Abstract
The fourth edition of the Occupational Therapy Practice Framework: Domain and Process (hereinafter referred to as the OTPF–4), is an official document of the American Occupational Therapy Association (AOTA). Intended for occupational therapy practitioners and students, other health care professionals, educators, researchers, payers, policymakers, and consumers, the OTPF–4 presents a summary of interrelated constructs that describe occupational therapy practice.
Definitions
Within the OTPF–4, occupational therapy is defined as the therapeutic use of everyday life occupations with persons, groups, or populations (i.e., the client) for the purpose of enhancing or enabling participation. Occupational therapy practitioners use their knowledge of the transactional relationship among the client, the client’s engagement in valuable occupations, and the context to design occupation-based intervention plans. Occupational therapy services are provided for habilitation, rehabilitation, and promotion of health and wellness for clients with disability- and non–disability-related needs. These services include acquisition and preservation of occupational identity for clients who have or are at risk for developing an illness, injury, disease, disorder, condition, impairment, disability, activity limitation, or participation restriction (AOTA, 2011; see the glossary in Appendix A for additional definitions).
When the term occupational therapy practitioners is used in this document, it refers to both occupational therapists and occupational therapy assistants (AOTA, 2015b). Occupational therapists are responsible for all aspects of occupational therapy service delivery and are accountable for the safety and effectiveness of the occupational therapy service delivery process. Occupational therapy assistants deliver occupational therapy services under the supervision of and in partnership with an occupational therapist (AOTA, 2020a).
The clients of occupational therapy are typically classified as persons (including those involved in care of a client), groups (collections of individuals having shared characteristics or a common or shared purpose; e.g., family members, workers, students, people with similar interests or occupational challenges), and populations (aggregates of people with common attributes such as contexts, characteristics, or concerns, including health risks; Scaffa & Reitz, 2014). People may also consider themselves as part of a community, such as the Deaf community or the disability community; a community is a collection of populations that is changeable and diverse and includes various people, groups, networks, and organizations (Scaffa, 2019; World Federation of Occupational Therapists [WFOT], 2019). It is important to consider the community or communities with which a client identifies throughout the occupational therapy process.
Whether the client is a person, group, or population, information about the client’s wants, needs, strengths, contexts, limitations, and occupational risks is gathered, synthesized, and framed from an occupational perspective. Throughout the OTPF–4, the term client is used broadly to refer to persons, groups, and populations unless otherwise specified. In the OTPF–4, “group” as a client is distinct from “group” as an intervention approach. For examples of clients, see Table 1 (all tables are placed together at the end of this document). The glossary in Appendix A provides definitions of other terms used in this document.
Examples of Clients: Persons, Groups, and Populations
Note. IDD = intellectual and developmental disabilities; SMI = serious mental illness.
Evolution of This Document
The Occupational Therapy Practice Framework was originally developed to articulate occupational therapy’s distinct perspective and contribution to promoting the health and participation of persons, groups, and populations through engagement in occupation. The first edition of the OTPF emerged from an examination of documents related to the Occupational Therapy Product Output Reporting System and Uniform Terminology for Reporting Occupational Therapy Services (AOTA, 1979). Originally a document that responded to a federal requirement to develop a uniform reporting system, this text gradually shifted to describing and outlining the domains of concern of occupational therapy.
The second edition of Uniform Terminology for Occupational Therapy (AOTA, 1989) was adopted by the AOTA Representative Assembly (RA) and published in 1989. The document focused on delineating and defining only the occupational performance areas and occupational performance components that are addressed in occupational therapy direct services. The third and final edition of Uniform Terminology for Occupational Therapy (UT–III; AOTA, 1994) was adopted by the RA in 1994 and was “expanded to reflect current practice and to incorporate contextual aspects of performance” (p. 1047). Each revision reflected changes in practice and provided consistent terminology for use by the profession.
In fall 1998, the AOTA Commission on Practice (COP) embarked on the journey that culminated in the Occupational Therapy Practice Framework: Domain and Process (AOTA, 2002a). At that time, AOTA also published The Guide to Occupational Therapy Practice (Moyers, 1999), which outlined contemporary practice for the profession. Using this document and the feedback received during the review process for the UT–III, the COP proceeded to develop a document that more fully articulated occupational therapy.
The OTPF is an ever-evolving document. As an official AOTA document, it is reviewed on a 5-year cycle for usefulness and the potential need for further refinements or changes. During the review period, the COP collects feedback from AOTA members, scholars, authors, practitioners, AOTA volunteer leadership and staff, and other stakeholders. The revision process ensures that the OTPF maintains its integrity while responding to internal and external influences that should be reflected in emerging concepts and advances in occupational therapy.
The OTPF was first revised and approved by the RA in 2008. Changes to the document included refinement of the writing and the addition of emerging concepts and changes in occupational therapy. The rationale for specific changes can be found in Table 11 of the OTPF–2 (AOTA, 2008, pp. 665–667).
In 2012, the process of review and revision of the OTPF was initiated again, and several changes were made. The rationale for specific changes can be found on page S2 of the OTPF–3 (AOTA, 2014).
In 2018, the process to revise the OTPF began again. After member review and feedback, several modifications were made and are reflected in this document:
The focus on group and population clients is increased, and examples are provided for both.
Cornerstones of occupational therapy practice are identified and described as foundational to the success of occupational therapy practitioners.
Occupational science is more explicitly described and defined.
The terms occupation and activity are more clearly defined.
For occupations, the definition of sexual activity as an activity of daily living is revised, health management is added as a general occupation category, and intimate partner is added in the social participation category (see Table 2).
The contexts and environments aspect of the occupational therapy domain is changed to context on the basis of the World Health Organization (WHO; 2008) taxonomy from the International Classification of Functioning, Disability and Health (ICF) in an effort to adopt standard, well-accepted definitions (see Table 4).
For the client factors category of body functions, gender identity is now included under “experience of self and time,” the definition of psychosocial is expanded to match the ICF description, and interoception is added under sensory functions.
For types of intervention, “preparatory methods and tasks” has been changed to “interventions to support occupations” (see Table 12).
For outcomes, transitions and discontinuation are discussed as conclusions to occupational therapy services, and patient-reported outcomes are addressed (see Table 14).
Five new tables are added to expand on and clarify concepts:
∘ Table 1. Examples of Clients: Persons, Groups, and Populations
∘ Table 3. Examples of Occupations for Persons, Groups, and Populations
∘ Table 7. Performance Skills for Persons (includes examples of effective and ineffective performance skills)
∘ Table 8. Performance Skills for Groups (includes examples of the impact of ineffective individual performance skills on group collective outcome)
∘ Table 10. Occupational Therapy Process for Persons, Groups, and Populations.
Throughout, the use of OTPF rather than Framework acknowledges the current requirements for a unique identifier to maximize digital discoverability and to promote brevity in social media communications. It also reflects the longstanding use of the acronym in academic teaching and clinical practice.
Figure 1 has been revised to provide a simplified visual depiction of the domain and process of occupational therapy.
Occupations Occupations are “the everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do” (World Federation of Occupational Therapists, 2012a, para. 2). Occupations are categorized as activities of daily living, instrumental activities of daily living, health management, rest and sleep, education, work, play, leisure, and social participation.
Note. CPAP = continuous positive airway pressure.
Examples of Occupations for Persons, Groups, and Populations Persons engage in occupations, and groups engage in shared occupations; populations as a whole do not engage in shared occupations, which happen at the person or group level. Occupational therapy practitioners provide interventions for persons, groups, and populations.
Context: Environmental Factors Context is the broad construct that encompasses environmental factors and personal factors. Environmental factors are aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives.
Occupational Therapy Domain and Process
Vision for This Work
Although this edition of the OTPF represents the latest in the profession’s efforts to clearly articulate the occupational therapy domain and process, it builds on a set of values that the profession has held since its founding in 1917. The original vision had at its center a profound belief in the value of therapeutic occupations as a way to remediate illness and maintain health (Slagle, 1924). The founders emphasized the importance of establishing a therapeutic relationship with each client and designing a treatment plan based on knowledge about the client’s environment, values, goals, and desires (Meyer, 1922). They advocated for scientific practice based on systematic observation and treatment (Dunton, 1934). Paraphrased using today’s lexicon, the founders proposed a vision that was occupation based, client centered, contextual, and evidence based—the vision articulated in the OTPF–4.
Introduction
The purpose of a framework is to provide a structure or base on which to build a system or a concept (“Framework,” 2020). The OTPF describes the central concepts that ground occupational therapy practice and builds a common understanding of the basic tenets and vision of the profession. The OTPF–4 does not serve as a taxonomy, theory, or model of occupational therapy. By design, the OTPF–4 must be used to guide occupational therapy practice in conjunction with the knowledge and evidence relevant to occupation and occupational therapy within the identified areas of practice and with the appropriate clients. In addition, the OTPF–4 is intended to be a valuable tool in the academic preparation of students, communication with the public and policymakers, and provision of language that can shape and be shaped by research.
Occupation and Occupational Science
Embedded in this document is the occupational therapy profession’s core belief in the positive relationship between occupation and health and its view of people as occupational beings. Occupational therapy practice emphasizes the occupational nature of humans and the importance of occupational identity (Unruh, 2004) to healthful, productive, and satisfying living. As Hooper and Wood (2019) stated,
A core philosophical assumption of the profession, therefore, is that by virtue of our biological endowment, people of all ages and abilities require occupation to grow and thrive; in pursuing occupation, humans express the totality of their being, a mind–body–spirit union. Because human existence could not otherwise be, humankind is, in essence, occupational by nature. (p. 46)
Occupational science is important to the practice of occupational therapy and “provides a way of thinking that enables an understanding of occupation, the occupational nature of humans, the relationship between occupation, health and well-being, and the influences that shape occupation” (WFOT, 2012b, p. 2). Many of its concepts are emphasized throughout the OTPF–4, including occupational justice and injustice, identity, time use, satisfaction, engagement, and performance.
OTPF Organization
The OTPF–4 is divided into two major sections: (1) the domain, which outlines the profession’s purview and the areas in which its members have an established body of knowledge and expertise, and (2) the process, which describes the actions practitioners take when providing services that are client centered and focused on engagement in occupations. The profession’s understanding of the domain and process of occupational therapy guides practitioners as they seek to support clients’ participation in daily living, which results from the dynamic intersection of clients, their desired engagements, and their contexts (including environmental and personal factors; Christiansen & Baum, 1997; Christiansen et al., 2005; Law et al., 2005).
“Achieving health, well-being, and participation in life through engagement in occupation” is the overarching statement that describes the domain and process of occupational therapy in its fullest sense. This statement acknowledges the profession’s belief that active engagement in occupation promotes, facilitates, supports, and maintains health and participation. These interrelated concepts include
Health—“a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity” (WHO, 2006, p. 1).
Well-being—“a general term encompassing the total universe of human life domains, including physical, mental, and social aspects, that make up what can be called a ‘good life’” (WHO, 2006, p. 211).
Participation—“involvement in a life situation” (WHO, 2008, p. 10). Participation occurs naturally when clients are actively involved in carrying out occupations or daily life activities they find purposeful and meaningful. More specific outcomes of occupational therapy intervention are multidimensional and support the end result of participation.
Engagement in occupation—performance of occupations as the result of choice, motivation, and meaning within a supportive context (including environmental and personal factors). Engagement includes objective and subjective aspects of clients’ experiences and involves the transactional interaction of the mind, body, and spirit. Occupational therapy intervention focuses on creating or facilitating opportunities to engage in occupations that lead to participation in desired life situations (AOTA, 2008).
Although the domain and process are described separately, in actuality they are linked inextricably in a transactional relationship. The aspects that constitute the domain and those that constitute the process exist in constant interaction with one another during the delivery of occupational therapy services. Figure 1 represents aspects of the domain and process and the overarching goal of the profession as achieving health, well-being, and participation in life through engagement in occupation. Although the figure illustrates these two elements in distinct spaces, in reality the domain and process interact in complex and dynamic ways as described throughout this document. The nature of the interactions is impossible to capture in a static one-dimensional image.
Cornerstones of Occupational Therapy Practice
The transactional relationship between the domain and process is facilitated by the occupational therapy practitioner. Occupational therapy practitioners have distinct knowledge, skills, and qualities that contribute to the success of the occupational therapy process, described in this document as “cornerstones.” A cornerstone can be defined as something of great importance on which everything else depends (“Cornerstone,” n.d.), and the following cornerstones of occupational therapy help distinguish it from other professions:
Core values and beliefs rooted in occupation (Cohn, 2019; Hinojosa et al., 2017)
Knowledge of and expertise in the therapeutic use of occupation (Gillen, 2013; Gillen et al., 2019)
Professional behaviors and dispositions (AOTA 2015a, 2015c)
Therapeutic use of self (AOTA, 2015c; Taylor, 2020).
These cornerstones are not hierarchical; instead, each concept influences the others.
Occupational therapy cornerstones provide a fundamental foundation for practitioners from which to view clients and their occupations and facilitate the occupational therapy process. Practitioners develop the cornerstones over time through education, mentorship, and experience. In addition, the cornerstones are ever evolving, reflecting developments in occupational therapy practice and occupational science.
Many contributors influence each cornerstone. Like the cornerstones, the contributors are complementary and interact to provide a foundation for practitioners. The contributors include, but are not limited to, the following:
Client-centered practice
Clinical and professional reasoning
Competencies for practice
Cultural humility
Ethics
Evidence-informed practice
Inter- and intraprofessional collaborations
Leadership
Lifelong learning
Micro and macro systems knowledge
Occupation-based practice
Professionalism
Professional advocacy
Self-advocacy
Self-reflection
Theory-based practice.
Domain
Exhibit 1 identifies the aspects of the occupational therapy domain: occupations, contexts, performance patterns, performance skills, and client factors. All aspects of the domain have a dynamic interrelatedness. All aspects are of equal value and together interact to affect occupational identity, health, well-being, and participation in life.
Aspects of the Occupational Therapy Domain
All aspects of the occupational therapy domain transact to support engagement, participation, and health. This exhibit does not imply a hierarchy.
Occupational therapists are skilled in evaluating all aspects of the domain, the interrelationships among the aspects, and the client within context. Occupational therapy practitioners recognize the importance and impact of the mind–body–spirit connection on engagement and participation in daily life. Knowledge of the transactional relationship and the significance of meaningful and productive occupations forms the basis for the use of occupations as both the means and the ends of interventions (Trombly, 1995). This knowledge sets occupational therapy apart as a distinct and valuable service (Hildenbrand & Lamb, 2013) for which a focus on the whole is considered stronger than a focus on isolated aspects of human functioning.
The discussion that follows provides a brief explanation of each aspect of the domain. Tables included at the end of the document provide additional descriptions and definitions of terms.
Occupations
Occupations are central to a client’s (person’s, group’s, or population’s) health, identity, and sense of competence and have particular meaning and value to that client. “In occupational therapy, occupations refer to the everyday activities that people do as individuals, in families, and with communities to occupy time and bring meaning and purpose to life. Occupations include things people need to, want to and are expected to do” (WFOT, 2012a, para. 2).
In the OTPF–4, the term occupation denotes personalized and meaningful engagement in daily life events by a specific client. Conversely, the term activity denotes a form of action that is objective and not related to a specific client’s engagement or context (Schell et al., 2019) and, therefore, can be selected and designed to enhance occupational engagement by supporting the development of performance skills and performance patterns. Both occupations and activities are used as interventions by practitioners. For example, a practitioner may use the activity of chopping vegetables during an intervention to address fine motor skills with the ultimate goal of improving motor skills for the occupation of preparing a favorite meal. Participation in occupations is considered both the means and the end in the occupational therapy process.
Occupations occur in contexts and are influenced by the interplay among performance patterns, performance skills, and client factors. Occupations occur over time; have purpose, meaning, and perceived utility to the client; and can be observed by others (e.g., preparing a meal) or be known only to the person involved (e.g., learning through reading a textbook). Occupations can involve the execution of multiple activities for completion and can result in various outcomes.
The OTPF–4 identifies a broad range of occupations categorized as activities of daily living (ADLs), instrumental activities of daily living (IADLs), health management, rest and sleep, education, work, play, leisure, and social participation (Table 2). Within each of these nine broad categories of occupation are many specific occupations. For example, the broad category of IADLs has specific occupations that include grocery shopping and money management.
When occupational therapy practitioners work with clients, they identify the types of occupations clients engage in individually or with others. Differences among clients and the occupations they engage in are complex and multidimensional. The client’s perspective on how an occupation is categorized varies depending on that client’s needs, interests, and contexts. Moreover, values attached to occupations are dependent on cultural and sociopolitical determinants (Wilcock & Townsend, 2019). For example, one person may perceive gardening as leisure, whereas another person, who relies on the food produced from that garden to feed their family or community, may perceive it as work. Additional examples of occupations for persons, groups, and populations can be found in Table 3.
The ways in which clients prioritize engagement in selected occupations may vary at different times. For example, clients in a community psychiatric rehabilitation setting may prioritize registering to vote during an election season and food preparation during holidays. The unique features of occupations are noted and analyzed by occupational therapy practitioners, who consider all components of the engagement and use them effectively as both a therapeutic tool and a way to achieve the targeted outcomes of intervention.
The extent to which a client is engaged in a particular occupation is also important. Occupational therapy practitioners assess the client’s ability to engage in occupational performance, defined as the accomplishment of the selected occupation resulting from the dynamic transaction among the client, their contexts, and the occupation. Occupations can contribute to a well-balanced and fully functional lifestyle or to a lifestyle that is out of balance and characterized by occupational dysfunction. For example, excessive work without sufficient regard for other aspects of life, such as sleep or relationships, places clients at risk for health problems. External factors, including war, natural disasters, or extreme poverty, may hinder a client’s ability to create balance or engage in certain occupations (AOTA, 2017b; McElroy et al., 2012).
Because occupational performance does not exist in a vacuum, context must always be considered. For example, for a client who lives in food desert, lack of access to a grocery store may limit their ability to have balance in their performance of IADLs such as cooking and grocery shopping or to follow medical advice from health care professionals on health management and preparation of nutritious meals. For this client, the limitation is not caused by impaired client factors or performance skills but rather is shaped by the context in which the client functions. This context may include policies that resulted in the decline of commercial properties in the area, a socioeconomic status that does not enable the client to live in an area with access to a grocery store, and a social environment in which lack of access to fresh food is weighed as less important than the social supports the community provides.
Occupational therapy practitioners recognize that health is supported and maintained when clients are able to engage in home, school, workplace, and community life. Thus, practitioners are concerned not only with occupations but also with the variety of factors that disrupt or empower those occupations and influence clients’ engagement and participation in positive health-promoting occupations (Wilcock & Townsend, 2019).
Although engagement in occupations is generally considered a positive outcome of the occupational therapy process, it is important to consider that a client’s history might include negative, traumatic, or unhealthy occupational participation (Robinson Johnson & Dickie, 2019). For example, a person who has experienced a traumatic sexual encounter might negatively perceive and react to engagement in sexual intimacy. A person with an eating disorder might engage in eating in a maladaptive way, deterring health management and physical health.
In addition, some occupations that are meaningful to a client might also hinder performance in other occupations or negatively affect health. For example, a person who spends a disproportionate amount of time playing video games may develop a repetitive stress injury and may have less balance in their time spent on IADLs and other forms of social participation. A client engaging in the recreational use of prescription pain medications may experience barriers to participation in previously important occupations such as work or spending time with family.
Occupations have the capacity to support or promote other occupations. For example, children engage in play to develop the performance skills that later facilitate engagement in leisure and work. Adults may engage in social participation and leisure with an intimate partner that may improve satisfaction with sexual activity. The goal of engagement in sleep and health management includes maintaining or improving performance of work, leisure, social participation, and other occupations.
Occupations are often shared and done with others. Those that implicitly involve two or more individuals are termed co-occupations (Zemke & Clark, 1996). Co-occupations are the most interactive of all social occupations. Central to the concept of co-occupation is that two or more individuals share a high level of physicality, emotionality, and intentionality (Pickens & Pizur-Barnekow, 2009). In addition, co-occupations can be parallel (different occupations in close proximity to others; e.g., reading while others listen to music when relaxing at home) and shared (same occupation but different activities; e.g., preparing different dishes for a meal; Zemke & Clark, 1996).
Caregiving is a co-occupation that requires active participation by both the caregiver and the recipient of care. For the co-occupations required during parenting, the socially interactive routines of eating, feeding, and comforting may involve the parent, a partner, the child, and significant others (Olson, 2004). The specific occupations inherent in this social interaction are reciprocal, interactive, and nested (Dunlea, 1996; Esdaile & Olson, 2004). Consideration of co-occupations by practitioners supports an integrated view of the client’s engagement in the context of relationship to significant others.
Occupational participation can be considered independent whether it occurs individually or with others. It is important to acknowledge that clients can be independent in living regardless of the amount of assistance they receive while completing occupations. Clients may be considered independent even when they direct others (e.g., caregivers) in performing the actions necessary to participate, regardless of the amount or kind of assistance required, if clients are satisfied with their performance. In contrast to definitions of independence that imply direct physical interaction with the environment or objects within the environment, occupational therapy practitioners consider clients to be independent whether they perform the specific occupations by themselves, in an adapted or modified environment, with the use of various devices or alternative strategies, or while overseeing activity completion by others (AOTA, 2002b). For example, a person with spinal cord injury who directs a personal care assistant to assist them with ADLs is demonstrating independence in this essential aspect of their life.
It is also important to acknowledge that not all clients view success as independence. Interdependence, or co-occupational performance, can also be an indicator of personal success. How a client views success may be influenced by their client factors, including their culture.
Contexts
Context is a broad construct defined as the environmental and personal factors specific to each client (person, group, population) that influence engagement and participation in occupations. Context affects clients’ access to occupations and the quality of and satisfaction with performance (WHO, 2008). Practitioners recognize that for people to truly achieve full participation, meaning, and purpose, they must not only function but also engage comfortably within their own distinct combination of contexts.
In the literature, the terms environment and context often are used interchangeably, but this may result in confusion when describing aspects of situations in which occupational engagement takes place. Understanding the contexts in which occupations can and do occur provides practitioners with insights into the overarching, underlying, and embedded influences of environmental factors and personal factors on engagement in occupations.
Environmental Factors
Environmental factors are aspects of the physical, social, and attitudinal surroundings in which people live and conduct their lives (Table 4). Environmental factors influence functioning and disability and have positive aspects (facilitators) or negative aspects (barriers or hindrances; WHO, 2008). Environmental factors include
Natural environment and human-made changes to the environment: Animate and inanimate elements of the natural or physical environment and components of that environment that have been modified by people, as well as characteristics of human populations within that environment. Engagement in human occupation influences the sustainability of the natural environment, and changes to human behavior can have a positive impact on the environment (Dennis et al., 2015).
Products and technology: Natural or human-made products or systems of products, equipment, and technology that are gathered, created, produced, or manufactured.
Support and relationships: People or animals that provide practical physical or emotional support, nurturing, protection, assistance, and connections to other persons in the home, workplace, or school or at play or in other aspects of daily occupations.
Attitudes: Observable evidence of customs, practices, ideologies, values, norms, factual beliefs, and religious beliefs held by people other than the client.
Services, systems, and policies: Benefits, structured programs, and regulations for operations provided by institutions in various sectors of society designed to meet the needs of persons, groups, and populations.
When people interact with the world around them, environmental factors can either enable or restrict participation in meaningful occupations and can present barriers to or supports and resources for service delivery. Examples of environmental barriers that restrict participation include the following:
For persons, doorway widths that do not allow for wheelchair passage
For groups, absence of healthy social opportunities for those abstaining from alcohol use
For populations, businesses that are not welcoming to people who identify as LGBTQ+. (Note: In this document, LGBTQ+ is used to represent the large and diverse communities and individuals with nonmajority sexual orientations and gender identities.)
Addressing these barriers, such as by widening a doorway to allow access, results in environmental supports that enable participation. A client who has difficulty performing effectively in one context may be successful when the natural environment has human-made modifications or if the client uses applicable products and technology. In addition, occupational therapy practitioners must be aware of norms related to, for example, eating or deference to medical professionals when working with someone from a culture or socioeconomic status that differs from their own.
Personal Factors
Personal factors are the unique features of a person that are not part of a health condition or health state and that constitute the particular background of the person’s life and living (Table 5). Personal factors are internal influences affecting functioning and disability and are not considered positive or negative but rather reflect the essence of the person—“who they are.” When clients provide demographic information, they are typically describing personal factors. Personal factors also include customs, beliefs, activity patterns, behavioral standards, and expectations accepted by the society or cultural group of which a person is a member.
Context: Personal Factors Context is the broad construct that encompasses environmental factors and personal factors. Personal factors are the particular background of a person’s life and living and consist of the unique features of the person that are not part of a health condition or health state.
Personal factors are generally considered to be enduring, stable attributes of the person, although some personal factors change over time. They include, but are not limited to, the following:
Chronological age
Sexual orientation (sexual preference, sexual identity)
Gender identity
Race and ethnicity
Cultural identification and attitudes
Social background, social status, and socioeconomic status
Upbringing and life experiences
Habits and past and current behavioral patterns
Psychological assets, temperament, unique character traits, and coping styles
Education
Profession and professional identity
Lifestyle
Health conditions and fitness status (that may affect the person’s occupations but are not the primary concern of the occupational therapy encounter).
For example, siblings share personal factors of race and age, yet for those separated at birth, environmental differences may result in divergent personal factors in terms of cultural identification, upbringing, and life experiences, producing different contexts for their individual occupational engagement. Whether separated or raised together, as siblings move through life, they may develop differences in sexual orientation, life experience, habits, education, profession, and lifestyle.
Groups and populations are often formed or identified on the basis of shared or similar personal factors that make possible occupational therapy assessment and intervention. Of course, individual members of a group or population differ in other personal factors. For example, a group of fifth graders in a community public school are likely to share age and, perhaps, socioeconomic status. Yet race, fitness, habits, and coping styles make each group member unlike the others. Similarly, a population of older adults living in an urban low-income housing community may have few personal factors in common other than age and current socioeconomic status.
Application of Context to Occupational Justice
Interwoven throughout the concept of context is that of occupational justice, defined as “a justice that recognizes occupational rights to inclusive participation in everyday occupations for all persons in society, regardless of age, ability, gender, social class, or other differences” (Nilsson & Townsend, 2010, p. 58). Occupational therapy’s focus on engagement in occupations and occupational justice complements WHO’s (2008) perspective on health. To broaden the understanding of the effects of disease and disability on health, WHO emphasized that health can be affected by the inability to carry out occupations and activities and participate in life situations caused by contextual barriers and by problems that exist in body structures and body functions. The OTPF–4 identifies occupational justice as both an aspect of contexts and an outcome of intervention.
Occupational justice involves the concern that occupational therapy practitioners have with respect, fairness, and impartiality and equitable opportunities when considering the contexts of persons, groups, and populations (AOTA, 2015a). As part of the occupational therapy domain, practitioners consider how these aspects can affect the implementation of occupational therapy and the target outcome of participation. Practitioners recognize that for individuals to truly achieve full participation, meaning, and purpose, they must not only function but also engage comfortably within their own distinct combination of contexts (both environmental factors and personal factors).
Examples of contexts that can present occupational justice issues include the following:
An alternative school placement for children with mental health and behavioral disabilities that provides academic support and counseling but limited opportunities for participation in sports, music programs, and organized social activities
A residential facility for older adults that offers safety and medical support but provides little opportunity for engagement in the role-related occupations that were once a source of meaning
A community that lacks accessible and inclusive physical environments and provides limited services and supports, making participation difficult or even dangerous for people who have disabilities (e.g., lack of screening facilities and services resulting in higher rates of breast cancer among community members)
A community that lacks financial and other necessary resources, resulting in an adverse and disproportionate impact of natural disasters and severe weather events on vulnerable populations.
Occupational therapy practitioners recognize areas of occupational injustice and work to support policies, actions, and laws that allow people to engage in occupations that provide purpose and meaning in their lives. By understanding and addressing the specific justice issues in contexts such as an individual’s home, a group’s shared job site, or a population’s community center, practitioners promote occupational therapy outcomes that address empowerment and self-advocacy.
Performance Patterns
Performance patterns are the acquired habits, routines, roles, and rituals used in the process of engaging consistently in occupations and can support or hinder occupational performance (Table 6). Performance patterns help establish lifestyles (Uyeshiro Simon & Collins, 2017) and occupational balance (e.g., proportion of time spent in productive, restorative, and leisure occupations; Eklund et al., 2017; Wagman et al., 2015) and are shaped, in part, by context (e.g., consistency, work hours, social calendars) and cultural norms (Eklund et al., 2017; Larson & Zemke, 2003).
Performance Patterns Performance patterns are the habits, routines, roles, and rituals that may be associated with different lifestyles and used in the process of engaging in occupations or activities. These patterns are influenced by context and time use and can support or hinder occupational performance.
Time provides an organizational structure or rhythm for performance patterns (Larson & Zemke, 2003); for example, an adult goes to work every morning, a child completes homework every day after school, or an organization hosts a fundraiser every spring. The manner in which people think about and use time is influenced by biological rhythms (e.g., sleep–wake cycles), family of origin (e.g., amount of time a person is socialized to believe should be spent in productive occupations), work and social schedules (e.g., religious services held on the same day each week), and cyclic cultural patterns (e.g., birthday celebration with cake every year, annual cultural festival; Larson & Zemke, 2003). Other temporal factors influencing performance patterns are time management and time use. Time management is the manner in which a person, group, or population organizes, schedules, and prioritizes certain activities (Uyeshiro Simon & Collins, 2017). Time use is the manner in which a person manages their activity levels; adapts to changes in routines; and organizes their days, weeks, and years (Edgelow & Krupa, 2011).
Habits are specific, automatic adaptive or maladaptive behaviors. Habits may be healthy or unhealthy (e.g., exercising on a daily basis vs. smoking during every lunch break), efficient or inefficient (e.g., completing homework after school vs. in the few minutes before the school bus arrives), and supportive or harmful (e.g., setting an alarm clock before going to bed vs. not doing so; Clark, 2000; Dunn, 2000; Matuska & Barrett, 2019).
Routines are established sequences of occupations or activities that provide a structure for daily life; they can also promote or damage health (Fiese, 2007; Koome et al., 2012; Segal, 2004). Shared routines involve two or more people and take place in a similar manner regardless of the individuals involved (e.g., routines shared by parents to promote the health of their children; routines shared by coworkers to sort the mail; Primeau, 2000). Shared routines can be nested in co-occupations. For example, a young child’s occupation of completing oral hygiene with the assistance of an adult is a part of the child’s daily routine, and the adult who provides the assistance may also view helping the young child with oral hygiene as a part of the adult’s own daily routine.
Roles have historically been defined as sets of behaviors expected by society and shaped by culture and context; they may be further conceptualized and defined by a person, group, or population (Kielhofner, 2008; Taylor, 2017). Roles are an aspect of occupational identity—that is, they help define who a person, group, or population believes themselves to be on the basis of their occupational history and desires for the future. Certain roles are often associated with specific activities and occupations; for example, the role of parent is associated with feeding children (Kielhofner, 2008; Taylor, 2017). When exploring roles, occupational therapy practitioners consider the complexity of identity and the limitations associated with assigning stereotypical occupations to specific roles (e.g., on the basis of gender). Practitioners also consider how clients construct their occupations and establish efficient and supportive habits and routines to achieve health outcomes, fulfill their perceived roles and identity, and determine whether their roles reinforce their values and beliefs.
Rituals are symbolic actions with spiritual, cultural, or social meaning. Rituals contribute to a client’s identity and reinforce the client’s values and beliefs (Fiese, 2007; Segal, 2004). Some rituals (e.g., those associated with certain holidays) are associated with different seasons or times of the year (e.g., New Year’s Eve, Independence Day), whereas others are associated with times of the day or days of the week (e.g., daily prayers, weekly family dinners).
Performance patterns are influenced by all other aspects of the occupational therapy domain and develop over time. Occupational therapy practitioners who consider clients’ past and present behavioral and performance patterns are better able to understand the frequency and manner in which performance skills and healthy and unhealthy occupations are, or have been, integrated into clients’ lives. Although clients may have the ability to engage in skilled performance, if they do not embed essential skills in a productive set of engagement patterns, their health, well-being, and participation may be negatively affected. For example, a person may have skills associated with proficient health literacy but not embed them into consistent routines (e.g., a dietitian who consistently chooses to eat fast food rather than prepare a healthy meal) or struggle with modifying daily performance patterns to access health systems effectively (e.g., a nurse who struggles to modify work hours to get a routine mammogram).
Performance Skills
Performance skills are observable, goal-directed actions and consist of motor skills, process skills, and social interaction skills (Fisher & Griswold, 2019; Table 7). The occupational therapist evaluates and analyzes performance skills during actual performance to understand a client’s ability to perform an activity (i.e., smaller aspect of the larger occupation) in natural contexts (Fisher & Marterella, 2019). This evaluation requires analysis of the quality of the individual actions (performance skills) during actual performance. Regardless of the client population, the performance skills defined in this document are universal and provide the foundation for understanding performance (Fisher & Marterella, 2019).
Performance Skills for Persons
Performance skills are observable, goal-directed actions that result in a client’s quality of performing desired occupations. Skills are supported by the context in which the performance occurs, including environmental and client factors (Fisher & Marterella, 2019). Effective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of social interaction performance skills is demonstrated when the client completes interactions in a manner that matches the demands of the social situation. Ineffective use of performance skills is demonstrated when the client routinely requires assistance or support to perform activities or engage in social interactions.
The examples in this table are limited to descriptions of the client’s ability to use each performance skill in an effective or ineffective manner. A client who demonstrates ineffective use of performance skills may be able to successfully complete the entire occupation with the use of occupational or environmental adaptations. Successful occupational performance by the client may be achieved when such adaptions are used.
Note. ATM = automated teller machine; PIN = personal identification number.
Effective use of motor and process performance skills is demonstrated when the client carries out an activity efficiently, safely, with ease, or without assistance. Effective use of social interaction performance skills is demonstrated when the client completes interactions in a manner that matches the demands of the social situation.
Ineffective performance skills are demonstrated when the client routinely requires assistance or support to perform activities or engage in social interaction. Ineffective use of social interaction performance skills is demonstrated when the client engages in social interactions in a manner that does not appropriately meet the demands of the social situation.
Source. From Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
Performance skills can be analyzed for all occupations with clients of any age and level of ability, regardless of the setting in which occupational therapy services are provided (Fisher & Marterella, 2019). Motor and process skills are seen during performance of an activity that involves the use of tangible objects, and social interaction skills are seen in any situation in which a person is interacting with others:
Motor skills refer to how effectively a person moves self or interacts with objects, including positioning the body, obtaining and holding objects, moving self and objects, and sustaining performance.
Process skills refer to how effectively a person organizes objects, time, and space, including sustaining performance, applying knowledge, organizing timing, organizing space and objects, and adapting performance.
Social interaction skills refer to how effectively a person uses both verbal and nonverbal skills to communicate, including initiating and terminating, producing, physically supporting, shaping content of, maintaining flow of, verbally supporting, and adapting social interaction.
For example, when a client catches a ball, the practitioner can analyze how effectively they bend and reach for and then grasp the ball (motor skills). When a client cooks a meal, the practitioner can analyze how effectively they initiate and sequence the steps to complete the recipe in a logical order to prepare the meal in a timely and well-organized manner (process skills). Or when a client interacts with a friend at work, the practitioner can analyze the manner in which the client smiles, gestures, turns toward the friend, and responds to questions (social interaction skills). In these examples, many other motor skills, process skills, and social interaction skills are also used by the client.
By analyzing the client’s performance within an occupation at the level of performance skills, the occupational therapist identifies effective and ineffective use of skills (Fisher & Marterella, 2019). The result of this analysis indicates not only whether the person is able to complete an activity safely and independently but also the amount of physical effort and efficiency the client demonstrates in activities.
After the quality of occupational performance skills has been analyzed, the practitioner speculates about the reasons for decreased quality of occupational performance and determines the need to evaluate potential underlying causes (e.g., occupational demands, environmental factors, client factors; Fisher & Griswold, 2019). Performance skills are different from client factors (see the “Client Factors” section that follows), which include values, beliefs, and spirituality and body structures and functions (e.g., memory, strength) that reside within the person. Occupational therapy practitioners analyze performance skills as a client performs an activity, whereas client factors cannot be directly viewed during the performance of occupations. For example, the occupational therapy practitioner cannot directly view the client factors of cognitive ability or memory when a client is engaged in cooking but rather notes ineffective use of performance skills when the person hesitates to start a step or performs steps in an illogical order. The practitioner may then infer that a possible reason for the client’s hesitation may be diminished memory and elect to further assess the client factor of cognition.
Similarly, context influences the quality of a client’s occupational performance. After analyzing the client’s performance skills while completing an activity, the practitioner can hypothesize how the client factors and context might have influenced the client’s performance. Thus, client factors and contexts converge and may support or limit a person’s quality of occupational performance.
Application of Performance Skills With Persons
When completing the analysis of occupational performance (described in the “Evaluation” section later in this document), the practitioner analyzes the client’s challenges in performance and generates a hypothesis about gaps between current performance and effective performance and the need for occupational therapy services. To plan appropriate interventions, the practitioner considers the underlying reasons for the gaps, which may involve performance skills, performance patterns, and client factors. The hypothesis is generated on the basis of what the practitioner analyzes when the client is actually performing occupations.
Regardless of the client population, the universal performance skills defined in this section provide the foundations for understanding performance (Fisher & Marterella, 2019). The following example crosses many client populations. The practitioner observes as a client rushes through the steps of an activity toward completion. On the basis of what the client does, the practitioner may interpret this rushing as resulting from a lack of impulse control. This limitation may be seen in clients living with anxiety, attention deficit hyperactivity disorder, dementia, traumatic brain injury, and other clinical conditions. The behavior of rushing may be captured in motor performance skills of manipulates, coordinates, or calibrates; in process performance skills of paces, initiates, continues, or organizes; or in social interaction performance skills of takes turn, transitions, times response, or times duration. Understanding the client’s specific occupational challenges enables the practitioner to determine the suitable intervention to address impulsivity to facilitate greater occupational performance. Clinical interventions then address the skills required for the client’s specific occupational demands on the basis of their alignment with the universal performance skills (Fisher & Marterella, 2019). Thus, the application of universal performance skills guides practitioners in developing the intervention plan for specific clients to address the specific concerns occurring in the specific practice setting.
Application of Performance Skills With Groups
Analysis of performance skills is always focused on individuals (Fisher & Marterella, 2019). Thus, when analyzing performance skills with a group client, the occupational therapist always focuses on one individual at a time (Table 8). The therapist may choose to analyze some or all members of the group engaging in relevant group occupations over time as the group members contribute to the collective actions of the group.
Performance Skills for Groups To address performance skills for a group client, occupational therapy practitioners analyze the motor, process, and social interaction skills of individual group members to identify whether ineffective performance skills may limit the group’s collective outcome. Italicized words in the middle column are specific performance skills defined in Table 7.
Source. Performance skill categories are from Powerful Practice: A Model for Authentic Occupational Therapy, by A. G. Fisher and A. Marterella, 2019, Fort Collins, CO: Center for Innovative OT Solutions. Copyright © 2019 by the Center for Innovative OT Solutions. Adapted with permission.
If all members demonstrate effective performance skills, then the group client may achieve its collective outcomes. If one or more group members demonstrate ineffective performance skills, the collective outcomes may be diminished. Only in cases in which group members demonstrate ongoing limitations in performance skills that hinder the collective outcomes of the group would the practitioner recommend interventions for individual group members. Interventions would then be directed at those members demonstrating diminished performance skills to facilitate their contributions to the collective group outcomes.
Application of Performance Skills With Populations
Using an occupation-based approach to population health, occupational therapy addresses the needs of populations by enhancing occupational performance and participation for communities of people (see “Service Delivery” in the “Process” section). Service delivery to populations focuses on aggregates of people rather than on intervention for persons or groups; thus, it is not relevant to analyze performance skills at the person level in service delivery to populations.
Client Factors
Client factors are specific capacities, characteristics, or beliefs that reside within the person, group, or population and influence performance in occupations (Table 9). Client factors are affected by the presence or absence of illness, disease, deprivation, and disability, as well as by life stages and experiences. These factors can affect performance skills (e.g., a client may have weakness in the right arm [a client factor], affecting their ability to manipulate a button [a motor and process skill] to button a shirt; a child in a classroom may be nearsighted [a client factor], affecting their ability to copy from a chalkboard [a motor and process skill]).
Client Factors Client factors include (1) values, beliefs, and spirituality; (2) body functions; and (3) body structures. Client factors reside within the client and influence the client’s performance in occupations.
Note. The categorization of body functions and body structures is based on the ICF (WHO, 2001). The classification was selected because it has received wide exposure and presents a language that is understood by external audiences. ICF = International Classification of Function, Disability and Health; WHO = World Health Organization.
In addition, client factors are affected by occupations, contexts, performance patterns, and performance skills. For example, a client in a controlled and calm environment might be able to problem solve to complete an occupation or activity, but when they are in a louder, more chaotic environment, their ability to process and plan may be adversely affected. It is through this interactive relationship that occupations and interventions to support occupations can be used to address client factors and vice versa.
Values, beliefs, and spirituality influence clients’ motivation to engage in occupations and give their life or existence meaning. Values are principles, standards, or qualities considered worthwhile by the client who holds them. A belief is “something that is accepted, considered to be true, or held as an opinion” (“Belief,” 2020). Spirituality is “a deep experience of meaning brought about by engaging in occupations that involve the enacting of personal values and beliefs, reflection, and intention within a supportive contextual environment” (Billock, 2005, p. 887). It is important to recognize spirituality “as dynamic and often evolving” (Humbert, 2016, p. 12).
Body functions and body structures refer to the “physiological function of body systems (including psychological functions) and anatomical parts of the body such as organs, limbs, and their components,” respectively (WHO, 2008, p. 10). Examples of body functions include sensory, musculoskeletal, mental (affective, cognitive, perceptual), cardiovascular, respiratory, and endocrine functions. Examples of body structures include the heart and blood vessels that support cardiovascular function. Body structures and body functions are interrelated, and occupational therapy practitioners consider them when seeking to promote clients’ ability to engage in desired occupations.
Occupational therapy practitioners understand that the presence, absence, or limitation of specific body functions and body structures does not necessarily determine a client’s success or difficulty with daily life occupations. Occupational performance and client factors may benefit from supports in the physical, social, or attitudinal contexts that enhance or allow participation. It is through the process of assessing clients as they engage in occupations that practitioners are able to determine the transaction between client factors and performance skills; to create adaptations, modifications, and remediation; and to select occupation-based interventions that best promote enhanced participation.
Client factors can also be understood as pertaining to group and population clients and may be used to help define the group or population. Although client factors may be described differently when applied to a group or population, the underlying principles do not change substantively. Client factors of a group or population are explored by performing needs assessments, and interventions might include program development and strategic planning to help the members engage in occupations.
Process
This section operationalizes the process undertaken by occupational therapy practitioners when providing services to clients. Exhibit 2 summarizes the aspects of the occupational therapy process.
Operationalizing the Occupational Therapy Process Ongoing interaction among evaluation, intervention, and outcomes occurs throughout the occupational therapy process.
The occupational therapy process is the client-centered delivery of occupational therapy services. The three-part process includes (1) evaluation and (2) intervention to achieve (3) targeted outcomes and occurs within the purview of the occupational therapy domain (Table 10). The process is facilitated by the distinct perspective of occupational therapy practitioners engaging in professional reasoning, analyzing occupations and activities, and collaborating with clients. The cornerstones of occupational therapy practice underpin the process of service delivery.
Occupational Therapy Process for Persons, Groups, and Populations The occupational therapy process applies to work with persons, groups, and populations. The process for groups and populations mirrors that for persons. The process for populations includes public health approaches, and the process for groups may include both person and population methods to address occupational performance (Scaffa & Reitz, 2014).
Overview of the Occupational Therapy Process
Many professions use a similar process of evaluating, intervening, and targeting outcomes. However, only occupational therapy practitioners focus on the therapeutic use of occupations to promote health, well-being, and participation in life. Practitioners use professional reasoning to select occupations as primary methods of intervention throughout the process. To help clients achieve desired outcomes, practitioners facilitate interactions among the clients, their contexts, and the occupations in which they engage. This perspective is based on the theories, knowledge, and skills generated and used by the profession and informed by available evidence.
Analyzing occupational performance requires an understanding of the complex and dynamic interaction among the demands of the occupation and the client’s contexts, performance patterns, performance skills, and client factors. Occupational therapy practitioners fully consider each aspect of the domain and gauge the influence of each on the others, individually and collectively. By understanding how these aspects influence one another, practitioners can better evaluate how each aspect contributes to clients’ participation and performance-related concerns and potentially to interventions that support occupational performance and participation.
The occupational therapy process is fluid and dynamic, allowing practitioners and clients to maintain their focus on the identified outcomes while continually reflecting on and changing the overall plan to accommodate new developments and insights along the way, including information gained from inter- and intraprofessional collaborations. The process may be influenced by the context of service delivery (e.g., setting, payer requirements); however, the primary focus is always on occupation.
Service Delivery Approaches
Various service delivery approaches are used when providing skilled occupational therapy services, of which intra- and interprofessional collaborations are a key component. It is imperative to communicate with all relevant providers and stakeholders to ensure a collaborative approach to the occupational therapy process. These providers and stakeholders can be within the profession (e.g., occupational therapist and occupational therapy assistant collaborating to work with a student in a school, a group of practitioners collaborating to develop community-based mental health programming in their region) or outside the profession (e.g., a team of rehabilitation and medical professionals on an inpatient hospital unit; a group of employees, human resources staff, and health and safety professionals in a large organization working with an occupational therapy practitioner on workplace wellness initiatives).
Regardless of the service delivery approach, the individual client may not be the exclusive focus of the occupational therapy process. For example, the needs of an at-risk infant may be the initial impetus for intervention, but the concerns and priorities of the parents, extended family, and funding agencies are also considered. Occupational therapy practitioners understand and focus intervention to include the issues and concerns surrounding the complex dynamics among the client, caregiver, family, and community. Similarly, services addressing independent living skills for adults coping with serious mental illness or chronic health conditions may also address the needs and expectations of state and local service agencies and of potential employers.
Direct Services.
Services are provided directly to clients using a collaborative approach in settings such as hospitals, clinics, industry, schools, homes, and communities. Direct services include interventions completed when in direct contact with the client through various mechanisms such as meeting in person, leading a group session, and interacting with clients and families through telehealth systems (AOTA, 2018c).
Examples of person-level direct service delivery include working with an adult on an inpatient rehabilitation unit, working with a child in the classroom while collaborating with the teacher to address identified goals, and working with an adolescent in an outpatient setting. Direct group interventions include working with a cooking group in a skilled nursing facility, working with an outpatient feeding group, and working with a handwriting group in a school. Examples of population-level direct services include implementing a large-scale healthy lifestyle or safe driver initiative in the community and delivering a training program for brain injury treatment facilities regarding safely accessing public transportation. An occupational therapy approach to population health focuses on aggregates or communities of people and the many factors that influence their health and well-being: “Occupational therapy practitioners develop and implement occupation-based health approaches to enhance occupational performance and participation, [quality of life], and occupational justice for populations” (AOTA, 2020b, p. 3).
Indirect Services.
When providing services to clients indirectly on their behalf, occupational therapy practitioners provide consultation to entities such as teachers, multidisciplinary teams, and community planning agencies. For example, a practitioner may consult with a group of elementary school teachers and administrators about opportunities for play during recess to promote health and well-being. A practitioner may also provide consultation on inclusive design to a park district or civic organization to address how the built and natural environments can support occupational performance and engagement. In addition, a practitioner may consult with a business regarding the work environment, ergonomic modifications, and compliance with the Americans With Disabilities Act of 1990 (Pub. L. 101-336).
Occupational therapy practitioners can advocate indirectly on behalf of their clients at the person, group, and population levels to ensure their occupational needs are met. For example, an occupational therapy practitioner may advocate for funding to support the costs of training a service animal for an individual client. A practitioner working with a group client may advocate for meeting space in the community for a peer support group of transgender youth. Examples of population-level advocacy include talking with legislators about improving transportation for older adults, developing services for people with disabilities to support their living and working in the community of their choice, establishing meaningful civic engagement opportunities for underserved youth, and assisting in the development of policies that address inequities in access to health care.
Additional Approaches.
Occupational therapy practitioners use additional approaches that may also be classified as direct or indirect for persons, groups, and populations. Examples include, but are not limited to, case management (AOTA, 2018b), telehealth (AOTA, 2018c), episodic care (Centers for Medicare & Medicaid Services, 2019), and family-centered care approaches (Hanna & Rodger, 2002).
Practice Within Organizations and Systems
Organization- or systems-level practice is a valid and important part of occupational therapy for several reasons. First, organizations serve as a mechanism through which occupational therapy practitioners provide interventions to support participation of people who are members of or served by the organization (e.g., falls prevention programming in a skilled nursing facility, ergonomic changes to an assembly line to reduce musculoskeletal disorders). Second, organizations support occupational therapy practice and practitioners as stakeholders in carrying out the mission of the organization. Practitioners have the responsibility to ensure that services provided to organizational stakeholders (e.g., third-party payers, employers) are of high quality and delivered in an ethical, efficient, and efficacious manner.
Finally, organizations employ occupational therapy practitioners in roles in which they use their knowledge of occupation and the profession of occupational therapy indirectly. For example, practitioners can serve in positions such as dean, administrator, and corporate leader (e.g., CEO, business owner). In these positions, practitioners support and enhance the organization but do not provide occupational therapy services in the traditional sense. Occupational therapy practitioners can also serve organizations in roles such as client advocate, program coordinator, transition manager, service or care coordinator, health and wellness coach, and community integration specialist.
Occupational and Activity Analysis
Occupational therapy practitioners are skilled in the analysis of occupations and activities and apply this important skill throughout the occupational therapy process. Occupational analysis is performed with an understanding of “the specific situation of the client and therefore . . . the specific occupations the client wants or needs to do in the actual context in which these occupations are performed” (Schell et al., 2019, p. 322). In contrast, activity analysis is generic and decontextualized in its purpose and serves to develop an understanding of typical activity demands within a given culture. Many professions use activity analysis, whereas occupational analysis requires the understanding of occupation as distinct from activity and brings an occupational therapy perspective to the analysis process (Schell et al., 2019).
Occupational therapy practitioners analyze the demands of an occupation or activity to understand the performance patterns, performance skills, and client factors that are required to perform it (Table 11). Depending on the purpose of the analysis, the meaning ascribed to and the contexts for performance of and engagement in the occupation or activity are considered either from a client-specific subjective perspective (occupational analysis) or a general perspective within a given culture (activity analysis).
Occupation and Activity Demands Occupation and activity demands are the components of occupations and activities that occupational therapy practitioners consider in their professional and clinical reasoning process. Activity demands are what is typically required to carry out the activity regardless of client and context. Occupation demands are what is required by the specific client (person, group, or population) to carry out an occupation. Depending on the context and needs of the client, occupation and activity demands can act as barriers to or supports for participation. Specific knowledge about activity demands assists practitioners in selecting occupations for therapeutic purposes.
Note. WHO = World Health Organization.
Therapeutic Use of Self
An integral part of the occupational therapy process is therapeutic use of self, in which occupational therapy practitioners develop and manage their therapeutic relationship with clients by using professional reasoning, empathy, and a client-centered, collaborative approach to service delivery (Taylor & Van Puymbrouck, 2013). Occupational therapy practitioners use professional reasoning to help clients make sense of the information they are receiving in the intervention process, discover meaning, and build hope (Taylor, 2019; Taylor & Van Puymbrouck, 2013). Empathy is the emotional exchange between occupational therapy practitioners and clients that allows more open communication, ensuring that practitioners connect with clients at an emotional level to assist them with their current life situation.
Practitioners develop a collaborative relationship with clients to understand their experiences and desires for intervention. The collaborative approach used throughout the process honors the contributions of clients along with practitioners. Through the use of interpersonal communication skills, practitioners shift the power of the relationship to allow clients more control in decision making and problem solving, which is essential to effective intervention. Clients have identified the therapeutic relationship as critical to the outcome of occupational therapy intervention (Cole & McLean, 2003).
Clients bring to the occupational therapy process their knowledge about their life experiences and their hopes and dreams for the future. They identify and share their needs and priorities. Occupational therapy practitioners must create an inclusive, supportive environment to enable clients to feel safe in expressing themselves authentically. To build an inclusive environment, practitioners can take actions such as pursuing education on gender-affirming care, acknowledging systemic issues affecting underrepresented groups, and using a lens of cultural humility throughout the occupational therapy process (AOTA, 2020c; Hammell, 2013).
Occupational therapy practitioners bring to the therapeutic relationship their knowledge about how engagement in occupation affects health, well-being, and participation; they use this information, coupled with theoretical perspectives and professional reasoning, to critically evaluate, analyze, describe, and interpret human performance. Practitioners and clients, together with caregivers, family members, community members, and other stakeholders (as appropriate), identify and prioritize the focus of the intervention plan.
Clinical and Professional Reasoning
Throughout the occupational therapy process, practitioners are continually engaged in clinical and professional reasoning about a client’s occupational performance. The term professional reasoning is used throughout this document as a broad term to encompass reasoning that occurs in all settings (Schell, 2019). Professional reasoning enables practitioners to
Identify the multiple demands, required skills, and potential meanings of the activities and occupations and
Gain a deeper understanding of the interrelationships among aspects of the domain that affect performance and that support client-centered interventions and outcomes.
Occupational therapy practitioners use theoretical principles and models, knowledge about the effects of conditions on participation, and available evidence on the effectiveness of interventions to guide their reasoning. Professional reasoning ensures the accurate selection and application of client-centered evaluation methods, interventions, and outcome measures. Practitioners also apply their knowledge and skills to enhance clients’ participation in occupations and promote their health and well-being regardless of the effects of disease, disability, and occupational disruption or deprivation.
Evaluation
The evaluation process is focused on finding out what the client wants and needs to do; determining what the client can do and has done; and identifying supports and barriers to health, well-being, and participation. Evaluation occurs during the initial and all subsequent interactions with a client. The type and focus of the evaluation differ depending on the practice setting; however, all evaluations should assess the complex and multifaceted needs of each client.
The evaluation consists of the occupational profile and the analysis of occupational performance, which are synthesized to inform the intervention plan (Hinojosa et al., 2014). Although it is the responsibility of the occupational therapist to initiate the evaluation process, both occupational therapists and occupational therapy assistants may contribute to the evaluation, following which the occupational therapist completes the analysis and synthesis of information for the development of the intervention plan (AOTA, 2020a). The occupational profile includes information about the client’s needs, problems, and concerns about performance in occupations. The analysis of occupational performance focuses on collecting and interpreting information specifically to identify supports and barriers related to occupational performance and establish targeted outcomes.
Although the OTPF–4 describes the components of the evaluation process separately and sequentially, the exact manner in which occupational therapy practitioners collect client information is influenced by client needs, practice settings, and frames of reference or practice models. The evaluation process for groups and populations mirrors that for individual clients.
In some settings, the occupational therapist first completes a screening or consultation to determine the appropriateness of a full occupational therapy evaluation (Hinojosa et al., 2014). This process may include
Review of client history (e.g., medical, health, social, or academic records),
Consultation with an interprofessional or referring team, and
Use of standardized or structured screening instruments.
The screening or consultation process may result in the development of a brief occupational profile and recommendations for full occupational therapy evaluation and intervention (Hinojosa et al., 2014).
Occupational Profile
The occupational profile is a summary of a client’s (person’s, group’s, or population’s) occupational history and experiences, patterns of daily living, interests, values, needs, and relevant contexts (AOTA, 2017a). Developing the occupational profile provides the occupational therapy practitioner with an understanding of the client’s perspective and background.
Using a client-centered approach, the occupational therapy practitioner gathers information to understand what is currently important and meaningful to the client (i.e., what the client wants and needs to do) and to identify past experiences and interests that may assist in the understanding of current issues and problems. During the process of collecting this information, the client, with the assistance of the practitioner, identifies priorities and desired targeted outcomes that will lead to the client’s engagement in occupations that support participation in daily life. Only clients can identify the occupations that give meaning to their lives and select the goals and priorities that are important to them. By valuing and respecting clients’ input, practitioners help foster their involvement and can more effectively guide interventions.
Occupational therapy practitioners collect information for the occupational profile at the beginning of contact with clients to establish client-centered outcomes. Over time, practitioners collect additional information, refine the profile, and ensure that the additional information is reflected in changes subsequently made to targeted outcomes. The process of completing and refining the occupational profile varies by setting and client and may occur continuously throughout the occupational therapy process.
Information gathering for the occupational profile may be completed in one session or over a longer period while working with the client. For clients who are unable to participate in this process, their profile may be compiled through interaction with family members or other significant people in their lives. Information for the occupational profile may also be gathered from available and relevant records.
Obtaining information for the occupational profile through both formal and informal interview techniques and conversation is a way to establish a therapeutic relationship with clients and their support network. Techniques used should be appropriate and reflective of clients’ preferred method and style of communication (e.g., use of a communication board, translation services). Practitioners may use AOTA’s Occupational Profile Template as a guide to completing the occupational profile (AOTA, 2017a). The information obtained through the occupational profile contributes to an individualized approach in the evaluation, intervention planning, and intervention implementation stages. Information is collected in the following areas:
Why is the client seeking services, and what are the client’s current concerns relative to engaging in occupations and in daily life activities?
In what occupations does the client feel successful, and what barriers are affecting their success in desired occupations?
What is the client’s occupational history (i.e., life experiences)?
What are the client’s values and interests?
What aspects of their contexts (environmental and personal factors) does the client see as supporting engagement in desired occupations, and what aspects are inhibiting engagement?
How are the client’s performance patterns supporting or limiting occupational performance and engagement?
What are the client’s patterns of engagement in occupations, and how have they changed over time?
What client factors does the client see as supporting engagement in desired occupations, and what aspects are inhibiting engagement (e.g., pain, active symptoms)?
What are the client’s priorities and desired targeted outcomes related to occupational performance, prevention, health and wellness, quality of life, participation, role competence, well-being, and occupational justice?
After the practitioner collects profile data, the occupational therapist views the information and develops a working hypothesis regarding possible reasons for the identified problems and concerns. Reasons could include impairments in performance skills, performance patterns, or client factors or barriers within relevant contexts. In addition, the therapist notes the client’s strengths and supports in all areas because these can inform the intervention plan and affect targeted outcomes.
Analysis of Occupational Performance
Occupational performance is the accomplishment of the selected occupation resulting from the dynamic transaction among the client, their contexts, and the occupation. In the analysis of occupational performance, the practitioner identifies the client’s ability to effectively complete desired occupations. The client’s assets and limitations or potential problems are more specifically determined through assessment tools designed to analyze, measure, and inquire about factors that support or hinder occupational performance.
Multiple methods often are used during the evaluation process to assess the client, contexts, occupations, and occupational performance. Methods may include observation and analysis of the client’s performance of specific occupations and assessment of specific aspects of the client or their performance. The approach to the analysis of occupational performance is determined by the information gathered through the occupational profile and influenced by models of practice and frames of reference appropriate to the client and setting. The analysis of occupational performance involves one or more of the following:
Synthesizing information from the occupational profile to determine specific occupations and contexts that need to be addressed
Completing an occupational or activity analysis to identify the demands of occupations and activities on the client
Selecting and using specific assessments to measure the quality of the client’s performance or performance deficits while completing occupations or activities relevant to desired occupations, noting the effectiveness of performance skills and performance patterns
Selecting and using specific assessments to measure client factors that influence performance skills and performance patterns
Selecting and administering assessments to identify and measure more specifically the client’s contexts and their impact on occupational performance.
Occupational performance may be measured through standardized, formal, and structured assessment tools, and when necessary informal approaches may also be used (Asher, 2014). Standardized assessments are preferred, when available, to provide objective data about various aspects of the domain influencing engagement and performance. The use of valid and reliable assessments for obtaining trustworthy information can also help support and justify the need for occupational therapy services (Doucet & Gutman, 2013; Hinojosa & Kramer, 2014). In addition, the use of standardized outcome performance measures and outcome tools assists in establishing a baseline of occupational performance to allow for objective measurement of progress after intervention.
Synthesis of the Evaluation Process
The occupational therapist synthesizes the information gathered through the occupational profile and analysis of occupational performance. This process may include the following:
Determining the client’s values and priorities for occupational participation
Interpreting the assessment data to identify supports and hindrances to occupational performance
Developing and refining hypotheses about the client’s occupational performance strengths and deficits
Considering existing support systems and contexts and their ability to support the intervention process
Determining desired outcomes of the intervention
Creating goals in collaboration with the client that address the desired outcomes
Selecting outcome measures and determining procedures to measure progress toward the goals of intervention, which may include repeating assessments used in the evaluation process.
Any outcome assessment used by occupational therapy practitioners must be consistent with clients’ belief systems and underlying assumptions regarding their desired occupational performance. Occupational therapy practitioners select outcome assessments pertinent to clients’ needs and goals, congruent with the practitioner’s theoretical model of practice. Assessment selection is also based on the practitioner’s knowledge of and available evidence for the psychometric properties of standardized measures or the rationale and protocols for nonstandardized structured measures. In addition, clients’ perception of success in engaging in desired occupations is a vital part of outcome assessment (Bandura, 1986). The occupational therapist uses the synthesis and summary of information from the evaluation and established targeted outcomes to guide the intervention process.
Intervention
The intervention process consists of services provided by occupational therapy practitioners in collaboration with clients to facilitate engagement in occupation related to health, well-being, and achievement of established goals consistent with the various service delivery models. Practitioners use the information about clients gathered during the evaluation and theoretical principles to select and provide occupation-based interventions to assist clients in achieving physical, mental, and social well-being; identifying and realizing aspirations; satisfying needs; and changing or coping with contextual factors.
Types of occupational therapy interventions are categorized as occupations and activities, interventions to support occupations, education and training, advocacy, group interventions, and virtual interventions (Table 12). Approaches to intervention include create or promote, establish or restore, maintain, modify, and prevent (Table 13). Across all types of and approaches to interventions, it is imperative that occupational therapy practitioners maintain an understanding of the Occupational Therapy Code of Ethics (AOTA, 2015a) and the Standards of Practice for Occupational Therapy (AOTA, 2015c).
Types of Occupational Therapy Interventions Occupational therapy intervention types include occupations and activities, interventions to support occupations, education and training, advocacy, group interventions, and virtual interventions. Occupational therapy interventions facilitate engagement in occupation to enable persons, groups, and populations to achieve health, well-being, and participation in life. The examples provided illustrate the types of interventions that clients engage in (denoted as “client”) and that occupational therapy practitioners provide (denoted as “practitioner”) and are not intended to be all-inclusive.
Note. mHealth = mobile health; PAMs = physical agent modalities.
Approaches to Intervention Approaches to intervention are specific strategies selected to direct the evaluation and intervention processes on the basis of the client’s desired outcomes, evaluation data, and research evidence. Approaches inform the selection of practice models, frames of references, and treatment theories.
Intervention is intended to promote health, well-being, and participation. Health promotion is “the process of enabling people to increase control over, and to improve, their health” (WHO, 1986). Wilcock (2006) stated,
Following an occupation-based health promotion approach to well-being embraces a belief that the potential range of what people can do, be, and strive to become is the primary concern, and that health is a by-product. A varied and full occupational lifestyle will coincidentally maintain and improve health and well-being if it enables people to be creative and adventurous physically, mentally, and socially. (p. 315)
Interventions vary depending on the client—person, group, or population—and the context of service delivery. The actual term used for clients or groups of clients receiving occupational therapy varies among practice settings and delivery models. For example, when working in a hospital, the person or group might be referred to as a patient or patients, and in a school, the clients might be students. Early intervention requires practitioners to work with the family system as their clients. When practitioners provide consultation to an organization, clients may be called consumers or members. Terms used for others who may help or be served indirectly include, but are not limited to, caregiver, teacher, parent, employer, or spouse.
Intervention can also be in the form of collective services to groups and populations. Such intervention can occur as direct service provision or consultation. When consulting with an organization, occupational therapy practitioners may use strategic planning, change agent plans, and other program development approaches. Practitioners addressing the needs of a population direct their interventions toward current or potential diseases or conditions with the goal of enhancing the health, well-being, and participation of all members collectively. With groups and populations, the intervention focus is often on health promotion, prevention, and screening. Interventions may include (but are not limited to) self-management training, educational services, and environmental modification. For instance, occupational therapy practitioners may provide education on falls prevention and the impact of fear of falling to residents in an assisted living center or training to people facing a mental health challenge in use of the internet to identify and coordinate community resources that meet their needs.
Occupational therapy practitioners work with a wide variety of populations experiencing difficulty in accessing and engaging in healthy occupations because of factors such as poverty, homelessness, displacement, and discrimination. For example, practitioners can work with organizations providing services to refugees and asylum seekers to identify opportunities to reestablish occupational roles and enhance well-being and quality of life.
The intervention process is divided into three components: (1) intervention plan, (2) intervention implementation, and (3) intervention review. During the intervention process, the occupational therapy practitioner integrates information from the evaluation with theory, practice models, frames of reference, and research evidence on interventions, including those that support occupations. This information guides the practitioner’s professional reasoning in intervention planning, implementation, and review. Because evaluation is ongoing, revision may occur at any point during the intervention process.
Intervention Plan
The intervention plan, which directs the actions of occupational therapy practitioners, describes the occupational therapy approaches and types of interventions selected for use in reaching clients’ targeted outcomes. The intervention plan is developed collaboratively with clients or their proxies and is directed by
Client goals, values, beliefs, and occupational needs and
Client health and well-being,
as well as by the practitioners’ evaluation of
Client occupational performance needs;
Collective influence of the contexts, occupational or activity demands, and client factors on the client;
Client performance skills and performance patterns;
Context of service delivery in which the intervention is provided; and
Best available evidence.
The occupational therapist designs the intervention plan on the basis of established treatment goals, addressing the client’s current and potential situation related to engagement in occupations or activities. The intervention plan should reflect the priorities of the client, information on occupational performance gathered through the evaluation process, and targeted outcomes of the intervention. Intervention planning includes the following steps:
Developing the plan, which involves selecting
∘ Objective and measurable occupation-based goals and related time frames;
∘ Occupational therapy intervention approach or approaches; and
∘ Methods for service delivery, including what types of interventions will be provided, who will provide the interventions, and which service delivery approaches will be used;
Considering potential discharge needs and plans; and
Making recommendations or referrals to other professionals as needed.
Steps 2 and 3 are discussed in the Outcomes section.
Intervention Implementation
Intervention implementation is the process of putting the intervention plan into action and occurs after the initial evaluation process and development of the intervention plan. Interventions may focus on a single aspect of the occupational therapy domain, such as a specific occupation, or on several aspects of the domain, such as contexts, performance patterns, and performance skills, as components of one or more occupations. Intervention implementation must always reflect the occupational therapy scope of practice; occupational practitioners should not perform interventions that do not use purposeful and occupation-based approaches (Gillen et al., 2019).
Intervention implementation includes the following steps (see Table 12):
Select and carry out the intervention or interventions, which may include the following:
∘ Therapeutic use of occupations and activities
∘ Interventions to support occupations
∘ Education
∘ Training
∘ Advocacy
∘ Self-advocacy
∘ Group intervention
∘ Virtual interventions.
Monitor the client’s response through ongoing evaluation and reevaluation.
Given that aspects of the domain are interrelated and influence one another in a continuous, dynamic process, occupational therapy practitioners expect that a client’s ability to adapt, change, and develop in one area will affect other areas. Because of this dynamic interrelationship, evaluation, including analysis of occupational performance, and intervention planning continue throughout the implementation process. In addition, intervention implementation includes monitoring of the client’s response to specific interventions and progress toward goals.
Intervention Review
Intervention review is the continuous process of reevaluating and reviewing the intervention plan, the effectiveness of its delivery, and progress toward outcomes. As during intervention planning, this process includes collaboration with the client to identify progress toward goals and outcomes. Reevaluation and review may lead to change in the intervention plan. Practitioners should review best practices for using process indicators and, as appropriate, modify the intervention plan and monitor progress using outcome performance measures and outcome tools. Intervention review includes the following steps:
Reevaluating the plan and how it is implemented relative to achieving outcomes
Modifying the plan as needed
Determining the need for continuation or discontinuation of occupational therapy services and for referral to other services.
Outcomes
Outcomes emerge from the occupational therapy process and describe the results clients can achieve through occupational therapy intervention (Table 14). The outcomes of occupational therapy are multifaceted and may occur in all aspects of the domain of concern. Outcomes should be measured with the same methods used at evaluation and determined through comparison of the client’s status at evaluation with the client’s status at discharge or transition. Results of occupational therapy services are established using outcome performance measures and outcome tools.
Outcomes Outcomes are the end result of the occupational therapy process; they describe what clients can achieve through occupational therapy intervention. Some outcomes are measurable and are used for intervention planning and review and discharge planning. These outcomes reflect the attainment of treatment goals that relate to engagement in occupation. Other outcomes are experienced by clients when they have realized the effects of engagement in occupation and are able to return to desired habits, routines, roles, and rituals. Adaptation is embedded in all categories of outcomes. The examples listed specify how the broad outcome of health and participation in life may be operationalized.
Note. AOTA = American Occupational Therapy Association; WHO = World Health Organization.
Outcomes are directly related to the interventions provided and to the targeted occupations, performance patterns, performance skills, client factors, and contexts. Outcomes may be traced to improvement in areas of the domain, such as performance skills and client factors, but should ultimately be reflected in clients’ ability to engage in their desired occupations. Outcomes targeted in occupational therapy can be summarized as
Occupational performance,
Prevention,
Health and wellness,
Quality of life,
Participation,
Role competence,
Well-being, and
Occupational justice.
Occupational adaptation, or the client’s effective and efficient response to occupational and contextual demands (Grajo, 2019), is interwoven through all of these outcomes.
The impact of outcomes and the way they are defined are specific to clients (persons, groups, or populations) and to other stakeholders such as payers and regulators. Outcomes and their documentation vary by practice setting and are influenced by the stakeholders in each setting (AOTA, 2018a).
The focus on outcomes is woven throughout the process of occupational therapy. During evaluation, occupational therapy practitioners and clients (and often others, such as parents and caregivers) collaborate to identify targeted outcomes related to engagement in valued occupations or daily life activities. These outcomes are the basis for development of the intervention plan. During intervention implementation and review, clients and practitioners may modify targeted outcomes to accommodate changing needs, contexts, and performance abilities. Ultimately, the intervention process should result in the achievement of outcomes related to health, well-being, and participation in life through engagement in occupation.
Outcome Measurement
Objective outcomes are measurable and tangible aspects of improved performance. Outcome measurement is sometimes derived from standardized assessments, with results reflected in numerical data following specific scoring instructions. These data quantify a client’s response to intervention in a way that can be used by all relevant stakeholders. Objective outcome measures are selected early in the occupational therapy process on the basis of properties showing that they are
Valid, reliable, and appropriately sensitive to change in the client’s occupational performance,
Consistent with targeted outcomes,
Congruent with the client’s goals, and
Able to predict future outcomes.
Practitioners use objective outcome measures to measure progress and adjust goals and interventions by
Comparing progress toward goal achievement with outcomes throughout the intervention process and
Measuring and assessing results to make decisions about the future direction of intervention (e.g., continue, modify, transition, discontinue, provide follow-up, refer for other service).
In some settings, the focus is on patient-reported outcomes (PROs), which have been defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else” (National Quality Forum, n.d., para. 1). PROs can be used as subjective measures of improved outlook, confidence, hope, playfulness, self-efficacy, sustainability of valued occupations, pain reduction, resilience, and perceived well-being. An example of a PRO is parents’ greater perceived efficacy in parenting through a new understanding of their child’s behavior (Cohn, 2001; Cohn et al., 2000; Graham et al., 2013). Another example is a report by an outpatient client with a hand injury of a reduction in pain during the IADL of doing laundry. “PRO tools measure what patients are able to do and how they feel by asking questions. These tools enable assessment of patient-reported health status for physical, mental, and social well-being” (National Quality Forum, n.d., para. 1).
Outcomes can also be designed for caregivers—for example, improved quality of life for both care recipient and caregiver. Studies of caregivers of people with dementia who received a home environmental intervention found fewer declines in occupational performance, enhanced mastery and skill, improved sense of self-efficacy and well-being, and less need for help with care recipients (Gitlin & Corcoran, 2005; Gitlin et al., 2001, 2003, 2008; Graff et al., 2007; Piersol et al., 2017).
Outcomes for groups that receive an educational intervention may include improved social interaction, increased self-awareness through peer support, a larger social network, or improved employee health and productivity. For example, education interventions for groups of employees on safety and workplace wellness have been shown to decrease work injuries and increase workplace productivity and satisfaction (Snodgrass & Amini, 2017).
Outcomes for populations may address health promotion, occupational justice and self-advocacy, health literacy, community integration, community living, and access to services. As with other occupational therapy clients, outcomes for populations are focused on occupational performance, engagement, and participation. For example, outcomes at the population level as a result of advocacy interventions include construction of accessible playground facilities, improved accessibility for polling places, and reconstruction of a school after a natural disaster.
Transition and Discontinuation
Transition is movement from one life role or experience to another. Transitions in services, like all life transitions, may require preparation, new knowledge, and time to accommodate to the new situation (Orentlicher et al., 2015). Transition planning may be needed, for example, when a client moves from one setting to another along the care continuum (e.g., acute hospital to skilled nursing facility) or ages out of one program and into a new one (e.g., early intervention to elementary school). Collaboration among practitioners is necessary to ensure safety, well-being, and optimal outcomes for clients (Joint Commission, 2012, 2013).
Transition planning may include a referral to a provider within occupational therapy with advanced knowledge and skill (e.g., vestibular rehabilitation, driver evaluation, hand therapy) or outside the profession (e.g., psychologist, optometrist). Transition planning for groups and populations may be needed for a transition from one stage to another (e.g., middle school students in a life skills program who transition to high school) or from one set of needs to another (e.g., older adults in a community falls prevention program who transition to a community exercise program).
Planning for discontinuation of occupational therapy services begins at initial evaluation. Discontinuation of care occurs when the client ends services after meeting short- and long-term goals or chooses to discontinue receiving services (consistent with client-centered care). Safe and effective discharge planning for a person may include education on the use of new equipment, adaptation of an occupation, caregiver training, environmental modification, or determination of the appropriate setting for transition of care. A key goal of discharge planning for individual clients is prevention of readmission (Rogers et al., 2017). Discontinuation of services for groups and populations occurs when goals are met and sustainability plans are implemented for long-term success.
Conclusion
The OTPF–4 describes the central concepts that ground occupational therapy practice and builds a common understanding of the basic tenets and distinct contribution of the profession. The occupational therapy domain and process are linked inextricably in a transactional relationship. An understanding of this relationship supports and guides the complex decision making required in the daily practice of occupational therapy and enhances practitioners’ ability to define the reasons for and justify the provision of services when communicating with clients, family members, team members, employers, payers, and policymakers.
This edition of the OTPF provides a broader view than previous editions of occupational therapy as related to groups and populations and current and future occupational needs of clients. It also presents and describes the cornerstones of occupational therapy practice, which are discrete and critical qualities of occupational therapy practitioners that provide them with a foundation for success in the occupational therapy process. The OTPF–4 highlights the distinct value of occupation and occupational therapy in contributing to health, well-being, and participation in life for persons, groups, and populations. This document can be used to advocate for the importance of occupational therapy in meeting society’s current and future needs, ultimately advancing the profession to ensure a sustainable future.
Authors
Cheryl Boop, MS, OTR/L
Susan M. Cahill, PhD, OTR/L, FAOTA
Charlotte Davis, MS, OTR/L
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA
Varleisha Gibbs, PhD, OTD, OTR/L
Brian Herr, MOT, OTR/L
Kimberly Kearney, COTA/L
Elizabeth “Liz” Griffin Lannigan, PhD, OTR/L, FAOTA
Lizabeth Metzger, MS, OTR/L
Julie Miller, MOT, OTR/L, SWC
Amy Owens, OTR
Krysta Rives, MBA, COTA/L, CKTP
Caitlin Synovec, OTD, OTR/L, BCMH
Wayne L. Winistorfer, MPA, OTR, FAOTA
Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison
Julie Dorsey, OTD, OTR/L, CEAS, FAOTA, Chairperson
Footnotes
Acknowledgments
In addition to those named below, the COP thanks everyone who has contributed to the dialogue, feedback, and concepts presented in the document. Sincerest appreciation is extended to AOTA Staff members Chris Davis, Jennifer Folden, Caroline Polk, and Debbie Shelton for all their support. Further appreciation and thanks are extended to Anne G. Fisher, ScD, OT, FAOTA; Lou Ann Griswold, PhD, OTR/L, FAOTA; and Abbey Marterella, PhD, OTR/L.
The COP wishes to acknowledge the authors of the third edition of this document: Deborah Ann Amini, EdD, OTR/L, CHT, FAOTA, Chairperson, 2011–2014; Kathy Kannenberg, MA, OTR/L, CCM, Chairperson-Elect, 2013–2014; Stefanie Bodison, OTD, OTR/L; Pei-Fen Chang, PhD, OTR/L; Donna Colaianni, PhD, OTR/L, CHT; Beth Goodrich, OTR, ATP, PhD; Lisa Mahaffey, MS, OTR/L, FAOTA; Mashelle Painter, MEd, COTA/L; Michael Urban, MS, OTR/L, CEAS, MBA, CWCE; Dottie Handley-More, MS, OTR/L, SIS Liaison; Kiel Cooluris, MOT, OTR/L, ASD Liaison; Andrea McElroy, MS, OTR/L, Immediate-Past ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison.
The COP wishes to acknowledge the authors of the second edition of this document: Susanne Smith Roley, MS, OTR/L, FAOTA, Chairperson, 2005–2008; Janet V. DeLany, DEd, OTR/L, FAOTA; Cynthia J. Barrows, MS, OTR/L; Susan Brownrigg, OTR/L; DeLana Honaker, PhD, OTR/L, BCP; Deanna Iris Sava, MS, OTR/L; Vibeke Talley, OTR/L; Kristi Voelkerding, BS, COTA/L, ATP; Deborah Ann Amini, MEd, OTR/L, CHT, FAOTA, SIS Liaison; Emily Smith, MOT, ASD Liaison; Pamela Toto, MS, OTR/L, BCG, FAOTA, Immediate-Past SIS Liaison; Sarah King, MOT, OTR, Immediate-Past ASD Liaison; Deborah Lieberman, MHSA, OTR/L, FAOTA, AOTA Headquarters Liaison; with contributions from M. Carolyn Baum, PhD, OTR/L, FAOTA; Ellen S. Cohn, ScD, OTR/L, FAOTA; Penelope A. Moyers Cleveland, EdD, OTR/L, BCMH, FAOTA; and Mary Jane Youngstrom, MS, OTR, FAOTA.
The COP also wishes to acknowledge the authors of the first edition of this document: Mary Jane Youngstrom, MS, OTR, FAOTA, Chairperson (1998–2002); Sara Jane Brayman, PhD, OTR, FAOTA, Chairperson-Elect (2001–2002); Paige Anthony, COTA; Mary Brinson, MS, OTR/L, FAOTA; Susan Brownrigg, OTR/L; Gloria Frolek Clark, MS, OTR/L, FAOTA; Susanne Smith Roley, MS, OTR; James Sellers, OTR/L; Nancy L. Van Slyke, EdD, OTR; Stacy M. Desmarais, MS,OTR/L, ASD Liaison; Jane Oldham, MOTS, Immediate-Past ASCOTA Liaison; Mary Vining Radomski, MA, OTR, FAOTA, SIS Liaison; Sarah D. Hertfelder, MEd, MOT, OTR, FAOTA, National Office Liaison.