everyday advocacy

Policies supporting OT's role in shaping contexts and environments

Federal policies and legislation support occupational therapy's role in shaping social contexts and environments to facilitate health, well-being, and participation in occupations. Understanding these policies is important to achieving the best outcomes for your clients.

Across all areas of practice, occupational therapy practitioners select, create, modify, and use the physical environment to facilitate clients achieving health, well-being, and participation in desired occupations. Practitioners’ capacity to influence clients’ environments is limited or enhanced by current laws and policies, and a practitioner's understanding of these policies, regulations, and reimbursement that affect practice. 

We want to ensure occupational therapy practitioners have information about the environmental factors of services, systems, and policies, in order to maximize clients’ occupational performance through modification of environments and provision of products, technologies, and supports. 

Practitioners should be aware of how legislation and policies may support or hinder opportunities for engagement in occupations within clients' communities and how these policies may disproportionately affect some of the clients and communities they work with.  Below is a list of legislation, regulations, and policies that impact occupational therapy practice, particularly as it relates to influencing the physical environment, along with case studies describing how these policies relate to the provision of services.

Legislation, regulations, and policies with case study examples

While this list is not all inclusive, here are some of the most well-known pieces of policy and legislation that impact occupational therapy practice, and case studies describing their application to practice. There are additional policies that may apply to your specific area of practice.

The Social Security Amendments of 1965 (Pub. L. 89-97)

  • Established a national public health care program, Medicare, to meet the needs of older Americans and people with disabilities who qualify for services, and included an optional state–federal program to provide health care and rehabilitation.

The Older Americans Act of 1965 (OAA; Pub. L. 89-73)

  • Created and funded a network of local and state entities, many called Area Agencies on Aging. These programs and services focus on helping older people plan and care for their lifelong needs, keeping older adults living independently in their own homes, and providing a broad range of other services.
  • In March 2020, the OAA was amended through the Supporting Older Americans Act of 2020 (Pub. L. 116-131), which made local and state entities eligible for grants under Section 411 that bring to scale evidence-based programs focused on reducing falls, promoting chronic disease self-management, and managing chronic conditions.

The Fair Housing Act of 1968 (Pub. L. 100-420)

  • Includes Title VIII of the Civil Rights Act of 1968, as amended, which prohibits discrimination in the sale, rental, and financing of dwellings and in other housing-related transactions because of race, color, religion, sex, familial status, national origin, and disability.
  • Requires that all federal programs relating to housing and urban development be administered in a manner that affirmatively furthers fair housing.

Section 504 of the Rehabilitation Act of 1973 (Pub. L. 93-112)

  • Part of a civil rights law that states that no person may, on the basis of their disability, be excluded from participation in or denied the benefits of any program or activity receiving federal financial assistance.
  • In educational settings, the law requires schools to ensure equal education opportunities for students with a qualifying disability through the provision of special education services related to service modification or accommodations.

The Rehabilitation, Comprehensive Services, and Developmental Disabilities Amendments of 1978 (Pub. L. 95-602)

  • Provides federal funding in cooperation with states to establish a national network of consumer-run community facilities and services.
  • Advocates for the removal of architectural and transportation barriers that prevent people with disabilities from sharing fully in aspects of society.

The Omnibus Budget Reconciliation Act of 1987 (Federal Nursing Home Reform Act; Pub. L. 100-203)

  • Created national minimum standards of care and a bill of rights for people living in certified nursing home facilities. It requires nursing homes to develop individualized care plans that focus on maintaining or improving residents’ ADL performance, training paraprofessional staff, and protecting residents from unnecessary and inappropriate physical and chemical restraints.
  • Created both requirements and opportunities for occupational therapy practitioners to facilitate optimum function, address mental health, and maximize participation.

The Americans with Disabilities Act of 1990 (ADA; Pub L. 101-336), updated in the ADA Amendments Act of 2008 (Pub. L. 110-325)

  • Built on previous civil rights legislation targeted at protecting the rights and enhancing the participation of minority groups.
  • Includes five titles that address employment, state and local government services, transportation, public accommodation, and telecommunications with the goal of ending discrimination against people with disabilities in all areas of life.
  • Title II prohibits discrimination based on disability in programs and activities provided or made available by public entities; protections for housing-related programs are enforced by the U.S. Department of Housing and Urban Development.
  • Title III of ADA prohibits discrimination based on disability in the goods, services, facilities, privileges, advantages, and accommodations of public places owned, leased, or operated by private entities.

Olmstead v. L. C. (1999)

  • U.S. Supreme Court ruling against the state of Georgia that affirmed the right of people with disabilities whose living situation is supported by state or federal funds to live in their community rather than an institution whenever possible.
  • Dictates transfer from institutional care to a less restrictive setting when not opposed by the affected person and with reasonable accommodation for the placement, taking into account state resources and the needs of others with psychological and cognitive limitations.

The Individuals with Disabilities Education Improvement Act of 2004 (IDEA; Pub. L. 108-446)

  • Governs the provision of early intervention services for children aged birth–3 and special education and related services to students aged 3–21.
  • Specifies that children be removed from the regular education environment only if the nature or severity of the disability is such that education in a regular classroom cannot be achieved.
  • Part B ensures that students aged 3–21 have access to a free appropriate public education that emphasizes special education and related services to prepare them for further education, employment, and independent living.
  • Part C, for children aged birth–3 and their families, enhanced and expanded states’ capacity to provide early intervention services and to help maintain, implement, and coordinate interagency services.

The Every Student Succeeds Act of 2015 (Pub. L. 114-95)

  • The latest reauthorization of the Elementary and Secondary Education Act of 1965 (Pub. L. 89-313), replaces the No Child Left Behind Act of 2001 (Pub. L. 107-110)
  • Among the many opportunities in this latest legislation, occupational therapy practitioners are included as “specialized instructional support personnel” (SISP), a new term for “pupil services personnel.” SISPs must be consulted on the development of state accountability plans, which address how schools are assessed, and the formulation of alternative academic achievement standards for students with cognitive impairment.
  • States must also provide “comprehensive support and improvement” funding to low-rated schools. This assistance includes at-risk students and is, in part, determined and implemented by SISPs.

The Recognize, Assist, Include, Support, and Engage Family Caregivers Act of 2017, also called the RAISE Family Caregivers Act (Pub. L. 115-119)

  • Directs the U.S. Department of Health and Human Services to develop a national family caregiving strategy to promote greater use of person- and family-centered care in health care and long-term care, assessment and planning for care, information, education, training support, referral, care coordination, respite options, and attention to financial security and workplace issues.
  • This Act presents opportunities for occupational therapy practitioners working with people across the lifespan.

Case study examples

Charles, age 54: Insecure housing case example

Case description

Context focus of occupational therapy services

Examples of interventions to address the context

Research evidence and related practice guidance

Legislation to support intervention

Charles is a 54-year-old man residing in a city shelter for homeless adults. Charles has a history of stroke resulting in aphasia, and an ongoing history of alcohol use and abuse. Charles’s aphasia severely limits his expressive language, and often he is able to say only “yeah” or “no” in response to questions; however, his receptive language is intact. Charles is applying for the city’s supportive housing and reduced rent program with a goal of living independently.

 

Charles was referred to occupational therapy by the shelter’s and housing program’s social workers because of concerns about his safety and hesitation about supporting his goal of living independently. The potential landlord expressed similar concerns, suggesting that Charles was not a good candidate for an apartment.

The shelter setting limits Charles’s occupational performance; he is unable to complete most IADLs because of his inability to access facilities (e.g., kitchen for meal prep, laundry equipment), and the lack of physical accessibility in the shelter bathrooms means he requires some support for ADLs.

 

Because of these limitations of the shelter and the attitudes and beliefs of its employees, Charles’s providers were not aware of his intact functional skills and made assumptions based on his language limitations, assuming that his perceived cognitive impairment and his history of alcohol use would prohibit his ability to complete tasks independently.

Complete a functional assessment of Charles’s independent living skills and functional cognition. Charles demonstrates safety in his ability to prepare meals, completes basic home cleaning tasks, and shows appropriate safety awareness responses.

 

Provide training in skills to use adaptive equipment for ADLs that can be easily implemented in a standard, nonaccessible apartment and safety supports such as LifeAlert systems for emergencies.

 

Educate the housing program and shelter staff regarding the Fair Housing Act of 1968, which prevents discrimination based on disability.

Gutman & Raphael-Greenfield (2017)

 

Helfrich & Fogg (2007)

 

Helfrich & Synovec (2019)

 

Raphael-Greenfield (2012)

 

Roy et al. (2017)

Synovec et al. (2020)

Wolf et al. (2015)

The Fair Housing Act supports diversity in housing, which connects to occupational therapy’s commitment to inclusion and diversity. It also can be used as a tool to reaffirm the World Health Organization (2018) guidelines that housing is health care.

Section 504 of the Rehabilitation Act of 1973 (§ 794) states that occupational therapy services can be used in any program funded with federal funds to ensure equal access for people with disabilities.

Title II of the Americans with Disabilities Act of 1990 prevents discrimination in public housing, housing assistance, and housing referrals.

Title III of the Americans with Disabilities Act of 1990 prohibits discrimination based on disability in services and accommodations, including therapy and housing.

Olmstead v. L. C. (1999) affirmed that states must place people with psychological and cognitive impairments in community settings when possible.

Clive, age 7: School-based case example

Case description

Context focus of occupational therapy services

Examples of interventions to address the context

Research evidence and related practice guidance

Legislation to support intervention

Clive is a 7-year-old Chinese American boy who qualifies for an individualized education program (IEP) and special education and related services because of developmental delay. Clive was born at 27 weeks gestation and participated in early intervention services before transitioning into the school district for services.

 

Clive has low muscle tone, difficulties with visual acuity and strabismus, fine and gross motor delays, and difficulty with focused attention, classroom participation, and peer social interactions.

Intervention will focus on collaborating with Clive’s teachers to ensure access to education and the curriculum. Individual therapy will address Clive’s occupational engagement, with goals to support fine motor and visual–motor skill development and activity tolerance. In push-in classroom visits, the treating practitioner assesses environmental barriers and makes activity modifications and recommendations for Clive’s participation in classroom routines.

 

Clive’s health and well-being must be considered while providing the same access as his peers to all physical environments, including all areas of the building, outdoor spaces, and field trips.

 

Equity in service delivery includes ensuring that Clive has access to modified furniture and materials, social participation, and school-based extracurricular activities. Parent collaboration and student input will promote self-advocacy.

Trial use of modified seating options to support Clive’s attention and engagement and his low tone for extended periods of seated work in the classroom.

Consider Clive’s positioning within the classroom to address his vision challenges and limit environmental (visual, auditory, peer) distractions.

Collaborate with other members of the IEP team to support Clive’s social participation, peer-to-peer interaction, and play.

Evaluate the space used for all school activities including classroom work, electives, physical education, and extracurricular activities, and provide recommendations for environmental modifications for both universal design and client-specific needs to maximize participation.

Educate and collaborate with the interdisciplinary team and community to advocate for the elimination of environmental health barriers such as poor outdoor air quality, polluted surface and ground water, and toxic substances, because these factors influence access to education and health, well-being, and participation.

Cahill & Beisbier (2020)

 

University of Cambridge. (n.d.).

 

Kramer et al. (2017)

 

Section 504 of the Rehabilitation Act of 1973 mandates equal educational opportunities for students with disabilities through service modifications or accommodations.

 

The Individuals with Disabilities Education Improvement Act of 2004, Section 300.34, Part B, names occupational therapy as a related service that is in place to “assist a child with a disability to benefit from special education” and should be applied to all parts of education.

 

The Every Student Succeeds Act of 2015 allows occupational therapy practitioners to be involved in the development of academic achievement standards.

Rubén, age 2: Early intervention case study

Case description

Context focus of occupational therapy services

Examples of interventions to address the context

Research evidence and related practice guidance

Legislation to support intervention

Rubén is a 2 1/2-year-old Cuban boy with autism. He is currently receiving services through early intervention. He and his parents recently migrated from Cuba. They are of Afro-Cuban descent and identify strongly with their Hispanic roots. Spanish is the primary language spoken in the home.

 

Rubén’s parents report concerns with Rubén’s communication skills, as he is nonverbal and uses grunting when expressing his wants and needs. Rubén demonstrates difficulty globally in regard to development; he demonstrates significant delays in gross motor skills, fine motor skills, ADLs, and play skills. Rubén has tactile defensiveness, seen during his everyday activities and when he plays with his preferred stuffed animal.

Intervention will focus on Rubén’s two primary familiar environments: his home and the day care facility. Rubén’s parents report that they are especially concerned about Rubén’s cultural development because of their mixed ethnicities and their neighbors stating that Rubén is a “beautiful Black child,” suggesting that the neighbors are overly concerned about race. Back in Cuba, Rubén was taken care of daily by his grandmother when his parents were at work. The family system (support and relationships) must be considered during Rubén’s treatment sessions.

Address Rubén’s deficit areas through the use of environments familiar to the family and Rubén in their one-floor single-family home and day care. The community his family resides in has a pediatric sensory park that is great for sensory exposure, play skill development, gross motor skills planning, social role modeling, and praxis.

Train Rubén and his parents to use an alternative communication picture board with familiar items, age-appropriate objects, and simple commands. This tool will be taught to help address the language barriers and Rubén’s communication deficits.

Educate Rubén’s parents on legislation and rights regarding access to services moving forward to allow maximum parental advocacy.

Begin the transition planning from early intervention services, which take place primarily in the home, to the school setting.

May-Benson & Koomar (2010)

 

Pfeiffer et al. (2011)

 

Thiemann-Bourque et al. (2016)

The Individuals with Disabilities Education Improvement Act of 2004, Part C, for children aged birth–3 and their families, enhanced and expanded states’ capacity to provide early intervention services and to maintain, implement, and coordinate interagency services for early intervention, including analyzing and adjusting the environment for learning. Occupational therapy was established as a primary service provider.