Changes in the health system require occupational therapy
Occupational Therapy
Practice: Focusing on
Occupational
Performance
Carolyn M. Baum, Mary Law
Key Words: managed care programs • rehabili-
tation
Carolyn M. Baum, PhD. OTRlC. FAOTA, is Elias Michael
Director and Assistant Professor of Occupational Therapy
and Neurology, Program in Occupational Therapy. Wash-
ington University School of Medicine, 4444 Forest Park, Box
8505, Sr. Louis, Missouri 63108.
Mary Law, PhD. OT(C), is Associate Professor, School of
Rehabilitation Science, and Director, Neurodevelopmemal
Clinical Research Unit, McMaster University, Hamilton,
Ontario, Canada.
This article was acceptedfor publication June 24, 1996.
The American Journal ofOccupational Therapy
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practitioners to fOcus their concerns on the long-term health
needs ofpeople and to help them develop healthy behaviors
not only to improve their health, but also to minimize the
health care costs associated with dysfUnction. Occupational
therapy practitioners must initiate efforts in the community
to integrate a range ofservices that promote, protect, and
improve the health ofthe public. This article shares the
experiences ofCanadian occupational therapy practition-
ers, who were challenged by their government nearly 15
years ago to establish a system that demonstrates effective-
ness by improving the health ofoccupational therapy
clients.
By focusing on occupationalperformance, occupational
therapy practitioners assist clients in becoming actively
engaged in their life activities. This requires client-centered
andfamily-centered practice and services that span from
the agency or institution to the community. Occupational
therapy practitioners must work collaboratively with per-
sons in the client's environment (e.g., family members,
teachers, independent living specialists, employers, neigh-
bors, friends) to assist the client in obtaining skills and to
make modifications to remove barriers that create a social
disadvantage. A focus on occupational performance re-
quires occupational therapy personnel to reframe how we
think about occupational therapy to a sociomedical context
and to take an active role in building healthy communities.
W
ith shifts to managed care, occupational ther-
apy practice patterns are rapidly changing.
Such times of rapid change present opportu-
nities to refocus practice on enabling occupational perfor-
mance. Occupational therapy practice has evolved over
nearly eight decades to meet the needs of persons with
disabilities. In the early years, practice was based in men-
tal institutions and postwar rehabilitation curative work-
shops. It has matured to address the needs of persons in a
number of environments, including health institutions,
schools, work sites, and the community. Until recently,
practice patterns and payment mechanisms forced greater
emphasis on institutional care, where the focus of occu-
pational therapy often addressed persons' performance
components rather than their occupational performance
needs. The purpose of this article is to emphasize the
uniqueness of our profession in enabling clients to achieve
their goals by helping them overcome problems that limit
their occupational performance.
277
 History and Context: Building a Strong
Foundation for Occupational Therapy To
Address the Health Needs of Our Nations
Although it is important to place occupational therapy's
development in the context of its history, it is also impor-
tant to address the needs of U.S. and Canadian societies as
we struggle with issues of chronic disease, disability, and
handicapping situations. To our societies, these issues mean
lost productivity and costly services. To individuals, they
mean poorer health and a compromised well-being. A
brief review of the health issues of Canada and the United
States will provide a context in which to examine what
occupational therapy practitioners can do to highlight
their contribution to helping both society and the indi-
viduals who can benefit from our interventions.
About 35 million Americans, 1 in 7 (Pope & Tatlov,
1991), and 4 million Canadians, 15% (Statistics Canada,
1992), have a physical or mental impairment that inter-
feres with their daily activities, yet only 25% are so severe
that they cannot work or participate in their communi-
ties. Disability is now a public health problem, affecting
not only persons with disabling conditions and their im-
mediate families, but also society (Pope & Tarlov, 1991).
The problems associated with chronic disease and
disability are so prevalent that in 1990, the U.S. govern-
ment published the Healthy People 2000 (U.S. Depart-
ment of Health and Human Services, 1991) objectives,
with priorities that challenged communities and health
professionals to promote prevention strategies for Ameri-
can citizens. A number of the objectives should be of
interest to occupational therapy practitioners: (a) improv-
ing functional independence of American citizens; (b)
preventing persons with illnesses from becoming disabled;
(c) encouraging physical activity; (d) reducing the num-
ber of persons 65 years of age and older who have cLffi-
culty performing two or more personal care activities; (e)
reducing deaths caused by motor vehicle accidents; (f)
reducing fall-related injuries; and (g) increasing the pro-
portion of primary care providers who routinely evaluate
persons 65 years of age and older for visual, hearing, cog-
nitive, and functional status impairments.
In Canada, the federal government has been working
to improve the health and participation in the everyday
life of Canadians through health-promotion strategies
(Health and Welfare Canada, 1986, 1987). Health is
viewed by the Canadian government as much more than
the absence of disease, and many provinces have set health
goals for their populations. For example, Ontario's health
goals emphasize (a) health promotion and disease preven-
tion; (b) building healthy, supportive communities; (c) re-
ducing illness, disability, and death; (d) improving the
physical environment; and (e) ensuring accessible and af-
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fordable heahh services for all citizens (Premier's Council
on Health, Well-Being and Social Justice, 1993).
A Context for Practice in a Changing Health
System: Strategies for a Managed Care
Environment
Over the past two decades, our nations have shifted from
being manufacturing societies to being information soci-
eties (Drucker, 1989). This shift has had a profound
impact on how business is conducted and how health care
is delivered. Occupational therapy practitioners are, as are
all health professionals, required to go beyond performing
services; their services must be understood by providers
and by clients who do not have a health knowledge base.
The emergence of clinical reasoning in health care is di-
rectly related to the need to make explicit thar which we
know and want to be understood by others.
The shift to an information society has also resulted
in occupational therapy practitioners being forced to be-
come specialists just to manage the breadth of knowledge
required to be competent in practice. Unfortunately, be-
cause occupational therapy has been steeped in the med-
ical model, we have built specialization around medical
conditions rather than occupational performance needs.
The professional need to access information requires that
occupational therapy practitioners work collaboratively to
meet clients' needs. This collaboration takes place not so
much across disciplines but within project teams. For
example, rather than working as a specialist focused on
the sensory integrative needs of children, occupational
therapy practitioners are now working as experts in occu-
pational performance on teams (clinical service lines) that
address the rehabiliration or habilitation needs of these
children. This expertise goes far beyond the child's senso-
ry integrative needs to include all factors that affect his or
her performance.
The payment structures supporting health care in the
United States are changing because information now
links demographic, service delivery, and outcomes data.
Rather than work as independent practitioners, occupa-
tional therapy practitioners are more and more working
either directly or contractually for organizations that man-
age services on the basis of these data. This shift requires
praCtitioners to document their effectiveness by entering
standard data into large data sets; hence, the capabilities
of the organization as a whole are being evaluated and
recognized rather than those of the individual therapist.
These changes offer practitioners an opportunity to affect
the overall outcomes of the health delivery system, which
wants to achieve high outcomes with minimal costs.
What contributes more to the achievement of these out-
comes than clients and their family members having the
knowledge and skill to participate in the clients' recovery
April 1997, Volume 51, Number 4
 and to learn the behaviors that will sustain their health
and function over time?
The changes in the health care system do not affect
just occupational therapy practitioners but all health pro-
fessionals. Even physicians are taking salaried positions.
Being effective in this era of health care requires knowing
how to work with and achieve the goals of the organiza-
tion as a whole. Occupational therapy practitioners have
traditionally stepped to the forefront in times of reform to
prevent the clients' rights from being compromised by
services not directed to support them. For example, our
early leaders contributed to the reform of mental institu-
tions by introducing the use of meaningful occupations to
facilitate recovery. Understanding the needs of a changing
. .. .
system IS a prerequIsite to action.
Hospitals and health care agencies have been forced
to restructure their health care delivery mechanisms be-
cause technological advances to save lives, coupled with
an aging population, have made the cost of medical care a
threat to the financial stability of our nations. Health care
reform has been guided by business and its success in
using interorganization mechanisms to take advantage of
the economy of scale. Changes are rising from a mutual
need for all health services to reach common objectives
and a willingness to share risks and costs as well as knowl-
edge and capabilities. Many of these changes make good
sense: It is not logical or cost-effective to have empty beds,
to bypass large discounts for purchasing, or to have
multiple hospitals staffed and equipped to do open heart
or transplant surgery. Much of the discussion on health
care reform centers around costs, but any large change in
health care delivery is difficult and will only be understood
when the turbulence subsides.
Some benefits to interorganizational cooperation in-
clude the opportunity to learn and adapt to new compe-
tencies; gain access to resources; share risks, including the
COSt of products and technology development; manage
uncertainty; and solve complex problems. With this coop-
eration, there are some costs, including a loss of autonomy
and canrrol; conflict over domains, goals, and methods;
and delays in solutions because of coordination problems
(Kaluzny, Zuckerman, & Ricketts, 1995).
The changes emerging with managed care are not the
first our profession has seen, although we have not seen
major health care reform since Medicare and Medicaid
were initiated in the mid-1960s. It is important for those
occupational therapy practitioners who have built their
professional careers in a fee-for-service system that is
changing to gain a historical perspective to see that the
profession has endured many changes over the past eight
decades.
The American Journal o/Occupational Therapy
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A Context for Effective Occupational Therapy
Practice
When occupational therapy began in the early part of this
century, it was for moral reasons. In this period before
drugs were used for treatment of mental illness, persons
with mental conditions were institutionalized without
means of occupying themselves. Professionals from the
fields of medicine, neurobiology, nursing, social work, and
architecture believed that residents of mental institutions
had needs that could be met by giving them meaningful
work. These professionals who shared a common interest
in using occupation as treatment found each other, and
the profession of occupational therapy was born (Chris-
tiansen, 1991). Finding ways to address the needs of per-
sons as they use occupation to improve their health con-
tinues to be a challenge for occupational therapy today.
Occupation is a term that describes the interaction of
the person with his or her self-directed life activities. Adolf
Meyer (1922), a neurobiologist, psychiatrist, and founder
of occupational therapy, proposed that "the proper use of
time in some helpful and gratifYing activity appears to be
a fundamental issue in the [management] of any neuro-
psychiatric patient" (p. 1). He professed that persons
should attain and retain a healthful "rhythm in sleep and
waking hours, of hunger and its gratification, and finally
the big four-work and play and rest and sleep" (p. 3).
Wilcock (1993) viewed occupation as a central aspect of
the human experience and unique to each individual. The
definition of occupation should be basic to every occupa-
tional therapy practitioner's vocabulary. Occupation meets
"the [person's] intrinsic needs for self-maintenance, expres-
sion, and fulfillment within the context of personal roles
and environment" (Law et al., 1996, p. 16). Thus, it is
through the process of engagement in occupation that
people develop and maintain health. Conversely, the lack
of occupation causes a breakdown in habits, which leads to
physiological deterioration and lessens the ability to per-
form competently in daily life (Kielhofner, 1992). As the
health system changes its focus to persons' long-term
health needs, issues surrounding occupation become cen-
tral to promoting health and reducing the COSt of chronic
disability.
Adopting interventions to support the health and
function of persons in their communities was a plea ex-
pressed some time ago (Finn, 1972; West, 1968). We no
longer can ignore the challenges of finding mechanisms to
meet community health needs if occupational therapy is
to remain "a sufficiently vital and unique service for medi-
cine to support and society to reward" (Reilly, 1962, p. 1).
These mechanisms are currently being developed by large
community health systems under the label of disease
management.
279
 Disease management is a comprehensive, integrated
approach to care and reimbursement that is based on the
natural course of a disease. Intervention is designed to
address the illness by maximizing the effectiveness and
efficiency of service delivery. Disease management differs
from care paths in mat it attempts to encompass the en-
tire course of a disease, whether it is in an acute phase or
remission and whether the care is delivered in the hospi-
tal, the home, or the community. This approach also con-
siders the consequences of the condition across time. The
purpose of disease management is to help people develop
healthy behaviors not only to improve their health, but
also to cut health care costs associated with secondary
conditions. In the United States, nurses and health educa-
tors are carrying out much of this work.
Occupational therapy practitioners in the United
States can learn from the experiences of Canadian occu-
pational therapy practitioners who have had to address
similar issues. In Canada, occupational therapy practi-
tioners were challenged by their government nearly 15
years ago to put in place a quality assurance system that
would demonstrate effectiveness by improving the health
of occupational therapy clients (Canadian Association of
Occupational Therapists [CAOTJ, 1991; CAOT & De-
partment of National Health and Welfare, 1983). Rather
than focusing only on the process of therapy, the thera-
pists who accepted this challenge proposed a client-cen-
tered model of practice that would span from institution-
al-based services to community-based services. Because
this client-centered model has already been developed and
tested, it can serve as a model for the development of
community-based services in the United States.
Building a community model requires moving be-
yond the medical model, which focuses on cure and man-
agement of the disease and where the relationship is be-
tween the patient and physician Oesion & Rudin, 1983),
to a model of active collaboration between occupational
therapy practitioner and client to resolve occupational
performance problems. Such a model would focus on the
psychosocial, as well as medical, needs of clients and
encourage them to be as autonomous as possible, provid-
ing opportunities for choice in decisions and activities
(Smith & Eggleston, 1989).
Occupational therapy practice has been limited by
the health care system's focus on acute medical manage-
ment. Recent expansion of vertical health systems has
resulted in subacute, rehabilitation, home health, and
work-related programs becoming integrated pans of the
health system. As hospitals build community health initia-
tives, networks with independent living centers, schools,
fitness and wellness programs, and vocational rehabilita-
tion programs will become important. The team that his-
torically focused on acute medical care has been limited
280
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primarily to traditional medical rehabilitation professionals,
including physicians, occupational therapy practitioners,
physical therapy practitioners, speech-language patholo-
gists, psychologists, and rehabilitation nurses. The commu-
nity approach expands rehabilitation to include a whole
new cadre of colleagues, including persons with disabili-
ties, engineers, architects, personal assistants, independent
living counselors, recreation and exercise personnel, city
planners, law enforcers, and transportation specialists.
~onsumers (i.e., clients, policymakers, insurers, phy-
sician~) are seeking different information from occupa-
tional therapy practitioners. Performance component in-
formation will still playa role in the occupational therapy
practitioner's clinical reasoning process. However, with
the focus on outcomes and improved well-being, occupa-
tional therapy practitioners are increasingly expected to
teport on personal and environmental assets and limita-
tions that relate to the client's occupational performance
and the services needed to facilitate healthy behaviors.
Occupational therapy practitioners should be seen as ex-
pertS in applying effective intervention strategies that
contribute to optimal occupational function, including
self-sufficiency, social integration, improved health sta-
tus, and employment, in persons with chronic disease
and disability.
Rather than focus on professionally controlled ser-
vices that promote dependence, the new health paradigm
(see Table 1) will emphasize the development of commu-
nity partnerships in which consumers and professionals
work together to develop strategies to manage health
problems and prevent secondary disabling conditions
that can compromise function and translate directly into
increased medical costs. Although many of the changes
associated with this shift in focus are painful, the ulti-
mate goal, which focuses more on prevention, fits well
with the philosophy of occupational therapy, which sup-
pons the healthful behaviors and function of persons in
their daily lives.
Occupational therapy practitioners must assume re-
sponsibility for shaping their own future in the changing
health care system. Basic to implementing a model to
manage a client's long-term health and occupational
needs is placing value in the client directing his or her
own care. Occupational therapy practitioners use termi-
nology and design programs described as patient centered,
client centered, patient focused, client driven, partnerships,
and family centered: What do these terms mean, and how
do we assure that we are leaders in shifting the paradigm?
The Unique Contribution of Occupational
Therapy to a Managed Care System
Man is an organism that maintains and balances irself in the world
of reality and aCtuality by being in active life and active use... .It is
April 1997. Volume 51. Number 4
 Table 1
A Changing Health System Paradigm
Area Old New
Tne model Medical model Sociopolitical (community) model
Episodic care Planned or managed nealtn
Tne focus Focus on illness Focus on well ness
Acute care outcomes Well-being, function, and life
satisfaction
Individual Individual witnin the environment
Deficiency Capability
Survival Functional ability, quality of life
Professionally conttolled Petsonal tesponsibility flexible,
choice
Dependence Interdependence, participation .ENVIRONM.ErtT
Treatment Treatment, prevention
Tne system Institution centered Community centeted
Single faciliry Networked system
Competitive focus Collaborative focus
Fragmented service Coordinated service

OCCUPATION
the use that we make of ourselves that gives the ultimate Stamp to
out every organ. (Meyer, 1922, p. 5)

Engagement in occupation is the way that people use

their motOr and memory skills to enhance their perfor-
mance and maintain both cognitive and physiological fit-
ness. Reilly (1962) stated that "there is a reservoir of sensi-
tivity and skill in the hands of man which can be tapped
for his health [and a] rich adaptability and durability of
the central nervous system which can be influenced by
experiences" (p. 2). As our colleagues in nursing, medi-
cine, and physical therapy use terminology and approach-
es with the intent of improving function, we also must
make our unique contribution to function visible and
understOod. The term occupational therapy practitioners
use for function is occupationaL peifOrmance, or the point
when the person, the environment, and the person's occu-
pation in tersect to support the tasks, activities, and roles
that define that person as an individual (see Figure 1).
Being able "to do" requires the integration of factors
within the person with those external to the person (i.e.,
culture, economics, resources, the physical and social en-
vironment). Of particular interest is how these environ-
mental factOrs interact with the person's occupational
structure. Persons who perceive that they have control
over their environments and can address obstacles derive
satisfaction from their occupational roles (Burke, 1977;
Sharott & Cooper-Fraps, 1986). Thus, the unique contri-
bution of occupational therapy is to maximize the fit
between what the person wants and needs to do and his
or her capability to do it (see Figure 2).
Some key concepts must be mastered to describe how
occupational therapy fits into the larger context of medi-
cine and rehabilitation. The traditional approach to med-
ical care has focused on impairments or the loss or abnor-
mality of mental, emotional, physiological, or anatOmical
Figure 1. Occupational performance. Note. Adapted with
permission from: Law, M., Cooper, B., Strong, S., Stewart,
S., Rigby, P., & Letts, L. (1996). The person-environment-
occupational model: A transactive approach to occupational
performance. Figure 3. Canadian Journal of Occupational
Therapy, 63, 18.
structure or function. This term includes all losses or ab-
normalities, not JUSt those attributable to the initial patho-
physiology, and includes pain as a limiting experience
(National Center for Medical Rehabilitation Research
[NCMRR], 1993). When there is an interruption or in-
terference of normal physiological and developmental
processes or structures the term used is pathophysioLogy
(NCMRR, 1993).
Acute rehabilitation usually focuses on functionaL
Limitations (i.e., restrictions or lack of ability to perform
an action or activity in the manner or within the range
considered normal) that result in impairment or failure
of a person to recurn to a preexisting level or function
(NCMRR, 1993). This impairment is synonymous with
occupational therapy practitioners' description of perfor-
mance components. In contrast, disabiLity is defined as
an inability or limitation in performing socially defined
activities and roles within a social and physical environ-
ment as a result of internal or external factors and their
interplay (NCMRR, 1993).
As the occupational therapy practitioner approaches
problem solving with clients, three sets of information are
basic to the plan: (a) person ftctors, which are the person's
neurobehavioral, cognitive, physical, and psychosocial
srrengths and deficits (Christiansen & Baum, in press);

The American journal ofOccupational TheraPJ' 281

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 Figure 2. Occupational therapy process environment. Note, Adapted with permission from: Fearing, V, G" Law, M., & Clark,
J, (1997). An occupation performance process model: Fostering client and therapist alliances, Figure 4, Canadian Journal of
Occupational Therapy, 64, p. 11,

(b) environmental factors, which include rhe person's cul-
rural, economic, insrirurional, polirical, and social conrexr
(Chrisriansen & Baum, in press); and (c) occupationalfac-
tors, which include rhe person's self-mainrenance, work,
home, leisure, and family roles and acriviries. The unique
rerm occuparional rherapy pracririoners use ro express
funcrion is occupational perftrmance. If reflens rhe per-
son's dynamic experience of engaging in daily occuparions
wirhin rhe environmenr (Law & Baum, 1994).
A social disadvantage or handicap resulrs when a per-
son is nor able ro fulfill a role mar he or she expecrs or is
required ro fill. If rhe environmenr presenrs a barrier ro
rhe performance of an acriviry (e.g., a nonaccessible build-
ing, an ani rude of discriminarion, a policy rhar denies
access), rhe barrier is defined as a handicapping situation
(Fougeyrollas, 1994). When socieral policy, arrirudes, and
acrions, or lack of anions, creare a physical, social, or fi-
nancial barrier ro access healrh care, housing, or vocarion-
at or avocarional opporruniries, rhe rerm used is societal
limitation (NCMRR, 1993).
Client-Centered Practice
A managed care occuparional rherapy pracrice rhar is
based on conceprs of clienr-cenreredness is more likely ro
engage cliems in rhe occuparional rherapy process and
lead ro increased adherence and sarisfacrion wirh rherapy
(Law, Baprisre, & Mills, 1995) rhan a service focused
only on whar rhe rherapisr perceives as a problem. Cliem-

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 centered practice creates a caring, dignified, and empow-
ering environment in which clients dlrect the course of
their care, calling on their personal and spiritual resources
to speed the healing process (Matheis-Kraft, George,
Olinger, & York, 1990).
In a client-centered approach, clients and therapists
work together to define the nature of the occupational
performance problem, the focus and need for interven-
tion, and the preferred outcomes of therapy. Basic as-
sumptions of a client-centered approach are: (a) clients
and their family members know themselves best, (b) all
clients and family members are different and unique, and
(c) optimal client performance occurs within a supportive
family and community context (Law et al., 1995). On the
basis of these assumptions, clients and therapists can focus
on their unique contribution and responsibilities to build-
ing a client-centered partnership. In such a partnership,
clients expect to lead the decision-making process. To do
this, clients require information that will enable them to
make decisions about the services that will most effective-
ly meet their needs. This information, when given in an
understandable way, will ensure that clients can define
occupational performance priorities for intervention. Cli-
ents expect to receive a service in a timely manner and to
be treated with respect and dignity during the occupa-
tional therapy process. The therapist encourages ciiems [Q
use their own resources to help solve occupational perfor-
mance problems. Clients participate at different levels,
depending on their capabilities, but all are capable of
making at least some choices about how they spend their
daily lives.
A client-centered approach encourages occupational
therapy practitioners to assume new responsibilities in
enabling clients to idemify their own needs and to indi-
vidualize service delivery. With this approach, therapists
support client decisions or communicate the reason why
he or she cannot suPPOrt the client's decision. Addi tion-
ally, therapists respect the client's values and visions as well
as the client's style of coping wlthout judging what is right
or wrong. They encourage clients to recognize and build
on their strengths, using natural community supports as
much as possible.
A Model for Planning and Implementing Client-
Centered Occupational Therapy Services
An occupational therapy practitioner brings knowledge
and experience to the therapeutic relationship, as does the
client. When a new therapeutic relationship is evolving, it
is important for the context of that relationship to be
understood by both panies. It is just as important for
clients to understand why an occupational therapy practi-
tioner is involved in their care and what they can expect
to achieve through occupational therapy as it is for the
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therapist to understand the client's issues and needs. Ad-
ditionally, it is important for the client to understand the
scope of the therapist's knowledge and access to resources.
Likewise, the client's knowledge of his or her condition,
experience with the problem, and goals must become
clear for the relationship to progress. If the client has a
cognitive deficit or is a child who as yet does not have the
capacity for independent decision making, the parent or
person selected to be the guardian or caregiver must par-
ticipate in this phase of treatment planning. If the occu-
pational therapy practitioner does not have the knowledge
to address the client's needs, the therapist should help the
client seek the resources needed in order to be sure to
address the problem.
It is important for the occupational therapist to de-
sign the first phase of the intervention [Q seek information
from the client about his or her perception of the prob-
lem, needs, and goals. Information is shared to build the
occupational performance history, which includes infor-
mation about the person, the environment, and the occu-
pational factors that require intervention. The seven steps
of this process are:
1. Name, validate, and prioritize the client's occupa-
tional performance issues
2. Identify potential intervention model(s)
3. Identify occupational performance components
and environmental conditions
4. Identify strengths and resources
5. Negotiate targeted outcomes, develop action plan
G. Implement plans through occupation
7. Evaluate occupational performance outcomes
Implementing an Occupational Performance-
Based Model
The implementation of an occupational performance
model requires reexamination of how therapists access
information to support a client-centered approach. Tra-
ditionally, therapists have measured the components of
function or the impairments of a person with a functional
problem. A top-down approach (Mathiowetz & Haugen,
1994; Trombly, 1995) is used in which the therapist
determines with the client what the client perceives to be
the important occupational performance issues causing
difficulties in carrying out his or her daily activities (i.e.,
work, self-maintenance, leisure, rest).
Because occupational therapy assessments are only
part of the system of care, therapists must be able to com-
municate with their colleagues in medicine, institlltions,
and the community; with the client; and with the family
members. Even though the occupational therapist may
measure performance components and environmental
conditions to understand why problems occur and what
283
 might be done about them, the unique measuremem
conuibution is at the occupational performance level
where the diem imeracts with his or her environmem (0
perform occupations and roles of choice.
Comprehensive measuremem models are beginning
(0 emerge (see Figures 3 and 4) that suppon the new
health paradigm. We have expanded these models (0
demonstrate the measuremem issues that can be addressed
when building a comprehensive outcomes-based model
for occupacional merapy (see Figures 5 and 6).
Whether me Imernal C1assificacion of Impairmem,
Disease, and Handicap (ICIDH) model or me NCMRR
model is used in organizing assessmems, imervemions,
and services, one issue is critical (0 me survival of occupa-
tional therapy in the changing health system: Occupa-
tional merapy practitioners must place their primary fo-
cus at the level of me person-environmem imeraction so
that occupational performance issues can be assessed and
addressed in the therapy plan. These issues are addressed
in the ICIDH model at me life habit, environmema! fac-
tors, and disability, and in me NCMRR model at me dis-
ability and societal limitations levels. When occupational
performance issues are not addressed, me contributions of
occupational therapy are not made explicit, and diems
are left to fend for themselves in resolving the problems
that will compromise their function and health.
Influencing Outcomes
The health system is focusing on outcomes because of me
need (0 be accoumable not only (0 the diems in need of
services, but also (0 the third-parry payers. With a shift in
focus (Oward primary and secondary preventive care, it is
important to know whether intervemions are successful
in reducing me impact of secondary problems. Outcomes
are being defined as well-being and quality of life. Im-
proved occupational performance is a critical construct in
measuring qualiry of life, regardless of the measure used
(Edwards, in press). There is increasing evidence that
diem-cemered practice improves not only the process,
but also the outcomes of care. This practice has led (0
increased diem satisfaction and adherence (0 merapy rec-
ommendations, increased diem participation in the occu-
pational therapy process, improved diem self-efficacy, and
improved functional outcome (Dunst, Trivette, Boyd, &
Brookfield, 1994; Dunst, Trivette, Davis, & Cornwall,
1988; Greenfield, Kaplan, & Ware, 1985; Moxley-Hae-
gert & Serbin, 1983; Stein &]essop, 1991).
Responsibilities of Therapists in a Changing
System
All healm professionals are being challenged to demon-
suate a broader understanding of the determinams of
health, such as environments, socioeconomic conditions,

RISK FAcrORS

I CAUSES I

,
ORGANIC SYSTEMS ENVIRONMENTAL

I
- ABILITIES FAcrORS

IIMPAIRMENTS I DIS ABU ,!TIES I I OBSIACI ES I

( \ I
~~ INTERACTION

LIFE HABITS

I HANDICAP
SmJATION
I

Figure 3. Internal Classification of Impairment, Disease, and Handicap model. Note. From "The Handicap Creation Process:
Analysis of the Consultation and New Full Proposals" by P. Fougeyrollas, H. Bergeron, R. Cloutier, & G. St. Michel, June 1991,
InternationallCIDH Network, 4(1), p. 17, Copyright 1991 by the Canadian Society for the ICIDH. Repnnted With permiSSion.

284 April 1997, Volume 51, Number 4

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 Societal Li mitat ion 5 o isab i lity Functional Impairment Pathophysi ology
f--- L i mita tion - t--

I SOCIETY
I I INDIVIDUAL
I I ACTION/ACTIVITY I I 51 RUCTURE/FUNCTIONI I CEll/TIS SUE
I

Figure 4. National Center for Medical Rehabilitation Research model.

behaviors, medical care, and genetics. Occupational ther-
apy practitioners must initiate efforts to work wim others
in the community to integrate a range of services that
promote, protect, and improve the health of the public.
The Pew Health Professions Commission (1993) de-
scribed the health professional of the future as one who
collaborates, is an effective communicator, and works in
teams to meet the primary health needs of the public.
Occupational therapy practitioners are uniquely qualified
for this role because of our focus on productive living.
The government and leaders of health delivery sys-
tems are looking for solutions to the health care crisis.
Occupational therapy praCtitioners should seek to under-
stand both health and the delivery of health services from
a broad political, economic, social, and legal perspective.
We should come forward to lead in me development of
resources to suPPOrt the health of our communities by
helping to eliminate me disabling conditions that are so
costly not only to health care systems, but also to individ-
uals and to society.
What Do Therapists Need To Know To Deliver
Effective Care?
Much of what occupational therapy practitioners current-
ly know has come from a rich experience, but it is not
well documented in studies. The field's growing cadre of
trained scientists can answer important questions to guide
programs and policy. The plan prepared for the U.S. Con-
gress by the NCMRR (1993) at the National Institutes of
Health posed a number of questions that should be ad-
dressed by occupation scientists to guide practice. Thera-
pists in practice can help answer these questions by join-
ing research teams with faculty members and students in
academic institutions:
• IdentifY factors that enable persons with disabilities
to perform self-care or to create and manage sup-
port networks to provide assistance in activities of
daily living (ADL).
• IdentifY the strategies that contribute to optimal
function, including self-sufficiency, social integra-

En vi r on me ntal
Life Habit s Disabilities Impairment Risk Factors
Factors

(HandiCapPing
Situations
( Obstacles) Abilities Organic Systems
( Causes
)
.• Fitness
• Communication • Hearing, Vision • Neurological Dencit
• Family Relations • Cultural
• Functional • Speech Articulation • Physiological Dencit
• Employment • Physical
Mobility • Tone • Immunological Dencit
• Volunteer Adivities • Economic
• Socia! Skills • Comprehension • Nutritional Dencit
• Interpersonal • Institutional
• Intellectual • Problem Solving • Occcupational/
~. Relations • Social
Activity • Pattern Recognitior Environmental
• Education
• Coordination • Attention Exposure
• Leisure
• Self care • l"1emory • Behavioral Risk
• Play
• l"1otivation • Genetic Abnormality
• Instrumental Tasks
• Mood

Figure 5. Internal Classification of Impairment, Disease, and Handicap context for research, measurement, and service.

The American journal ofOccupational Therapy 285

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 Socie t a: I Limit ati on
Rewiction attri1<lble to
social policy or barriers
(structural or attitudinal)
which limits fullfilment of
roles or dentes access to
services or opportunmes.
Disab.ility
'.'
Inability or limitation in
performIng socially defined
actiVIties and roles withIn a
social and physical eo'"roo·
ment as a result of internal
or extemal factors and their
interplay.
Functional Limitation Impairment Pat hophYsidl ogy '.
.' ....... ' '::'" .,':
RestricilOn or lack of
ability to perform an Loss and/or abnormality Interuption or inter- ::
action or activity in of mental, emotional, ference of nonnal
the manner or range physiological, or anatomical physiological and
considered normal that structure or function; developmental processes
results from impairment including secondary losses or structures
and pain.

Performance of .. ( Task Performance Performance of Organs and ,oS,' ( Cells and Tissue
Roles by Person in . of Person in Physical Action or Activity Organ Systems
. and Social Context ( (
Societal Context
Roles: Task Performance • Initiate, Organize
• Worker' Student • Basic Self·Care • Hearing, Vision • Neurological Defic~
Sequence, Judge
• Friend • Parent • Instrumental Tasks • Speech Articulation • Physiological Defic~
Attend,Select
• Tone • Immunological Defic~
• SpouseiPartner • Worker Tasks • S~, Roll,Lift,Stoop
• Comprehensive • Nutr~ional Defid
• Volunteer • Leisure Activ~ieiPlay Squat,Stand,C1imb,
• Recreation • Education Ambulate Understanding • Occcupational
Context Context • Problem Solving Exposure
• Reach, Pinch, Grip.
• Attitudes, customs, • Physical Environment Grasp,Hold,Release • Pattern Recogn~ion • Behavioral Risk
beliefs, norms • Social Environment • Attention • Genetic Abnormality
• Relate, Interact,Cop€
., • Memory
• Accessibility including family Manage, Adapt
• Irdusion , • Cogn~ive Environment:-· • Read, \II/rite, Learn, • Motivation
• Accomodation ,,' • Cu~ure Understand • Mood

Figure 6. Measurement model built on the National Center for Medical Rehabilitation Research scheme (NCMRR, 1993).

tion, and employment.
• Identify the factors that contribute to successful
long-term integration of persons with functional
impairment into families and communities.
• Seek means of modifying habits or behavior pat-
terns that contribute to substance abuse in persons
with disabilities.
• Determine how to understand and enhance hu-
man learning, cognition, and skill acquisition after
brain injury.
• Develop, apply, and evaluate personal, environ-
mental, and activity-specific technologies that will
enable persons with a disabilities to perform ADL,
including vocational and recreational activities.
• Study the effects of disability on children, including
physical and cognitive functioning, educational
attainment, and transition to adult roles, and of
educationally related services in the public schools.
Building the Future
In order for a profession ro mainrain its relevancy it must be aware
of the times, inrerpreting its contribution ro mankind in accordance
with the need~ of the times. (Finn, 1972, p. 59)
The profession's focus-enhancing the fit between a per-
son and his or her environment in order to support the
person's ADL-is appropriate for the emerging health
system. Services framed within the medical model alone
will face ongoing cuts, whereas services framed within a
broader, community-based model will enable clients to be
responsible for their own health and occupational func-
tion. The challenge is to build occupational therapy ser-
vice models that will support the daily functions of per-
sons in the community across a continuum of primary,
secondary, and tertiary care. This fits nicely with the
evolving model of population-based care.
The rapidly changing health system is challenging all
service delivery models. These challenges can be perceived
as a threat to current occupational therapy practice or as a
unique opportunity to renew our historical focus on en-
abling occupational performance as well as enabling per-
sons with disabilities to lead independent and healthful
lives.
We envision that occupational therapy practice will
focus on occupational performance; will be more client
and family centered; and, as a result, will be community
based. We see occupational therapy practitioners build-
ing partnerships with clients and working collaboratively
with persons with chronic health conditions and disabili-
ties to remove environmental barriers that diminish or
discourage their participation in everyday life in their
commuOlty.
This type of practice requires all occupational therapy
personnel to become active in their communities. Occu-
pational therapists and occupational therapy assistants can
help clients obtain the skills for living. Occupational ther-

286 Apri11997, Volume 51, Number 4

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 apy educators can instill in students the importance of
lifelong learning and provide them with the skills to use
technology in order to access and produce information.
Additionally, occupational therapy education must be
expanded to include consultative and educational roles.
This type of practice also requires evidence that the
occupational therapy services delivered are effective. For
practitioners, this means using standardized measures and
basing our practice on client-centered goals and evidence-
based practice. For occupational therapy educators, this
means educating students to be lifelong learners who can
use technology to access and produce information and
serve in consultation and educational roles. By under-
standing and facilitating the relationship between occupa-
tion and health, occupational therapy personnel can play
an important role within the changing health system to
ensure the desired outcome of health and well-being. •
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Coming in May:
• The Effects of a Neonatal Positioner on Scapular
Rotation
• Teaching Diagnostic Reasoning: Using a Classroom-as-
Clinic Methodology With Videotapes
• Off-Road Driving Evaluations for Patients With Cerebral
Injury: A Factor Analytic Study of Predriver and
Simulator Training i

• Evaluating Patient Motivation in Physical Disabilities

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