THE ISSUE IS . . .

Integration of Medication Management Into Occupational

Therapy Practice

Jaclyn K. Schwartz, Roger O. Smith

Occupational therapy practitioners enable clients to improve performance in everyday occupations. As health
care reform precipitates changes across health care service organizations, occupational therapy professionals
must seize the opportunity to apply their unique skills and perspective to meet the changing needs of clients
and other stakeholders. In this article, we explore the role and distinct value of occupational therapy
practitioners in one area of changing need: medication management. We find that occupational therapy
practitioners have unique skills that complement the factors affecting medication nonadherence and evidence-
based interventions. With reforms to research, teaching, and practice, occupational therapy practitioners can
better integrate medication management into regular evaluation and treatment, thereby contributing to broader
patient outcomes defined by the Affordable Care Act.

Schwartz, J. K., & Smith, R. O. (2017). The Issue Is—Integration of medication management into occupational therapy
practice. American Journal of Occupational Therapy, 71, 7104360010. https://doi.org/10.5014/ajot.2017.015032

Jaclyn K. Schwartz, PhD, OTR/L, is Assistant
Professor, Department of Occupational Therapy, Nicole
Wertheim College of Nursing and Health Sciences,
Florida International University, Miami;
jaclyn.schwartz@fiu.edu
Roger O. Smith, PhD, OT, FAOTA, RESNA Fellow,
is Professor, Department of Occupational Science and
Technology, College of Health Sciences, and Director,
Rehabilitation Research Design and Disability Center,
University of Wisconsin–Milwaukee.
I n 2010, Congress passed the Patient
Protection and Affordable Care Act
(ACA; Pub. L. 111–148). The ACA shifted
the focus of health care from healing the
sick to the “Triple Aim” of improving
health experiences, promoting population
health, and reducing the cost of care
(Berwick, Nolan, & Whittington, 2008).
The ACA provides occupational ther-
apy practitioners with many opportuni-
ties, including allowing the profession to
broaden its scope of influence. However,
occupational therapy policy experts warn
that there are also risks. For example, oc-
cupational therapy may not be seen as a
part of health care reform and therefore
may not be fully integrated into future
systems of care (Fisher & Friesema, 2013;
Leland, Crum, Phipps, Roberts, & Gage,
2015). Subsequently, policy experts call
on occupational therapy professionals to
better describe the profession’s distinct
value and contributions to broader patient
outcomes.
In this article, we provide a response
to the experts by exploring the role of
occupational therapy in medication man-
agement. Through this process, we seek to
accomplish three goals: (1) define medi-
cation management and understand its
importance within the scope of health
care reform, (2) describe the distinct value
of occupational therapy within the con-
text of medication management, and (3)
understand the changes needed to help
the profession reach full potential as a
service provider in this area. Through
this discussion, we seek to inform stake-
holders and occupational therapy practi-
tioners to improve provision of medication
management services.
Defining Medication Management
Medication management is an inter-
professional issue that includes pre-
scribers, nurses, pharmacists, occupational
therapy practitioners, and related techni-
cians and assistants. Each profession has
essential and irreplaceable duties as well as
an individualized definition of medica-
tion management (Bluml, 2005). In this
article, we discuss medication manage-
ment as it relates to occupational therapy
practitioners.
Within occupational therapy, medi-
cation management refers to the daily sys-
tems and processes of taking medications

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 as prescribed (American Occupational
Therapy Association, 2017; Sanders &
Van Oss, 2013). A brief activity analysis
reveals that to manage one medication, a
client must negotiate with the physician for
a prescription, fill the prescription at the
pharmacy, interpret complicated health
information, take the medication on a
daily basis, and refill the prescription
in a timely manner. Occupational therapy
practitioners cannot prescribe medications or
alter the medical advice from a physician or
pharmacist, but they can help clients better
navigate many of the tasks associated with
medication management.
Medication adherence is defined as “the
extent to which a person’s behavior—
taking medication . . . corresponds
with the agreed recommendations from
a healthcare provider” (World Health
Organization [WHO], 2003, p. 2). Med-
ication adherence is often described as a
percentage, indicating the ratio of pills
consumed over those prescribed. An ad-
herence rate of 100% indicates perfect ad-
herence, with higher numbers indicating
overdosing and lower numbers indicat-
ing underdosing. The goal of medication
management intervention is to help clients
attain perfect (or near perfect) medication
adherence.
Occupational Therapy’s Distinct
Value in Medication Management
As demonstrated by the activity analysis,
clients’ medication adherence is related to
their ability to manage their daily medica-
tions. Occupational therapy practitioners
have a specialized skill set that prepares them
to address the occupational performance of
this instrumental activity of daily living.
Intervention
Unique skills enable occupational ther-
apy practitioners to implement quality
evidence-based medication management
interventions. To define these unique skills,
we compared the skills of practitioners
on the medication team. We analyzed
data from the Occupational Information
Network (OpNET), a federal database of
standardized job descriptions (https://www.
onetonline.org/).
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The O pNET database provides
an objective way to compare job skills.
OpNET researchers identified 35 skills
inherent across jobs. For each job, occu-
pational analysts familiarize themselves
with the position’s requirements. They
then rate the importance of each of
the 35 skills on a scale from 0 to 100,
with 100 indicating very important. The
use of trained occupational analysts
strengthens the OpNET data, because it
instills reliability across data points and
prevents professionals from inflating their
own job ratings to influence policy decisions.
For this analysis, we compared oc-
cupational therapist OpNET skills ratings
to the ratings of three professionals typi-
cally involved in medication management:
general internist physicians, registered
nurses, and pharmacists. We calculated the
average importance of each of the 35 job
skills for the three professions historically
on the medication management team. We
then compared the skills ratings for occu-
pational therapists with the average ratings
of the other professions (Table 1).
Generally, occupational therapists had
similar skills as the other professionals. In
25 of the job skills (71%), occupational
therapists were rated within 1 standard
deviation of professionals typically in-
volved in medication adherence. Occu-
pational therapists did score 1 standard
deviation below the other professionals in
science (scientific problem solving) and 2
standard deviations below in mathematics
and quality control analysis. Occupational
therapists had higher ratings in seven
categories. They were 1 standard deviation
higher in operations analysis (analyzing
needs and creating a plan to meet needs),
service orientation (helping people), and
time management and 2 standard devia-
tions higher in learning strategies (select-
ing the best educational training methods),
monitoring, persuasion, and technology
design.
Although prescribing medications
relies heavily on knowledge of math and
science, interventions for medication ad-
herence are often behavioral. Evidence-
based medication adherence interventions
include developing good provider–patient
interactions, education, behavior change
techniques, training in self-monitoring,
incorporating medications into daily sched-
ules, and assistive technology (Nieuwlaat
et al., 2014; Schaffer & Yoon, 2001; Zullig,
Peterson, & Bosworth, 2013). This analy-
sis revealed that compared with the other
professions, occupational therapists’ skills
best complement the evidence-based in-
tervention approaches needed to support
clients’ medication adherence.
Remediating Impairments
Occupational therapy skills not only
complement evidence-based adherence
interventions but also can address many of
the factors that affect nonadherence. For
example, Williams et al. (1995) found that
42% of low-income hospital patients could
not understand the labels on their pre-
scription bottles. Occupational therapy
practitioners can implement health literacy
interventions to improve clients’ capacity
to decode complicated health information,
adapt the health literacy environment by
making materials easier to understand, and
support other team members in creat-
ing quality patient education experiences
(Smith & Gutman, 2011).
Occupational therapy practitioners
can also address medication adherence
in people with good health literacy who
struggle with other components. For
example, people fail to take their medi-
cation as prescribed for either intentional
or unintentional reasons. Gadkari and
McHorney’s (2012) survey of more than
24,000 adults with chronic health condi-
tions found that few people intentionally
neglect their medications. The survey in-
dicated that only about 30% of people at-
tribute their nonadherence to intentional
reasons. Eighteen percent of participants
reported skipping medications to make
them last longer, and 14% indicated al-
tering the dose of a medication to suit their
own needs. Conversely, 70% of survey
participants attributed their nonadherence
to unintentional factors. Specifically, par-
ticipants reported forgetting (62%), running
out of medications (37%), or simply being
careless (23%).
Although many people report for-
getting their medications, people forget
for different reasons. For example, as
the number of daily doses, number of
July/August 2017, Volume 71, Number 4
 Table 1. Job Skill Comparison of Occupational Therapists to Professionals Historically on the Medication Team
Skill MD RN Pharm M SD OTa
Monitoring 66 69 72 69.00 3.00 7811
Service orientation 66 75 72 71.00 4.58 781
Time management 50 50 66 55.33 9.24 691
Learning strategies 53 53 50 52.00 1.73 6311
Persuasion 53 50 50 51.00 1.73 6011
Operations analysis 47 25 44 38.67 11.93 601
Science 85 47 69 67.00 19.08 47–
Mathematics 41 47 60 49.33 9.71 28– –
Quality control analysis 38 47 38 41.00 5.2 28– –
Technology design 16 19 19 18.00 1.73 2511
Active listening 75 78 75 76.00 1.73 75
Critical thinking 78 72 72 74.00 3.46 75
Judgment and decision making 78 69 69 72.00 5.2 75
Reading comprehension 75 72 78 75.00 3.00 75
Social perceptiveness 72 78 63 71.00 7.55 75
Speaking 78 75 72 75.00 3.00 75
Active learning 72 60 66 66.00 6.00 72
Writing 75 66 72 71.00 4.58 72
Coordination 53 72 60 61.67 9.61 69
Instructing 53 56 72 60.33 10.21 69
Complex problem solving 78 60 63 67.00 9.64 60
Systems analysis 56 47 53 52.00 4.58 53
Systems evaluation 60 47 47 51.33 7.51 53
Management of personnel resources 47 47 63 52.33 9.24 50
Negotiation 44 47 50 47.00 3.00 50
Operation monitoring 22 47 28 32.33 13.05 31
Management of financial resources 19 22 31 24.00 6.24 25
Management of material resources 19 28 44 30.33 12.66 25
Troubleshooting 16 19 22 19.00 3.00 22
Programming 16 16 16 16.00 0.00 16
Operation and control 10 35 3 16.00 16.82 13
Equipment selection 13 19 6 12.67 6.51 10
Note. M 5 mean scores of MD, RN, and Pharm; MD 5 internist physician; OT 5 occupational therapist; Pharm 5 pharmacist; RN 5 registered nurse; SD 5 standard
deviation. Three job skills (not listed)—installation, equipment maintenance, and repairing—were rated as 0 for all four health professionals.
a
Standard deviations between OTs and other professionals: – 5 1 SD below; – – 5 2 SDs below; 1 5 1 SD above; 11 5 2 SDs above; no symbol 5 within 1 SD.

prescribing physicians, or complexity
of medication instructions increases, the
client is more likely to forget a dose
(Coleman et al., 2012; Marek & Antle,
2008). Researchers have identified several
factors that affect medication adherence
(Figure 1; Gadkari & McHorney, 2012;
Vlasnik, Aliotta, & DeLor, 2005; WHO,
2003). Analysis of adherence barriers
reveals that occupational dysfunction in
medication management is likely due to a
complex interaction of factors among the
person, the environment, and the task.
To further complicate matters, each
person experiences an inimitable set of bar-
riers to medication adherence. Each client
has a particular set of health conditions that
affects his or her ability to manage medica-
tions. For example, arthritis may create barriers
in manipulating containers, whereas demen-
tia can impair cognitive aspects of the task.
Each client also takes an exclusive set of
medications based on his or her symptoms,
health insurance, and prescribers’ prefer-
ences. Finally, each client experiences differ-
ent barriers and supports related to his
or her environment, previous experiences,
and beliefs. Although there are common
themes in medication nonadherence, infinite
combinations of health conditions, medica-
tions, and individual experiences influence
nonadherence, meaning that each person’s
nonadherence is caused by a unique set of
barriers.
Research reveals that almost no
one fails to take medication with the
intent to cause harm. Instead, people
are overcome by a series of multidimen-
sional individualized barriers. Many of
the factors that affect medication adher-
ence are responsive to occupational ther-
apy intervention (Figure 1). Occupational
therapy practitioners can help clients
overcome medication adherence bar-
riers by creating a client-centered plan
that includes developing cues, pre-
scribing assistive technology, or altering
the environment (Sanders & Van Oss,
2013). Occupational therapy practi-
tioners have the skills to address the most
common causes of medication nonadherence.

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 Figure 1. Factors that affect medication adherence.
p
Factor is likely responsive to occupational therapy intervention.
The Appendix describes a case study
that demonstrates the potential of occu-
pational therapy services in medication
management.
Current Practice
Although occupational therapy prac-
titioners have the skills to address
medication management impairments
and implement evidenced-based inter-
ventions, few occupational therapy
professionals seem to be incorporating
medication adherence into research, teach-
ing, or practice. For research, a search
for the term medication in the title or
abstract of articles in the American
Journal of Occupational Therapy reveals
only 13 publications. A similar lack of
coverage is seen in key teaching resources.
For example, a search of Pedretti’s Occu-
pational Therapy Practice Skills for Physical
Dysfunction (using Amazon’s inside-the-
book search) reveals 2 mentions of medi-
cation adherence and 15 mentions of
medication management in 1,328 pages
(Pendleton & Schultz-Krohn, 2013). In
practice, a recent national survey on a
purposefully selected group of 70 occupa-
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tional therapists reported that only about a
quarter of therapists working in adult
physical dysfunction settings consis-
tently evaluate or treat for medication
management impairments (Schwartz &
Smith, 2014). The majority of survey
respondents specifically reported that
they do not engage in medication man-
agement because of lack of knowledge,
lack of interest, lack of resources, or time
constraints. Therefore, although the oppor-
tunity is present, occupational therapy pro-
fessionals are limited by their knowledge of
medication and evidence supporting practice
in this area.
Importance Within Health Care
Reform
Occupational therapy professionals should
improve their capacity to address medi-
cation management because they already
have unique skills that can improve clients’
medication adherence and because this is-
sue is strongly aligned with the broader
patient outcomes of the ACA. Medication
adherence directly affects the Triple Aim,
that is, population health, cost of care, and
patient experience.
Population Health
Medication nonadherence is a population
health issue. The National Center for Health
Statistics (NCHS; 2014) reports that half of
Americans take medications. Specifically,
90% of older adults, 60% of adults, and 24%
of children have taken one or more pre-
scription drugs in the past 30 days (NCHS,
2014). Although many people take medica-
tion, few do so correctly. Approximately half
of people on medications are nonadhe-
rent (Nieuwlaat et al., 2014; Osterberg &
Blaschke, 2005; Vlasnik et al., 2005; WHO,
2003). Therefore, in the United States, ap-
proximately 80 million people do not take
their medications as prescribed
Everyone occasionally forgets to take
prescribed medication, but consistent
nonadherence can quickly affect health
outcomes. Researchers have estimated
that a person must take at least 80% of
a medication to receive the benefits of
intervention (Fitzgerald et al., 2011;
Osterberg & Blaschke, 2005; West of
Scotland Coronary Prevention Study
Group, 1997). These studies have shown
that when clients’ adherence drops be-
low 80%, their health outcomes are more
July/August 2017, Volume 71, Number 4
 consistent with placebo control groups
than with intervention groups. In other
words, if a person forgets as few as six pills of
a once-daily medication in a 1-mo period,
he or she may fail to benefit from the
treatment.
When clients’ poor adherence limits
treatment effects, they often experience
declines in health and function. For ex-
ample, people who fail to take their
diabetes medications have higher glycated
hemoglobin levels than their adherent
peers (Bogner, Morales, de Vries, &
Cappola, 2012). Prolonged periods of
elevated blood sugar may lead to im-
pairments such as peripheral neuropathy,
kidney failure, and diabetic retinopathy
(Estes, 2012). These health conditions are
frequently associated with declines in the
occupational performance of everyday ac-
tivities. Moreover, people who are non-
adherent to their medications are not only
sicker but also have significantly higher
rates of all-cause mortality (Currie et al.,
2012; Fitzgerald et al., 2011; Osterberg &
Blaschke, 2005). These studies suggest that
improved medication adherence can de-
crease symptoms, reduce the risk of mor-
tality, and increase functional performance
of large client populations.
Cost of Care
Medication nonadherence is linked to
health care spending and hospitalizations.
Researchers have identified that people
who are not adherent to their medica-
tions are more likely to be admitted
(or readmitted) to a hospital and dis-
charged to a long-term care facility (Col,
Fanale, & Kronholm, 1990; Johnson &
Bootman, 1995; Schoen, DiDomenico,
Connor, Dischler, & Bauman, 2001;
Sokol, McGuigan, Verbrugge, & Epstein,
2005). Because of the increased time in the
hospital, people who are nonadherent to
their medications spend an average of 41%
more than their adherent peers on in-
patient health care (Egede et al., 2012;
Sokol et al., 2005). Altogether, researchers
have estimated that in the United States,
more than $100 billion per year is spent
on hospitalizations related to medication
nonadherence (Lewis, 1997; Osterberg &
Blaschke, 2005). These studies suggest
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that improved medication adherence
may reduce health care spending and
rehospitalizations.
Health Care Experience
It is no surprise that nonadherent clients,
who are sicker and have higher health care
expenditures, are not satisfied with their
care. Pollack, Purayidathil, Bolge, and
Williams (2010) found that nonadherent
adults with diabetes experienced increased
negative symptoms (e.g., weight gain,
water retention, headaches) and reduced
treatment satisfaction. Researchers across
diagnoses have found similar findings,
indicating a strong association between
satisfaction and medication adherence
(Roberts, 2002; Wroth & Pathman, 2006).
These studies suggest that efforts to improve
the health care experience may go hand in
hand with efforts to improve medication
adherence.
Implications for Occupational
Therapy Practice
Occupational therapy health policy ex-
perts have suggested that for the profession
to thrive, occupational therapy researchers,
clinicians, and educators must “develop
strategies that will align the practice of oc-
cupational therapy with the Triple Aim of
health care reform” (Leland et al., 2015,
p. 4). This article demonstrates that med-
ication management is an issue strongly
associated with the Triple Aim and that
occupational therapy practitioners have
the skills needed to remediate impair-
ments and deliver evidence-based inter-
ventions. Despite their strong practice
skills in enhancing health literacy, pre-
scribing assistive technology, creating cue-
ing systems, and developing supportive
environments, practitioners seem to be
lacking knowledge and skills specific to
pharmacology. Therefore, this article has
the following implications for occupa-
tional therapy practice:
• New and experienced occupational
therapy practitioners need more preser-
vice and continuing education to help
them better understand medications
(i.e., demonstrate competence in types
of medications, jargon, drug interac-
tions, and the profession’s scope of
practice at the state and federal level).
• Researchers need to better support ad-
ministrators and clinicians by creating
evidence about occupational therapy
evaluation, intervention, and outcomes
in medication management.
• With foundational pharmacology
knowledge and evidence to support
evaluation and treatment, occupational
therapy professionals can begin to in-
tegrate medication management into
practice to meet the demand from cli-
ents and health service organizations.
Conclusion
As a profession, occupational therapy
has an opportunity to enable millions of
Americans to have healthy, productive
lives by enhancing medication manage-
ment performance and subsequent medi-
cation adherence. Occupational therapy
practitioners are ideally positioned to
support physicians, pharmacists, and other
health care professionals and their clients
in the pursuit of health and well-being.
Practitioners have a unique and valu-
able skill set that includes a high regard
for clients, time management, education,
monitoring, persuasion, and assistive
technology. With a few changes to current
practice, education, and research, the oc-
cupational therapy profession can become
a leader in this issue. Health care reform
has provided the motivation and timing to
enable occupational therapy practitioners
to affect change in the area of medication
adherence. By engaging in medication
management, the profession can demon-
strate the value of occupational therapy to
clients, professional peers, and payers. s
Acknowledgments
This research was funded by the Distin-
guished Dissertation Fellowship from
the graduate school at the University of
Wisconsin–Milwaukee and the Student
Research Grant Award from the College
of Health Sciences at the University of
Wisconsin–Milwaukee, and it was con-
ducted at the University of Wisconsin–
Milwaukee. This article was written in
partial fulfillment of the requirements
7104360010p5
 for the Doctor of Philosophy in Health
Sciences degree at the University of
Wisconsin–Milwaukee. Jaclyn K. Schwartz
thanks her dissertation committee mem-
bers, Michael Brondino of the Helen Bader
School of Social Welfare, Ron Cisler
of the Center for Urban Population
Health, Brian Schermer of the School of
Architecture and Urban Planning, and
Virginia C. (Ginny) Stoffel of the De-
partment of Occupational Science and
Technology.
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Appendix: Medication Management Case Study

The purpose of this case study is to demonstrate the distinct value and unique skills of an occupational therapy practitioner
in medication management.
Nina is a 36-yr-old wife and the mother of two young sons. In Nina’s last visit to the primary care physician, the doctor noted
signs of heart disease and prescribed cholesterol and blood pressure medication. Nina was very busy with her family and
frequently missed doses of her medication. One morning, Nina woke up with symptoms of stroke and was admitted to the
hospital. After a day, her symptoms resolved. Nina’s care team diagnosed her with a transient ischemic attack, adjusted her
blood pressure medications, and discharged her home. During her brief stay in the hospital, Nina met with a neurologist;
cardiologist; hospitalist; pharmacist; and dozens of residents, medical students, nurses, and technicians. When Nina returned
home, she took her medications and resumed her busy routine. She soon realized that her medications caused her to be
lethargic and dizzy, making it difficult for her to care for her children. Nina could not determine which medication was
making her feel sick, so she stopped taking all of her medications and decided to wait to tell her doctor until her follow-up in a
month.
Occupational therapy practitioners could have supported Nina and her care team in several ways. In the acute care
setting, the occupational therapist could have evaluated Nina’s performance of medication-related skills, identified her risk
of nonadherence, and recommended additional supports to reduce risk of nonadherence (and subsequent readmission). In
addition, in acute care, the occupational therapy practitioner could have monitored Nina’s fatigue, dizziness, blood pressure,
and heart rate while she performed everyday activities. Through this monitoring, the practitioner could have alerted the team
to adverse medication reactions before discharge.
Across the continuum of care, practitioners could provide a variety of other supports for Nina. Practitioners can review
Nina’s medications and ensure that she is using them as prescribed. The practitioner can also help Nina develop cues, adopt
new assistive technology, or alter the home environment to help her better remember to take her medications as prescribed
(Sanders & Van Oss, 2013). Practitioners may also train Nina on how to self-monitor her medication adherence, symptoms,
and health metrics such as blood pressure to enable her health care team to create a more informed and data-driven plan of
care. For clients like Nina, who experience adverse reactions, the practitioner can help with problem solving. For example,
the practitioner can help identify which of Nina’s many doctors prescribed the medication, how to contact the doctor or
pharmacist, and how to advocate for her needs in a large and complicated health organization. Finally, practitioners can
educate Nina on the importance of adherence and describe the risks associated with delayed action. Occupational therapy
practitioners can use their typical intervention approaches of occupation and activity, preparatory methods and tasks, ed-
ucation and training, and advocacy to support the medical team and enable the client to take his or her medication as
prescribed.

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