Role for Occupational Therapy in Community Mental Health: Using Policy to Advance Scholarship of Practice.

Occupational Therapy In Health Care, Early Online:1–14, 2015 C 2015 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2015.1051689

Occup Ther Health Downloaded from informahealthcare.com by Boston University on 08/10/15 For personal use only.

Role for Occupational Therapy in Community Mental Health: Using Policy to Advance Scholarship of Practice Lisa Mahaffey1 , Kathrine A. Burson2 , Celeste Januszewski3 , Deborah B. Pitts4 , & Katharine Priessner3 1

Department of Occupational Therapy, Midwestern University, Downers Grove, IL, USA, 2 Division of Mental Health, Illinois Department of Human Services, Hines, IL, USA, 3 Occupational Therapy, University of Illinois at Chicago, Chicago, IL, USA, 4 Occupational Therapy, University of Southern California, Los Angeles, CA, USA

ABSTRACT. Occupational therapists must be aware of professional and policy trends. More importantly, occupational therapists must be involved in efforts to influence policy both for the profession and for the people they serve (Bonder, 1987). Using the state of Illinois as an example, this article reviews the policies and initiatives that impact service decisions for persons with psychiatric disabilities as well as the rationale for including occupational therapy in community mental health service provision. Despite challenges in building a workforce of occupational therapists in the mental health system, this article makes the argument that the current climate of emerging policy and litigation combined with the supporting evidence provides the impetus to strengthen mental health as a primary area of practice. Implications for scholarship of practice related to occupational therapy services in community mental health programs for individuals with psychiatric disability are discussed. KEYWORDS. Americans with disabilities, Community mental health, Occupational therapy, Olmstead, Policy, Workforce development

The most eye-opening discrimination is that found in the very health care system that is intended to serve people living with mental illnesses. Joseph Glazer (National Council on Disability, 2000, p. 57).

Address Correspondence to: Lisa Mahaffey, MS, OTR/L, FAOTA, Midwestern University, Department of Occupational Therapy, 555 31st Street, Downers Gove, IL 60515, USA (E-mail: [email protected]). (Received 09 July 2014; accepted 12 May 2015)

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BACKGROUND: POLICY DRIVING THE TRANSITION TO THE COMMUNITY In 1990, Congress passed the Americans with Disabilities Act (ADA) with overwhelming support from congressmen and the general public (ADA, 1990). Much of the discussion around the ADA focused on public access to buildings and access to employment for people with disabilities. It appeared that few people connected Title II of the ADA, which stated that people with disabilities have a right to be integrated into mainstream society, with deinstitutionalization. Potier (2004) states that for many years there was minimal progress as a result of the law and next to nothing was written about improving access to supportive housing. In 1999 the Supreme Court Olmstead Decision changed all that, ruling that institutionalization takes away an individual’s basic human right to live and participate in the community of their choice. Failure to provide people with disabilities with the supports they need to live in the least restrictive setting of their choice was determined to be a violation of Title II of the ADA (Olmstead Decision, 1999). Still, 24 years after the passage of the ADA, many people with disabilities continue to lack opportunities for full inclusion. Senator Tom Harkin from the State of Iowa, in his report entitled “Separate and Unequal: States Fail to Fulfill the Community Living Promise of the Americans with Disabilities Act” stated that more than 200,000 individuals in the United States remain unnecessarily institutionalized (Harkin, 2013). For individuals with psychiatric disabilities, the picture is even bleaker. The State of Illinois has moved, albeit slowly, in supporting the shift from institutions to community-based care for people with disabilities. Illinois ranks number one, compared with other states, for having the highest number of people living in nursing homes who are under 65 years old (Harkins, 2013). In the year 2011, there were over 100,000 individuals with disabilities in Illinois living in nursing homes, 17,284 of which are under the age of 65 (Harkins, 2013). According to the University of Illinois at Chicago (UIC) College of Nursing, out of the total number of individuals residing in nursing homes in the state, 15,000 are there primarily due to psychiatric disabilities (UIC College of Nursing, 2012; Department of Health and Human Services, n.d.). However, several important policy changes have occurred in the last 6 years that are having an impact on the lives of people institutionalized with psychiatric disabilities. In 2009, Illinois took a step toward moving care for people with disabilities to the community by securing a grant through the Money Follows the Person (MFP) Medicaid demonstration project. MFP is a federal initiative that provides a monetary incentive to states working toward rebalancing their funding for long term care from institutions to community-based care (Centers for Medicare and Medicaid Services, n.d.). Under the MFP program Illinois transitioned 27 people with psychiatric disabilities out of their nursing homes the first year and another 100 people the second year (University of Illinois College of Nursing MFP report, 2012). In September of 2010, the State entered into the first of two class action lawsuits forcing the State to offer nursing home residents with psychiatric disabilities an opportunity to move into a less restrictive community setting. The Williams v. Quinn consent decree was settled in 2010 (Department of Human Services, 2011) affecting 4500 residents of Institutes of Mental Disease (IMDs) (Koyanagi, 2007). IMDs


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are facilities in which more than 50% of the residents have a primary psychiatric diagnosis (Department of Human Services, n.d.). In 2011, the State entered the Colbert v. Quinn consent decree affecting 6800 people with psychiatric disabilities who are residents of non-IMD nursing homes in Cook County, IL (Illinois Department of Healthcare and Family Services, n.d.). According to the MFP demonstration report published by Mathematica Policy Research in September of 2014 and the Williams Semi-annual Report for December 2013, 4 years after beginning the MFP initiative, the State has successfully transitioned a total of 968 people with psychiatric disabilities out of nursing homes and into the community (Morris et al., 2014; Illinois Department of Human Services/Division of Mental Health, (DHS-DMH) 2013). There is an economic advantage for the State of Illinois to provide communitybased support for individuals with psychiatric disabilities. States, by law, have a responsibility to provide funding for the services for people with disabilities through a combination of state and federal funds (Koyanagi, 2007). Illinois receives a 50/50 match of federal monies for each resident of a nursing home that receives statefunded Medicaid. IMDs do not qualify for federal matching funds, except for residents who are under 22 or over 64 years of age (Department of Health and Human Services, n.d.). In Illinois, the majority of residents in IMDs are between 22 and 64 years of age, and the State must cover 100% of their care (Johnson, 2010). In 2009, Illinois taxpayers spent more than $122 million to care for residents in these privately run, for-profit IMDs (Johnson, 2010), paying twice as much as it would if these residents lived in housing that receives federal matching money (Harkins, 2013). The recent implementation of the Affordable Care Act brings with it the Community First Choice provision which includes an additional 6% increase in federal matching funds for states that agree to rebalance funding to favor community-based services for people with disabilities (Taormina-Weiss, 2012). The State of Illinois therefore has an added financial incentive to improve access to community services for people with psychiatric disabilities. Living up to the spirit of the Olmstead Act by reducing institutionalization of individuals with psychiatric disabilities frees up state funds which can then be used for support in the community. Economic advantage aside, there are many studies that demonstrate that individuals with psychiatric disabilities prefer living in community settings (Taylor et al., 2009). According to Simon and Hodges (2011), participants who have transitioned to the community experience an increase in their quality of life. Those participants with psychiatric disabilities report a statistically significant increase in integration and inclusion in the community (Simon & Hodges, 2011). Thresholds, a community agency which is active in supporting individuals with psychiatric disabilities, reports that between 70% and 90% of individuals who transition to community living with appropriate support experience a reduction in symptoms, improvement in overall health, and improved quality of life (Thresholds, 2013). Although the Illinois Department of Human Services – Division of Mental Health (IL DHS-DMH) has demonstrated some success in moving people with psychiatric disabilities out of nursing homes and IMDs into the community during the first years of implementing MFP and the Williams Consent Decree, there are still many people who express interest in deinstutionalization who have not been able

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TABLE 1. Factors Contributing to People Being Disenrolled from the Transition Process or for Returning to Institutional Living According the IL DHS-DMH Service Examination Process Individuals have difficulty completing necessary activities of daily living (ADLs) or daily household tasks (IADLs) to a degree that the ACT and Community support teams feel unable to provide sufficient support and assistance. Individuals with mental illness are concerned about social isolation and lack of community inclusion. Many individuals with mental illness identify anxiety or discomfort with being alone in their apartment. Individuals with histories of substance abuse experience relapse and/or rapid escalation of use after they transition out of the nursing home. Team members feel unprepared to help people manage multiple, complex medical conditions in addition to mental illness. People being moved out of institutions have, on average, four comorbid medical conditions such as diabetes, COPD, CHF, obesity, and asthma. Source: Williams Consent Decree Annual Report, 2013

to move out (Jones, 2014). There are several reasons for the delay in progress in Illinois. First, although the organizations helping people transition in Illinois have shown good success (Thresholds, 2013), there are not enough organizations providing the necessary services to support the volume of people who would like to transition to the community. Second, the State is experiencing difficulty in identifying and securing affordable, accessible, and safe housing (DHS-DMH, 2013). One finding that stands out in the reports for Williams and MFP is that nearly 50% of individuals with psychiatric disabilities who expressed interest in transferring out of nursing homes have not been transitioned because “their needs were greater than the community services available” (Jones, 2014). The DHS-DMH and the state Medicaid Authority (Health Care and Family Services – HFS) formally examined its data and service system to see what it might do to increase the numbers of people who could sustain satisfying and safe lives in the community. The reports included data pertaining to why people were identified as not eligible for transition or why they were disenrolled prior to moving. DHS-DMH and the state Medicaid Authority considered diagnosis and medications, data related to emergency room visits and hospitalization and records related to why approximately 6% of individuals who had already moved out of an institution had to or chose to move back in. DHS-DMH then talked with mental health service providers to determine needs that were not being met by existing services, because there was no reimbursement for the service, their staffs were not sufficiently equipped, or the intensity needs were too great. Lastly, the State reviewed the survey data related to quality of life that is collected by as part of the MFP reporting process (Simon & Hodges, 2011). Table 1 outlines the challenges related to transitions identified by DHS-DMH through this process (see Table 1). Feedback from community mental health provider organizations specifically identified the need for more training and expressed concern about their capacity to provide the level of hands-on and direct assistance needed for this population (DHS-DMH, 2013). The Illinois DHS-DMH incorporated these findings into their Strategic Plan 2013–2018 that aims to address these needs in several ways. The primary goal is to include a greater integration of recovery-oriented approaches in all the settings



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in which services are provided to people with psychiatric disabilities, and to insure more effective transition planning from residential settings to the community. A key component of the transition planning process is the provision for more training in living skills prior to and following transition (Illinois Department of Human Services, 2013). Discussions related to achieving this provision led to a decision to include occupational therapy practitioners in the community-based mental health workforce. It was also decided to expand occupational therapy services in Illinois’ state operated psychiatric hospitals, in particular, those facilities serving justiceinvolved individuals and persons who require lengthy hospitalizations (Illinois Department of Human Services, 2013). This decision brings up an important question regarding the inclusion of occupational therapy practitioners as providers in these services. Why are we able to make the claim that occupational therapy will support the successful transition from institutions to community settings for persons with psychiatric disabilities? Community Initiatives In the mid-20th century, efforts to facilitate transition from institutions to community for persons labeled with psychiatric disabilities included the innovation of what were called halfway houses (Glasscote et al., 1971; Raush & Raush, 1968; Rothwell & Doniger, 1966). This approach was informed by the perspective that those discharged from psychiatric institutions and/or hospitals of the time needed a “transitional” space to develop the skills for community living before “going it alone.” Glasscote et al., (1971) stated that as a result of the extended institutional stay, living skills had atrophied or that the person had little independent living practice prior to being institutionalized. One of the earliest of these halfway houses was developed and staffed by occupational therapists Joan Doniger and Edith Maeda. Woodley House founded in 1958 housed 10 residents, and was expanded in the mid1970s to include an apartment program (Kresky et al., 1976; Rothwell & Doniger, 1966). Robert Cohen MD, emphasized the occupational therapy perspective that informed Woodley House’s recovery support practices. He reflected on Doniger and Maeda’s work noting that “from her first contact [the occupational therapist] deals with the patient’s integrative skills, his ego strengths, and fosters the development of his sense of mastery” (p. viii). During the 1980’s, occupational therapist Sally Friedlob and her colleagues at the Sepulveda Veterans Administration Medical Center in the greater Los Angeles area also contributed to the development of the halfway house model. They designed and researched a life-skills program embedded within a halfway house situated on the grounds of the medical center (Friedlob et al., 1986). This life-skills program served as the foundation for what is known as the UCLA Social and Independent Living Skills modules developed by Robert Liberman, MD and Chuck Wallace, PhD (Wallace et al., 1992). Over time, halfway houses drew criticism for being part of a linear continuum approach (Carling, 1995; Ridgway & Zipple, 1990) in which the person was moved from setting to setting as their needs changed. The disruption of these moves was seen as compromising recovery efforts and as a result, this approach has been supplanted by the supported housing or permanent supportive housing approach (SAMHSA, 2010). In supported housing, supports and resources are offered or faded as needed by the individual to sustain themselves in the housing of their


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choice. Here too, occupational therapists have contributed to service innovations. For example, occupational therapist Margaret Swarbrick, PhD, has contributed to the development and research of supported housing in her work with the statewide Collaborative Support Programs of New Jersey (Swarbrick, 2009; Nolan & Swarbrick, 2002). While there are likely more examples of individual occupational therapists practicing and researching community to transition initiatives, these three examples demonstrate our presence over time in such efforts. Successful transition from institutional settings, including “board and care homes” and nursing homes, requires an appreciation of the person’s functional strengths and needs, the resources and supports available at the community living setting and the fit between the person factors and community supports (Schriner & Scotch, 2001). Recent research on neurocognition and social cognition has demonstrated that “functional capacity appears to be influenced more by cognitive functioning, whereas functional performance and outcome are more determined by environmental factors” (Brekke & Nakagami, 2010, p. 26). This represents what has been referred to as the “competence/performance distinction.” This resonates with a well-articulated perspective in occupational therapy, specifically, the cognitive disabilities model’s “biopsychosocial perspective on function – CAN DO; WILL DO, and MAY DO” (McCraith et al., 2011, p. 384). In addition, research has demonstrated that “intrinsic motivation mediates the relationship between cognition and functional outcomes” (Brekke & Nakagami, 2010, p. 31). This resonates with long held views in occupational therapy on occupational engagement from our founders to more contemporary perspectives on motivation and meaning (Kielhofner, 2008; Hasselkus, 2002). In addition to the research, occupational therapy’s practice scope addresses both the person and contextual factors that impact successful transition from institution to community living (AOTA, 2010b, 2014). From the long tradition of functional assessment (Brown, 2009) to the profound understanding regarding the impact of occupational transitions (Heuchemer & Josephsson, 2006), occupational therapy brings a critical set of knowledge and skills to the transition to community living effort (AOTA, 2010a). Occupational therapy’s conceptual practice models that inform our assessment and intervention development provide critical frames for the reasoning needed to make decisions about the nature of the supports that someone may need. When informed by the recovery perspective and partnered with other psychiatric rehabilitation and mental health practices, occupational therapy can increase the likelihood that transitions to the community will be successful and sustained (Stoffel, 2008; Mee, Sumsion & Craik, 2004; Cone & Wilson, 2012). In particular, conceptual practice models that address cognition, sensory processing, occupational performance skills, motivational states, and the impact of the environment on occupational engagement can be brought to work in this area. Community Mental Health Scholarship and Practice The Illinois DHS-DMH has decided to incentivize the addition of occupational therapy into its community mental health workforce to address identified community reintegration needs (DHS-DMH, 2013, p. 16). Table 2 identifies recommended occupational therapy services based on the determination of need and the evidence supporting the addition of the service. Rather than a standalone service,


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TABLE 2. Recommendations for Occupational Therapy Service Provision in the Illinois Mental Health System • Using evaluation methods and interventions to improve performance of ADLs, IADLs, and health rest and sleep routines, including those especially relevant to living safely in the community (AOTA, 2014). • Using occupational therapy evaluations including any or all of the following pertinent areas as indicated (AOTA, 2014): o Affective, cognitive, perceptual, sensory, and motor functions. o Performance skills: Including motor skills, process skills, and communication and social skills. o Performance patterns: habits, routines, rituals, roles. o Analysis of the interaction between the person (body structures and functions, performance skills and patterns, interests, motivations, meaningfulness, etc.), the task requirements, and the environment. • Working with clients to identify strengths and potential strategies to improve performance. Supporting the clients as they learn and embed the strategies into their daily habits and routines to improve effectiveness and consistency of performance. • Teaching effective strategies to other team members in order to assist the client in performing more optimally. • Incorporating the use of natural supports (nonservice supports) into service plans.

occupational therapy will be added to assertive community treatment (ACT) and community support teams for individuals who need more assistance than usual to safely and effectively care for their health and homes or to engage meaningfully with others and participate in their communities. The occupational therapy practitioners will work with the individual, the ACT and community support workers, peer mentors, and anyone the individual wants included, to develop and implement strategies to improve performance and participation in desired areas. There are four identified strategies for expanding access to occupational therapy in the state’s Medicaid mental health system of care. They are as follows. Engage and Equip the Current Occupational Therapy Workforce This strategy includes plans for outreach, education, mentorship, and development of practice communities to ensure practitioners have the support they need to modify their practices to meet identified individual and service system needs. An educational workshop/webinar is being developed that will focus on topics identified by individuals who have recently transitioned to community living, practitioners and community agency staff as being of need in community practice. Topics will include role delineation, policy and system issues, billing and funding streams, evidence-based assessments, and intervention strategies. Monthly newsletters and teleconferences are planned for practitioners joining the community workforce. A bimonthly peer-mentoring program is currently available for therapists in occupational therapy positions in the state hospitals and community-based mental health programs. This group is made up of a variety of people including the occupational therapist who is employed by the state to head this initiative, several academics and researchers at local universities and practitioners in the state hospital and community mental health settings. This group is working together to create a referral system that can be used by providers in the state to determine when a person would benefit from occupational therapy services. The group is developing an assessment and intervention protocol and a statewide reporting tool that meets the needs of a variety of settings and is supported by the most current evidence. Not only will the

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mentoring program provide support to practitioners who are spread out in community settings, it will allow for a high level of fidelity in the way services are provided and reported throughout the state mental health system, which in turn will create opportunities to collect the data needed to answer the research questions identified earlier.


Engage and Equip the Students Who Will Contribute to the Community Mental Health Workforce in the Future Occupational therapy educational programs will need to make stronger linkages with other professional education efforts to ensure that their graduates are prepared to practice in the contemporary mental health service system (Annapolis Coalition, 2007; AOTA, 2010a). This includes having a deep and rich understanding of the occupational needs of people with psychiatric disabilities as they transition from institutional to community living. It also includes strengthening their skill sets for interprofessional teamwork in the community mental health practice context, which includes collaborating with ACT and community support workers, peer mentors, and other mental health and/or social service providers. Educational programs can draw on learner-centered approaches being promoted throughout institutions of higher learning that combine in-class didactic learning using team-based (Michaelson et al., 2004; Michaelsen et al., 2008) and/or problem-based (Sadlo, 2014; Whitcombe, 2013) approaches with experiential and fieldwork experiences. Academic programs can structure service learning, class assignments, and Level I fieldwork experiences in a way that directly addresses the community integration needs identified by both the mental health agencies and the individuals served. For example, a recent curriculum revision at the University of Southern California resulted in a semester-long practice immersion course in which students have ninehours per week of classroom-based instruction and eight-hours per week of Level I fieldwork devoted exclusively to mental health practice. The majority of the Level I placements are in local community mental health settings, primarily programs facilitating community integration for persons with psychiatric disabilities (e.g., ACT and Supported Housing). Students have successfully collaborated with other mental health professionals and peer providers to support individuals with psychiatric disabilities to succeed in their community living recovery goals. With its focus in preparing students to function as entry-level occupational therapists, Level II fieldwork can prepare students to develop into competent and confident community mental health practitioners. Because there are so few occupational therapists working in community mental health, innovative models for Level II fieldwork rather than the 1 to 1 and/or direct supervision models must be developed and adopted. ACOTE standards are in place to support such models (AOTA, 2012), and have already been implemented in many community-based service fieldwork placements. For example, Level II fieldwork students can be assigned in dyads or quads to ACT or community support teams. The team-based supervisor can support one or more dyads as they work with individuals who request support or are identified by the team as potentially benefiting from occupational therapy services. With this model, an occupational therapist can provide the minimum eight hours per week of direct supervision required by the Accreditation Council of Occupational Therapy Education for settings where occupational therapy services


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do not exist (AOTA, 2012). Students and fieldwork educators can use a collaborative model of fieldwork education (Cohn, Dooley & Simmons, 2001), which can facilitate reflective practice, problem-solving, and clinical reasoning to prepare future practitioners to work in complex practice environments. Within this collaborative model, special attention may need to be made to provide learning opportunities that also facilitate student progression toward independent practice. The fieldwork models described would accelerate the pace of equipping future practitioners to focus on community based practice.


Address Structural Systems Issues that Make it Difficult to Recruit and Employ Occupational Therapy Practitioners In Illinois, occupational therapists are identified as qualified mental health professionals and occupational therapy assistants as mental health professionals. However, the salaries commanded by occupational therapy practitioners in other practice areas are typically higher than those in the area of mental health. While this discrepancy is mostly the result of Medicaid being the primary revenue stream, it results in recruitment challenges when positions are available. The plan to address the structural systems issues contributing to decreased access to occupational therapy includes making changes to the State’s Medicaid Plan and Rule, as well as establishing and/or restructuring policies, procedures, job classifications, salaries, and billing procedures and rates. These adjustments will make it easier to recruit and employ occupational therapy practitioners. The success of these efforts in Illinois may provide support for changes in other states. Inform Internal and External Stakeholders of the Education, Specific Skill Set, and Evidence to Support Occupational Therapy Services in Community Mental Health The stakeholders who make these decisions in Illinois DHS-DMH were able to identify occupational therapy because there is an occupational therapists sitting at the table. Katherine Burson is part of the DHS-DMH executive leadership team, a unique position for occupational therapists that she attained through a series of steps. Burson began with a self-initiated review and analysis of Illinois’ mental health system’s plan, priorities, and concerns. She then spent time reflecting on the intersection between occupational therapy expertise and the system’s priority needs. Armed with that information Burson engaged in extensive professional net-working with nonoccupational therapy professionals and began articulating occupational therapy knowledge in everyday language that others viewed as innovative and transformational. Because of her effort in applying an activity analysis approach to the examination and transformation of systems of care Burson now serves on the Illinois DHS-DMH leadership team. However, Burson’s position on the team that reviews service gaps for Williams class members is not identified specifically as an occupational therapist. Regardless of her title her presence on the team allows her to articulate the ways that occupational therapy might address key concerns. This has allowed Burson to emphasize occupational therapy’s scope of practice and distinct skills related to evaluating the person factors and the environment, and facilitating a focus on performance and participation in everyday occupations


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Educating stakeholders must be ongoing, draw on evidence, and include both formal and informal venues. Stakeholders who are provided this information through these various approaches are more likely to understand and support the new role for occupational therapy as part of the community mental health teams. Most mental health professionals working in the current public mental health system have not worked side by side with occupational therapy practitioners. It will be important for occupational therapy practitioners to take the time to observe, listen, and understand how other team members approach the identified problems for the people being served and educate others of their role. Appreciating and validating the expertise of fellow team members will be important in order to avoid tension around role confusion. Within this context, the occupational therapy practitioner offers the team an additional perspective and approach to support individuals who are striving to do what they need or want to do. Strategies for Scholarship Although there is a body of literature supporting a role for occupational therapy in transition to community initiatives, there are several unanswered questions that lend themselves to occupational therapy research projects. The 2013 annual report to the court related to the Williams consent decree identified a growing number of people who, after expressing a desire to move out, were identified under the broad classification of “unable to serve” primarily due to cognitive incapacity. In addition approximately 14% of people with psychiatric disability return to institutions after a period of time in the community (Morris et al., 2014; Jones, 2015). Research related to outcomes in the transitional literature identifies mental deterioration and social isolation as reasons for returning to institutionalization (Morris et al., 2014). In addition transition leaders in the state of Illinois identify challenges with activities of daily living, instrumental activities of daily living and the responsibilities inherent in the role of tenancy as key determinates of success (Illinois Department of Human Services, 2013). The following research strategies are suggested. Establish Research to Support Occupational Therapy Interventions Designed to Help People Establish or Maintain Community Tenancy An occupational therapy perspective on the role of cognition in everyday activities can support research focused on determining if there is a level of cognitive capacity that prohibits community tenure. Another important area of research centers on the development of an assessment and intervention protocol that goes beyond determining a set of external supports, focusing instead on assessing and improving the quality of a person’s occupational performance and finding adaptations to increase their success and satisfaction in everyday tasks. Establish Research Designed to Support Satisfactory Community Engagement for People Who Have Moved Out of Institutions Occupational therapy research could support interventions focused on increasing community engagement. Research questions might include: What really interferes with a person’s ability to engage and become part of their chosen community? And what role can occupational therapy practitioners take in the process of supporting community engagement? Most important to both occupational therapy and the


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state’s transition to community initiatives is the need to determine if adding occupational therapy to state and community services has a positive impact on community tenure for people with psychiatric disabilities.


CONCLUSION Policy changes, new healthcare initiatives, and pressure to decrease state and federal debt have created new opportunities for service improvements targeting the community integration needs of people with psychiatric disability. Due to monetary initiatives such as MFP, the Affordable Care Act’s Community First Choice, and consent decrees such as Williams v. Quinn, states like Illinois are compelled to make community living work for people regardless of their support needs. Occupational therapy practitioners can contribute to the likelihood of success in those states where community-based providers are engaged in facilitating institution to the community transitions. Occupational therapy practitioners must familiarize themselves with current policy and healthcare initiatives. They must then communicate with the appropriate public health, mental health, and social service authorities in their state regarding our contributions to community mental health in the past, as well as how we might be incorporated into the contemporary service approaches adopted by their state. Occupational therapists can look for opportunities to obtain employment in their state’s department of mental health services. Having an occupational therapist sitting at the table improves the chance that decision-makers will see the value of occupational therapy as a way to solve many of the identified transition challenges. Most states are currently engaged in mental health workforce development efforts, and state occupational therapy associations can help occupational therapy mental health practitioners participate in and/or take the lead in these efforts. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper. ABOUT THE AUTHORS Lisa Mahaffey, MS, OTR/L, FAOTA, Midwestern University, Department of Occupational Therapy, Downers Grove, Illinois. Kathrine A. Burson, Illinois Department of Human Services, Division of Mental Health, Hines, Illinois. Celeste Januszewski, University of Illinois at Chicago, Occupational Therapy, Chicago, Illinois. Deborah B. Pitts, University of Southern California, Occupational Therapy, Los Angeles, California. Katharine Priessner, University of Illinois at Chicago, Occupational Therapy, Chicago, Illinois, USA. REFERENCES Annapolis Coalition. (2007). An action plan for behavioral health workforce development: A framework for discussion. Cincinnati, OH: Annapolis Coalition. American Occupational Therapy Association. (2010a). Specialized knowledge and skills in mental health promotion, prevention and intervention in occupational therapy practice. American Journal of Occupational Therapy, 64, S30–S43, doi:10.5014/ajot.2010.64S30.


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