Population Health: Implications for Occupational Therapists 

Population Health

Population Health continues to have an impact on the occupational therapy profession, however they can help communities in the long run.

Population health management is emerging as a newer model of improving health outcomes, especially as it relates to the Affordable Care Act (ACA). Kindig and Stoddart (2003) promoted population health as “the health outcomes of a group of individuals, including the distribution of such outcomes within the group.” Another definition states, “population health is the health of all people living in a place, such as New York City, Kansas, or Bangladesh.” It also refers to health disparities between the rich and the poor. Zip codes are more critical in determining health outcomes than one’s genetic code.

Population health can include a broad concept encompassing the elimination of diseases and injuries and the myriad factors that influence health. The physical and social environment, individual cognition and lifestyle, genetics, racism, poverty, food insecurity, education, housing, infrastructure, access to technology, transportation, and urban planning constitute factors which impact policy-making for improved health outcomes and equity. 

The Centers for Disease Control (CDC) views population health as an interdisciplinary, individualized approach allowing health departments to connect practice to policy for changes locally. This approach uses non-traditional partnerships among different sectors of the community; public health, industry, academia, health care, local government entities, etc.- to achieve positive health outcomes. Population health “brings significant health concerns into focus and addresses ways that resources are to be allocated to overcome the problems that drive poor health conditions in the population.”

How is Population Health Different from Public Health?

Public health acts to protect and improve communities’ health through policy-making, health education, outreach, and screening for disease and injury prevention. Significant determinants of health, such as education and income, are not included in the traditional public health scope of practice. The more holistic approach of population health is merging the knowledge base from many disciplines to address all of the factors that influence health.

Triple-Aim of the ACA

In 2007, the Institute for Health care Improvement developed a “three-pronged approach” for helping health care systems enhance performance using the following three metrics, known as the Triple Aim:

  1. Improving patient experience
  2. Reducing the per capita costs of healthcare
  3. Improving the health of populations overall

Many, but not all factors contributing to the rising costs include:

  • Aging of the population
  • Population growth
  • Prescription drug costs
  • Preventable chronic diseases- stroke, COPD, cancer, and heart disease are the leading causes of death. Chronic conditions are the major causes. Poor nutrition, obesity, inactivity, and smoking are the major risk factors.
  • Administrative costs
  • Over-utilization of emergency room services for the uninsured due to health inequality
  • Hospital readmissions 

In summary, the goal of Triple Aim is to encourage healthcare organizations to reduce costs, increase quality, identify at-risk populations, and address the health concerns of the community.

The Importance of Health Promotion and Disease Prevention

The U.S. Department of Health and Human Services underscores health promotion and disease prevention to improve the life expectancy, health, quality of life, and health equity of all Americans. The primary purpose of health promotions is to prevent disease and disability in individuals and populations. Although occupational therapists typically provide services to individuals and groups and address specific conditions or disabilities, this model warrants scrutiny with emerging systems focusing on disease prevention, health promotion, and health equity. Occupational therapists are called upon to change their mindset and adapt to the current prevention and health promotion philosophy addressing populations and communities.

Population Health and Occupational Therapy

The AOTA’s Vision 2025 asserts, “as an inclusive profession, occupational therapy maximizes health, well-being, and quality of life for all people, populations, and communities through effective solutions that facilitate participation in everyday living.” In 2018, an updated version made diversity and inclusion more explicit with an emphasis on embracing diversity in all its forms. The 2025 Vision is more aligned with population health management purported by the Triple Aim and the U.S. Health and Human Services.

Occupational Therapy in Primary Care

Primary care is frequently the first entry into the healthcare system. Primary care is defined as a setting “that provides integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” 

The absence of O.T.s in primary care can lead to hospital readmissions, increased health care costs, and continued decline in the health of adults with acute and chronic health conditions. The high number of patients that physicians are expected to see daily does not offer sufficient time to address many complicated health problems, especially mental health, safety, and meaningful occupational engagement.

The integration of occupational therapy into primary care has been successful in many European countries and Canada. In the U.S. it remains in the exploratory stage, offering opportunities and posing challenges. The barriers to practicing in primary care include uncertainty about the role of the profession, as well as a misunderstanding regarding reimbursement for O.T. services. Due to the holistic nature of occupational therapy, the profession can make a significant contribution to primary care in the following ways:

  • Addressing the risks of hospital readmissions
  • Identifying the need for early intervention
  • Promoting management of chronic conditions
  • Prevention of disease and disability
  • Improving the quality of life in the presence of an illness or disability
  • Promoting lifestyle redesign and health management
  • Driver Screening
  • Diabetes program management
  • Assessing the need for and the prescribing of adaptive equipment/DME
  • Using a person’s habits, routines, and roles to assist in regimen adherence
  • Aiding in community reintegration
  • Assessing mental health conditions that impact function and quality of life
  • Screening for substance misuse/abuse
  • Wheelchair fitting
  • Maintaining independence and safety
  • Promoting “aging in place” and delaying institutionalization
  • Fall prevention
  • Sexual health and sexuality
  • Sleep disorders leading to cognitive decline, accidents, heart disease, stroke, hypertension, diabetes, weight gain, depression, and death.
  • Pediatrics-obesity, developmental delays, learning disabilities, coaching for families, and early intervention.

Health Equity, Social Justice and Occupational Therapy

Federally Qualified Health Centers (FQHC) are community-based primary health care centers funded by the Health Resources and Services Administration (HRSA) to provide low-or-no-cost healthcare to under served communities. FQHCs can provide healthcare to patients receiving Medicaid, Medicare, and private payers. Occupational therapists can contribute to health equity by offering their unique and essential services to under served communities.

Childhood Obesity Epidemic

Childhood obesity has become a national and global epidemic. The World Health Organization (WHO) statistics reveal that inadequate physical activity and poor nutrition have become a pandemic. Obesity impacts children’s morbidity and quality of life.

Studies show that significant disparities exist in obesity by race and ethnicity, with almost half of all Hispanic youth overweight or obese. According to the CDC, childhood obesity rates are higher for those with a lower socioeconomic status and from racial/ethnic populations due to fewer resources such as limited access to recreational spaces and affordable nutritional food. Additionally, an increase in sedentary behavior such as prolonged screen time, including T.V. watching and video games, contributes to the pandemic.

More than 40% of children with a disability are at higher risk of being overweight or obese. Children with a developmental disability are more likely to be overweight at three years of age than non-disabled peers. Obese and overweight children are at risk of being stigmatized, bullied, or marginalized. Also, obese children are at risk for developing:

  • High Blood Pressure
  • Impaired glucose intolerance and insulin resistance
  • Diabetes Type 2
  • Cardiovascular Disease
  • Asthma
  • Sleep apnea limiting energy levels and attention at school.
  • Decreased joint mobility and musculoskeletal problems leading to limitations in physical play and sports participation.
  • Fatty liver disease
  • Gallstones
  • GERD
  • Pain
  • Depression, Behavioral Problems, and School Issues
  • Decreased Social, Physical, and Emotional Functioning

As occupational therapists, it is crucial to prevent diminished occupational engagement while promoting occupational justice for this population. Occupational therapists can play an essential role in addressing childhood obesity in schools, communities, and at home. Intervention can focus on providing:

  • Culturally appropriate healthy food preparation and meals
  • Enjoyable physical and social activities: participation in non-competitive sports, Walking and Biking Networks, Public Open Spaces, After-School Clubs
  • Strategies for decreasing weight bias stigma and bullying
  • Focus on a healthy and sustainable lifestyle rather than weight loss
  • Partnering with public health initiatives addressing obesity in under served communities

Occupational therapists can expand their roles in schools by:

  • Promoting anti-bullying programs teaching respect for differences 
  • Work with administrators to limit the availability of vending machines that offer foods containing sugar and high calories
  • Create a gardening program at the school
  • Infuse physical activity throughout the day
  • Promote after-school clubs focusing on physical activity, nutrition, and mental well-being with an interdisciplinary team.

Families

Occupational therapists can work with families to provide education, promote healthy meal choices, and engage in culturally relevant, consistent routines. Studies have shown that family meals can be a protective factor in reducing obesity, even with a frequency of 1-2 meals per week. The promotion of family participation in enjoyable physical activities such as walking and bike riding can reinforce the value of physical activity.

Conclusion

Occupational therapists can significantly contribute to disease/injury prevention, promote health and wellness behaviors, and strive for health equity through a paradigm shift in reaching out to communities and identifying populations at risk through innovative interventions.

References

American Occupation Therapy Association (2020). AOTA Unveils Vision, 2025. Retrieved from https://www.aota.org/AboutAOTA/vision-2025.aspx

Braverman, B. (2016). Population Health and Occupational Therapy. American Journal of Occupational Therapy, Vol. 70, 7001090010. Retrieved from https://doi.org/10.5014/ajot.2016.701002

Cantal, A. (2019). Managing Obesity in Pediatrics: A Role for Occupational Therapy. AOTA Continuing Education. Retrieved from https//www.aota.org/~/media/Corporate/Files/Publications/CE-Articles/CE-Article-January-2019-Obesity-Pediatrics.pdf

Centers for Disease Control and Prevention (2019). What is Population Health? Retrieved from https://www.cdc.gov/pophealthtraining/whatis.html

Faehnrich, S.McCann, K. (2015). An After-School Wellness Program for Children in Low Socioeconomic Neighborhoods. OT Capstones, University of North Dakota. Retrieved from https://www.commons.und.edu/ot-grad/62/

Halle, A.D., Mroz, T.M., Fogelber, D.J., Leland, N.E. (2018). Occupational Therapy and Primary Care Updates and Trends. American Journal of Occupational Therapy, Vol. 72, 7203090010. Retrieved from https://doi.org/10.5014/ajot.2018.723001

Interdisciplinary Association for Population Health (2020). What is Population Health? Retrieved from https://www.iaphs.org/what-is-population-health/

Morris, D.M., Jenkins, G.R. (2017). Preparing Physical and Occupational Therapists to Be Health Promotion Practitioners: A Call for Action. International Journal of Environmental Research and Public Health, 15(2), Pizzi, M.A.doi: 10.3390/ijerph15020392. Retrieved from https://www.ncbi.nim.nih.gov/pmc/articles/PMC5858461/

Norman, A. (2020). An Overview of the Triple Aim. A framework to help health care systems optimize performance. Retrieved from https://verywellhealth.com/triple-aim-4174961

Pizzi, M.A. (2016). Pizzi, M.A. (2016). Promoting Health, Well-Being, and Quality of Life for Children Who Are Overweight or Obese and Their Families. American Journal of Occupational Therapy, Vol. 70, 7005170010. Retrieved from https://doi.org/10.5014/ajot.2016.705001

University of Washington (2020). What is Population Health? Retrieved from https://www.washington.edu/populationhealth/about/what-is-population-health/

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