Shared decision making (SDM), or the process by which clients actively work with health care professionals to make informed decisions about health care options, is critical to value-based, client-centered care and representing client preferences as part of the occupational therapy process. With the enactment of the Patient Protection and Affordable Care Act and the continued focus on patient-centered care models and quality indicators, occupational therapy practitioners must be prepared to engage in SDM. In this Health Policy Perspectives article, we provide considerations about how occupational therapy practitioners may use Choosing Wisely® recommendations to engage clients in SDM and provide high-quality evidence-based care.
Policy shifts brought about by the Patient Protection and Affordable Care Act (ACA; 2010; Pub L. 111-148) have made patient engagement in health care decisions imperative. The main purpose of the ACA is to improve access to health care through health insurance. It does this by requiring all people to qualify for acceptable coverage, mandating that employers with 50 or more employees provide insurance, allowing small businesses to purchase subsidized plans, and expanding Medicare eligibility. The ACA also includes different rights and protections that establish the patient as an active consumer.
Consumers of any type of product or service need to understand what they are purchasing, weigh the pros and cons of different options, and make informed decisions. In addition, consumers of health services need to demonstrate health literacy. Health literacy is defined by the ACA (2010) as “the degree to which an individual has the capacity to obtain, communicate, process, and understand health information and services in order to make appropriate health decisions” (Title V, Subtitle A). Several provisions in the ACA emphasize health literacy, and Section 3506 calls on health care providers to collaborate with patients and caregivers in a manner that facilitates decision making and conveys information about different treatment options.
Shared Decision Making
Informed decision making about health care options is complex and involves many factors, such as the availability and usability of information, the receptivity and engagement of the consumer, and the willingness of the practitioner. Practitioners who are accustomed to basing their clinical decisions on evidence may be hesitant to share decision making with consumers whom they perceive to have low health literacy. Shared decision making (SDM) provides a framework for the challenging process of integrating the client’s perspectives with knowledge gained from research to assist consumers in making well-informed health care decisions (Albarqouni et al., 2020; Moleman et al., 2021).
SDM becomes increasingly important when clients are faced with health care options that are costly to third-party payers; require preapproval or out-of-pocket payments; or pose varied risks, benefits, and downstream consequences. SDM involves presenting the client with intervention options, supporting the client to gain information about intervention and treatment options, assessing the client’s understanding of the options, gaining insights into the client’s preferences, and integrating the client’s preferences into intervention (Moore & Kaplan, 2018).
Client gains associated with SDM include increased knowledge, understanding, satisfaction, trust, and adherence to recommendations (Légaré et al., 2018). From a health systems perspective, SDM helps to reduce the overuse of intervention and treatment options that are not associated with clear benefits for most clients and to increase clients’ agency over their health (Légaré et al., 2018). Lack of time is often viewed as a barrier to SDM (Moleman et al., 2021). Decision aids (e.g., synthesized research briefs, client education materials) can be used by practitioners to efficiently involve clients in the decision-making process and convey information about intervention options and outcomes in a time-effective manner (Légaré et al., 2018).
SDM is collaborative and client focused, so it is a natural complement to the occupational therapy process. Collaboration is central to the practice of occupational therapy (Hooper & Wood, 2019) and relies on the practitioner’s willingness to view the client as an expert on their own preferences and lived experience (Cohn & Crepeau, 2019), as well as on an understanding of the interplay among the client, their occupational engagement, and the environment or context in which this engagement occurs (American Occupational Therapy Association [AOTA], 2020,; Hooper & Wood, 2019). Engagement in occupations that are personally meaningful, sustainable, and supportive of health is the desired outcome of occupational therapy intervention (Schell et al., 2019).
AOTA’s Commitment to Fostering Meaningful Conversations
In 2012, Choosing Wisely®, an initiative of the American Board of Internal Medicine (ABIM) Foundation, began with the purpose to foster meaningful conversations about health care options between practitioners and their clients and to advance a national conversation about the overuse of ineffective and unnecessary medical tests and interventions. The primary objective of this ABIM initiative is to ensure that quality care is being provided and to promote assessment methods and interventions that are supported by evidence, not duplicative of other tests or procedures already received, free from harm, and truly necessary.
In 2016, AOTA joined this initiative and committed to engaging clients in SDM. AOTA recognized that the Choosing Wisely recommendations were a mechanism to support clients to make informed heath care choices, promote the effective use of health care resources, and assist in improvements in the quality and safety of health care in the United States (Gillen et al., 2019). AOTA staff and volunteer leaders initiated a three-phase process in Summer 2016 to develop and disseminate “Five Things Patients and Providers Should Question,” published in 2018 (ABIM, 2021), and a full account of the method used during this process is reported in Gillen et al. (2019).
Encouraging conversation and collaboration between practitioners and clients was a primary goal of AOTA’s involvement in the Choosing Wisely campaign. To support this goal, AOTA developed a consumer version of the recommendations. The consumer article “Five Occupational Therapy Treatments to Think Twice About” (ABIM, 2018) was written in lay language and provides information about occupational therapy and the types of interactions and services clients can expect, as well as examples related to the recommendations. This article may be helpful to consumers who independently seek information related to their own or another’s care, and occupational therapy practitioners may also use it as part of SDM when speaking to clients about their goals, interests, and preferences. Occupational therapy practitioners can increase their clients’ readiness to participate in decision making related to their care by providing education about current research and the types of occupational therapy practices that are most effective and safe for them.
Next Choosing Wisely Recommendations: Five More Things Patients and Providers Should Question
After the dissemination phase for the initial five recommendations, AOTA embarked on a plan to develop five additional recommendations. The method for selection and development of the new recommendations was similar to the original development process and involved an AOTA member survey, collaboration with member content experts, and a literature review.
In 2021, ABIM published Recommendations 6 to 10:
6. Don’t initiate occupational therapy interventions without completion of the client’s occupational profile and setting collaborative goals.
Best practice occupational therapy relies on a practitioner’s understanding of a client’s occupational history and experiences, patterns of daily living, interests, values, and needs, as well as active partnership with the client and care partners (e.g., partners, parents, caregivers) to develop meaningful goals. As stated in the fourth edition of the Occupational Therapy Practice Framework: Domain and Process (OTPF-4), “only clients can identify the occupations that give meaning to their lives and select the goals and priorities that are important to them” (AOTA, 2020 [p. 22]). If the client or care partners are not involved in developing the profile and identifying goals, priorities, and outcomes, full engagement in occupations may not be accomplished.
7. Don’t provide interventions for autistic persons to reduce or eliminate “restricted and repetitive patterns of behavior, activities, or interests” without evaluating and understanding the meaning of the behavior to the person, as well as personal and environmental factors.
Occupational therapy practitioners should provide person-centered, strengths-based interventions, and advocate for autistic persons on individual and societal levels by providing information to promote inclusivity and belonging, and to decrease stigma. Actions that are considered “restricted and repetitive behaviors” by the [5th edition of the Diagnostic and Statistical Manual of Mental Disorders] (American Psychiatric Association, 2013) may serve as meaningful activities for self-regulation, communication, or self-expression. Attempting to change or extinguish these behaviors without direct request from the individual, without understanding and incorporating the underlying meanings, or substituting other actions to meet self-regulatory reasons for the behavior commonly results in camouflaging (e.g., masking or hiding behaviors), that can result in negative self-image, depression, and an increased risk of suicidality.
8. Don’t use reflex integration programs for individuals with delayed primary motor reflexes without clear links to occupational outcomes.
Interventions designed solely to integrate retained reflexes do not promote participation in occupation, and while they may be observed in clients with difficulties in occupational performance, the presence of retained reflexes does not necessarily equate to functional impairment. If reflex integration techniques (i.e., techniques designed to integrate, or inhibit, primary motor reflexes that are retained beyond the typical developmental stage of integration) are being considered for intervention, standardized tools and assessment approaches are necessary to connect impairment to occupational performance. Intervention should focus on improving occupational participation and performance rather than solely on reflex integration.
9. Don’t use slings for individuals with a hemiplegic arm that place the arm in a flexor pattern for extended periods of time.
Standard shoulder slings immobilize the upper extremity in a flexor pattern (i.e., a position of elbow flexion, and shoulder adduction and internal rotation). Utilizing a sling that places a person’s hemiplegic arm in this position for extended periods of time increases the risk of contractures and pain, and limits active use of the extremity, thereby decreasing opportunities for neuroplastic changes that support an organic increase in function. Education should be provided to clients and caregivers on safe positioning of the hemiplegic arm during activity and at rest.
10. Don’t provide ambulation or gait training interventions that do not directly link to functional mobility.
Occupational therapy practice requires consideration of contextual factors that affect a person’s ability to participate in meaningful occupations. Gait training and ambulation interventions do not necessarily consider the context of performing everyday activities. While occupational therapists can assess underlying performance skills for ambulation and gait and use related interventions, they must address functional mobility by considering the context to implement effective, evidence-based interventions that are personally meaningful to the individual.
In 2022, AOTA will continue to disseminate the recommendations and develop resources to support implementation and SDM conversations between occupational therapy practitioners and clients. All recommendations are reviewed on an annual basis to ensure continued adherence to current evidence.
Considerations for Using Choosing Wisely Recommendations to Foster Shared Decision Making
The occupational therapy process is complex, and for it to be effective, occupational therapy practitioners must possess a wide range of skills associated with analyzing the many factors associated with occupational performance and participation (AOTA, 2020,; Schell et al., 2019). In addition, practitioners must also be adept at using interpersonal skills to create supportive relationships with clients and to partner with them in the therapeutic process (AOTA, 2020,; Schell et al., 2019). SDM provides a framework for practitioner–client collaboration and an opportunity to acknowledge the client as the primary driver of their own health management.
Stiggelbout et al. (2015) proposed four steps for SDM that can easily be applied to occupational therapy intervention decisions:
The practitioner presents the decision to the client and stresses that the client’s opinion is important.
The practitioner uses evidence and explains the pros and cons of each intervention option.
The practitioner elicits the client’s preferences and supports the client as they weigh different considerations.
The practitioner and the client negotiate and come to a decision.
To effectively collaborate with the client in SDM, the practitioner must understand the client’s expectations related to intervention goals and openly discuss the probability or likelihood that the client will benefit from the intervention (Albarqouni et al., 2020). The Choosing Wisely recommendations provide a client-centered and functionally based approach to engaging in conversations about goal expectations and the benefits of certain interventions compared with others. As part of the SDM process, occupational therapy practitioners may also inquire about a client’s knowledge or previous experiences with occupational therapy. If a client’s past experiences or expectations of occupational therapy do not reflect evidence-based practices, the Choosing Wisely recommendations may be introduced to provide education on deimplementation and how practitioners adapt practice on the basis of current evidence.
Deimplementation, or discontinuation of practices that are low value or harmful, is essential to the provision of quality health care. Multiple factors influence deimplementation, such as an individual practitioner’s knowledge and prior experiences, organizational factors such as resources and culture, the nature of the intervention in question, and the client’s historical experiences and unique characteristics (Norton & Chambers, 2020). In addressing client education about best-practice occupational therapy, including the need to discontinue or replace certain familiar or expected but low-value interventions, additional resources may be helpful to provide context about existing evidence, the occupational therapy process, and alternative interventions and applications.
To aid in deimplementation of the practices identified in the Choosing Wisely recommendations, AOTA staff members and volunteers developed a series of clinical application resources that use intervention examples to demonstrate the intervention that should be deimplemented and the evidence-informed intervention that may be used as a replacement (Richardson, 2019). The handouts also provide examples of how interventions may be graded to meet a client’s needs at various stages of the intervention plan, as well as ideas for addressing environmental considerations, such as the availability of necessary materials. Practitioners may use the handouts as an individual resource or in the SDM process as tools for health education and decision making.
Current legislation requires that health care providers collaborate with consumers to make health care decisions. SDM provides a framework to engage consumers in collaborative discussions and is well aligned with occupational therapy’s emphasis on client-centered and evidence-based care. AOTA’s Choosing Wisely recommendations and related resources provide an opportunity for practitioners to engage in health literacy education, and they act as tools for informed decision making by supporting conversations about deimplementation, best-practice care, and specific intervention options.
We acknowledge and thank the following individuals for their participation in the American Occupational Therapy Association’s Choosing Wisely initiative and their review and feedback on this article: Glen Gillen, Elizabeth G. Hunter, Deborah Lieberman, and Heather Parsons.