relate to policy goals. This column discusses the Older Americans Act of 1965 (reauthorized as the Supporting Older Americans Act of 2020) and describes ways in which the objectives of this legislation align with the principles and practice of occupational therapy. Recommendations are provided for how the field of occupational therapy can enhance current policy development and debate, thus leading to expanded opportunities for the profession.
The United States is experiencing a significant shift in its demographics such that by 2030, it is estimated that 1 in every 5 U.S. residents will be older than age 65, and by 2035, older adults will represent a larger proportion of the population than children (U.S. Census Bureau, 2018). This shift in the demographic composition of the country creates both challenges and opportunities for transformation in the health, economic, and community systems currently in place. Many older adults want to age in place in a familiar environment, thus creating a substantial need for community-based services targeting prevention, health, and wellness (Leland & Elliott, 2012). The growing population of older adults and their increased desire for community-based living and engagement raise the question of the degree to which existing services and funding will be able to keep pace with this population’s changing needs.
The need for attention to and leveraging of community-based services for older adults has never been more apparent. As a result of the coronavirus disease 2019 (COVID-19) pandemic, occupational therapy practitioners currently face complex policy and practice challenges related to the mental health, physical health, and quality of life of older adults. As leaders in promoting health, participation, and community engagement, occupational therapy practitioners are well positioned to improve the health and social services offered to older adults and influence public policy initiatives for healthy aging (American Occupational Therapy Association [AOTA], 2014, 2016; Scriven & Atwal, 2004).
Older Americans Act of 1965
A cornerstone U.S. federal law that addresses the community-based needs of older adults is the Older Americans Act (OAA) of 1965 (Pub. L. 89-73). The OAA has been reauthorized and amended several times (Congressional Research Service, 2018). Reauthorization of legislation provides an opportunity for Congress and advocates to examine its relevancy and identify its strengths and challenges in program effectiveness, and it obligates funding accordingly. Since its authorization in 1965, the OAA has had consistent, robust bipartisan support (Olah & Harvey, 2019). The OAA was slated for reauthorization by September 30, 2019 (Congressional Budget Office, 2018), and on March 25, 2020, it was successfully reauthorized and signed into law as the Supporting Older Americans Act of 2020 (OAA 2020; Pub. L. 116-131). The bill updates funding to programs through fiscal year 2024, providing resources and support to programs for
Caregivers of elderly adults;
Informational services, such as pension counseling;
Nutritional services, such as meal delivery;
Disease prevention and health promotion services;
Community and workforce training regarding elder care; and
Abuse and neglect prevention services.
One of the most relevant revisions to the OAA is recognition of the important negative effects that social isolation and loneliness can have on the health and well-being of older adults. Specifically, the OAA 2020 both extends the RAISE Family Caregivers Act of 2017 (Pub. L. 115-119), which requires the federal government to create a nationwide strategy to support family caregiving, and strengthens the National Family Caregiver Support Program, which provides family caregivers with vital respite care, education, training, and support (Gerontological Society of America, 2020). In addition, updated language highlights the need for access to person-centered, trauma-informed services, as appropriate, and to assistive technology; expands health promotion programs to include infectious disease and vaccine-preventable disease, including sexually transmitted disease; explicitly recommends suicide risk assessment along with depression screenings when appropriate; and targets improving coordination of services, including rehabilitation for fall-related injuries.
Logistically, the OAA 2020 continues to provide policy direction principles and financial support for home- and community-based services for older adults in the United States through discretionary funding programs (Congressional Research Service, 2018). The OAA aims to address older adults’ needs by supporting community-based programs that focus on older adults’ economic stability, health, and housing and prevent age-based discrimination. Figure 1 provides the foundational objectives outlined in the OAA, many of which align well with the domains of occupational therapy practice, as I discuss in the remainder of this article.
Objectives of the Older Americans Act of 1965.
Occupational Therapy’s Alignment With Older Americans Act Initiatives
The foundational vision of the OAA to support the “inherent dignity of the individual in our democratic society” aligns well with the foundational values of occupational therapy practice, research, and advocacy: to promote meaningful participation in daily life and routines for all people regardless of age, ability level, or socioeconomic or cultural background. Specifically, occupational therapy practitioners ultimately focus on participation and enabling engagement through adaptations and modifications to the environment (AOTA, 2014).
Occupational therapy interventions, programs, and practice that target community-based interventions, health promotion, and disability prevention are particularly suited to support initiatives funded through the OAA (AOTA, 2008; Hay et al., 2002). For example, in an effort to ensure independence and dignity for older adults as they age, OAA funding provides financial support and resources for local service coordination and delivery as well as for family and caregiver support. Many of the services provided under the OAA meet several essential needs of vulnerable older adults, including nutritional support, elder abuse prevention, transportation services, and caregiver support. In addition, the OAA supports programs to promote aging in place and prevent social isolation (Congressional Research Service, 2018).
OAA 2020 includes important new language regarding social isolation and loneliness. This revision is particularly important given the current climate, in which many older adults must adhere to curfews, practice social distancing, and avoid community-based contact to mitigate the spread of COVID-19 (Armitage & Nellums, 2020). Strategically harnessing resources and collaborating with OAA-supported programs may be an effective way in which occupational therapy practitioners can work to implement strategies to prevent the social isolation of vulnerable older adults (i.e., facilitate online peer support groups, telehealth cognitive–behavioral therapy for loneliness or general wellness, social networking through community outreach projects). Many of these policy initiatives include occupational therapy practitioners’ domains of expertise in a range of community-based practice settings. In addition, occupational therapy practitioners must continue to develop both research and practice evidence that can inform such policy initiatives and ensure the viability of vital community-based services administered under the OAA.
Strategically collaborating with other key stakeholders to support effective, sustainable programs and policies is a way to advance both occupational therapy policy and program initiatives. This expansion of occupational therapy’s role in interdisciplinary advocacy will not only require outreach to political stakeholders and other health care or social work professionals who may serve as natural allies of such initiatives but will also necessitate engagement among key community-based stakeholders, including local Councils on Aging, community leaders, and advocacy groups. With professional collaboration, innovation, and advocacy, occupational therapy practitioners can continue to influence public policies such as the OAA that are aimed at promoting older adults’ dignity, health, participation, and quality of life.
Recommendations to Integrate Policy Into Practice
As the composition and needs of the older adult population change, the extent to which the OAA can address this population’s health service and program demands is unknown (Herrera et al., 2013; Kunkel, 2019). The intersection of the purposes of the OAA and the principles of occupational therapy provides the profession with the opportunity to play an important role in meeting the OAA’s overall objective of improving older adults’ health and quality of life. As put forth by Hildenbrand and Lamb (2013), occupational therapy practitioners need not change direction, but they should consider innovative solutions to expand occupational therapy’s presence and leadership in emerging areas of policy and practice. Specifically, occupational therapy professionals can leverage their role and work to understand and advocate for older adults’ diverse needs in today’s society. In the sections that follow, I identify educational, research, and policy levers that can be used to strengthen occupational therapy’s contribution to advancing health policy and practice related to meeting the needs of older adults in the United States.
Education
Occupational therapy practitioners are well trained to consider factors at the individual level, yet they are often less prepared to critically evaluate how larger policy-level interventions meet the needs of the populations they serve. With a greater focus on program evaluation, evidence-based policy, and implementation science, educational programs can empower occupational therapy practitioners to become leaders in evaluating the effectiveness of population-level interventions that target improved health and wellness for older adults in various community-based settings. Recommendations to further occupational therapy practitioners’ role are as follows:
Strengthen the focus of advanced training to develop a deeper understanding of upstream (or population, i.e., global, government), intermediate (i.e., environmental, behavioral), and downstream (i.e., disease, individual) factors related to older adults’ health, participation, and quality of life.
Identify emerging practice areas in which occupational therapy can improve participation, health, and quality of life through community-based interventions for older adults.
Increase awareness of a broader range of public policy that is not directly related to health but has the potential for significant health implications (i.e., public policies such as those relating to transportation, employment, and environment).
Develop fluency in policy-level language to frame both problems and solutions directed at improving practitioners’ ability to effectively communicate occupational therapy–driven initiatives to a wide range of key stakeholders.
Research
Research is powerful and can be used to influence evidence-based practice and the establishment of evidence-based policy. As such, occupational therapy researchers must use innovative methodologies to understand and inform approaches to improve older adults’ health, quality of life, and participation. Recommendations to further the field of occupational therapy research are as follows:
Expand the profession’s research priorities to focus on population-level outcomes that align with health policy directions, including community-based initiatives.
Continue to capitalize on the profession’s distinct occupation-based and client-centered perspective when developing research aims and objectives.
Strategically develop multidisciplinary research teams to ensure feasibility and sustainability of occupational therapy–led interventions and strategies emerging from scholarly work.
Continue to explore systematic ways in which occupational therapy practitioners can promote better living for older adults by reducing environmental barriers (both physical and social) to promote access and accessibility, safety, and participation through community-based, implementation science research.
Policy
Occupational therapy practitioners are strong advocates and natural allies of policymakers working to achieve improved health for the nation and society. Occupational therapy practitioners can influence relevant initiatives by bringing occupational therapy principles into discussions that encourage key stakeholders to focus policy development and implementation on meaningful social, environmental, and occupation-based factors. Recommendations to further occupational therapy’s role are as follows:
Explicitly identify policy targets using a sociocultural lens to promote inclusive strategies that address the needs of vulnerable marginalized client populations.
Partner with related professional organizations that represent a diverse set of stakeholders to support legislation, including amendments to OAA 2020, to further promote older adults’ dignity, health, participation, and quality of life.
Increase the recognition of occupational therapy practitioners as important agents of social and economic change by becoming more politically active and demonstrating the effectiveness of occupational therapy in promoting health, participation, and quality of life for all older adults, including those who are socially excluded.
Conclusion
Given the health service and community needs of older adults in the United States, occupational therapy practitioners have a clear opportunity to emerge as leaders in promoting innovative practice and policy solutions to ensure the health, participation, and community engagement of this growing and increasingly diverse population. Occupational therapy principles and theories significantly align with and have the strength to inform and shape health policy debate and development. To improve community-based, population-level outcomes for older adults, a professional commitment to addressing health and environmental factors will require community partnership; sustainable interventions; and awareness of potential social justice and inequality issues in terms of access, use, and feasibility. A continued focus of U.S. educational, policy, and research programs on the evolving needs of older adults aging in the 21st century will be imperative in ensuring health and dignity for all. Last, in the larger political atmosphere the profession of occupational therapy must remain diligent in participating in policy debates on and advocating for investments in community-based programs and services such as those funded through the OAA.
Footnotes
Acknowledgment
I thank Mary Barnes for her contributions and perspective on alignment of recommendations presented in this article with foundational curricular and practice aims in the field of occupational therapy. I have no conflicts of interest or funding sources to report for this work.