american occupational therapy association's (aota) occupational therapy practice framework, 3rd edition, the domain of occupational therapy is described as "achieving health, well-being, and participation in life through engagement in occupation". occupational therapy practitioners have a distinct value in their ability to utilize daily occupations to achieve optimal health and well-being. by examining an individual's roles, routines, environment, and occupations, occupational therapists can identify the barriers in achieving overall health, well-being and participation. occupational therapy practitioners can intervene at primary, secondary and tertiary levels of intervention to promote health and wellness. it can be addressed in all practice settings to prevent disease and injuries, and adapt healthy lifestyle practices for those with chronic diseases. two of the occupational therapy programs that have emerged targeting health and wellness are the lifestyle redesign program and the real diabetes program. occupational therapy interventions for health and wellness vary in each setting: school occupational therapy practitioners target school-wide advocacy for health and wellness including: bullying prevention, backpack awareness, recess promotion, school lunches, and pe inclusion. they also heavily work with students with learning disabilities such as those on the autism spectrum. a study conducted in switzerland showed that a large majority of occupational therapists collaborate with schools, half of them providing direct services within mainstream school settings. the results also show that services were mainly provided to children with medical diagnoses, focusing on the school environment rather than the child's disability. outpatient occupational therapy practitioners conduct 1:1 treatment sessions and group interventions to address: leisure, health literacy and education, modified physical activity, stress/anger management, healthy meal preparation, and medication management. acute care occupational therapy practitioners conduct 1:1 treatment sessions, group interventions and promote hospital-wide programs targeting: self-care activities, neurocognitive assessment and intervention, pain management techniques, physical activity and mobility, leisure, social engagement, stress management, diet and lifestyle recommendations, and medication management. community-based occupational therapy practitioners develop and implement community wide programs to assist in prevention of diseases and encourage healthy lifestyles by: conducting education classes for prevention, facilitating gardening, offering ergonomic assessments, and offering pleasurable leisure and physical activity programs. mental health the occupational therapy profession believes that the health of an individual is fostered through active engagement in one's occupations (aota, 2014). when a person is experiencing any mental health need, his or her ability to actively participate in occupations may be hindered. for example, if a person has depression or anxiety, he or she may experience interruptions in sleep, difficulty completing self-care tasks, decreased motivation to participate in leisure activities, decreased concentration for school or job related work, and avoidance of social interactions. occupational therapy practitioners possess the educational knowledge base in mental health and can contribute to the efforts in mental health promotion, prevention, and intervention. occupational therapy practitioners can provide services that focus on social emotional well-being, prevention of negative behaviors, early detection through screenings, and intensive intervention (bazyk & downing, 2017). occupational therapy practitioners can work directly with clients, provide professional development for staff, and work in collaboration with other team members and families. for instance, occupational therapists are specifically skilled at understanding the relationship between the demands of a task and the person's abilities. with this knowledge, practitioners are able to devise an intervention plan to facilitate successful participation in meaningful occupations. occupational therapy services can focus on engagement in occupation to support participation in areas related to school, education, work, play, leisure, adls, and instrumental adls (bazyk & downing, 2017). occupational therapy utilizes the public health approach to mental health (who, 2001) which emphasizes the promotion of mental health as well as the prevention of, and intervention for, mental illness. this model highlights the distinct value of occupational therapists in mental health promotion, prevention, and intensive interventions across the lifespan (miles et al., 2010). below are the three major levels of service: tier 3: intensive interventions intensive interventions are provided for individuals with identified mental, emotional, or behavioral disorders that limit daily functioning, interpersonal relationships, feelings of emotional well-being, and the ability to cope with challenges in daily life. occupational therapy practitioners are committed to the recovery model which focuses on enabling persons with mental health challenges through a client-centered process to live a meaningful life in the community and reach their potential (champagne & gray, 2011). the focus of intensive interventions (direct–individual or group, consultation) is engagement in occupation to foster recovery or "reclaiming mental health" resulting in optimal levels of community participation, daily functioning, and quality of life; functional assessment and intervention (skills training, accommodations, compensatory strategies) (brown, 2012); identification and implementation of healthy habits, rituals, and routines to support wellness. tier 2: targeted services targeted services are designed to prevent mental health problems in persons who are at risk of developing mental health challenges, such as those who have emotional experiences (e.g., trauma, abuse), situational stressors (e.g., physical disability, bullying, social isolation, obesity) or genetic factors (e.g., family history of mental illness). occupational therapy practitioners are committed to early identification of and intervention for mental health challenges in all settings. the focus of targeted services (small groups, consultation, accommodations, education) is engagement in occupations to promote mental health and diminish early symptoms; small, therapeutic groups (olson, 2011); environmental modifications to enhance participation (e.g., create sensory friendly classrooms, home, or work environments) tier 1: universal services universal services are provided to all individuals with or without mental health or behavioral problems, including those with disabilities and illnesses (barry & jenkins, 2007). occupational therapy services focus on mental health promotion and prevention for all: encouraging participation in health-promoting occupations (e.g., enjoyable activities, healthy eating, exercise, adequate sleep); fostering self-regulation and coping strategies (e.g., mindfulness, yoga); promoting mental health literacy (e.g., knowing how to take care of one's mental health and what to do when experiencing symptoms associated with ill mental health). occupational therapy practitioners develop universal programs and embed strategies to promote mental health and well-being in a variety of settings, from schools to the workplace. the focus of universal services (individual, group, school-wide, employee/organizational level) is universal programs to help all individuals successfully participate in occupations that promote positive mental health (bazyk, 2011); educational and coaching strategies with a wide range of relevant stakeholders focusing on mental health promotion and prevention; the development of coping strategies and resilience; environmental modifications and supports to foster participation in health-promoting occupations. productive aging occupational therapists work with older adults to maintain independence, participate in meaningful activities, and live fulfilling lives. some examples of areas that occupational therapists address with older adults are driving, aging in place, low vision, and dementia or alzheimer's disease (ad). when addressing driving, driver evaluations are administered to determine if drivers are safe behind the wheel. to enable independence of older adults at home, occupational therapists perform falls risk assessments, assess clients functioning in their homes, and recommend specific home modifications. when addressing low vision, occupational therapists modify tasks and the environment. while working with individuals with ad, occupational therapists focus on maintaining quality of life, ensuring safety, and promoting independence. geriatrics/productive aging occupational therapists address all aspects of aging from health promotion to treatment of various disease processes. the goal of occupational therapy for older adults is to ensure that older adults can maintain independence and reduce health care costs associated with hospitalization and institutionalization. in the community, occupational therapists can assess an older adults ability to drive and if they are safe to do so. if it is found that an individual is not safe to drive the occupational therapist can assist with finding alternate transit options. occupational therapists also work with older adults in their home as part of home care. in the home, an occupational therapist can work on such things as fall prevention, maximizing independence with activities of daily living, ensuring safety and being able to stay in the home for as long as the person wants. an occupational therapist can also recommend home modifications to ensure safety in the home. many older adults have chronic conditions such as diabetes, arthritis, and cardiopulmonary conditions. occupational therapists can help manage these conditions by offering education on energy conservation strategies or coping strategies. not only do occupational therapists work with older adults in their homes, they also work with older adults in hospitals, nursing homes and post-acute rehabilitation. in nursing homes, the role of the occupational therapist is to work with clients and caregivers on education for safe care, modifying the environment, positioning needs and enhancing iadl skills to name a few. in post-acute rehabilitation, occupational therapists work with clients to get them back home and to their prior level of function after a hospitalization for an illness or accident. occupational therapists also play a unique role for those with dementia. the therapist may assist with modifying the environment to ensure safety as the disease progresses along with caregiver education to prevent burnout. occupational therapists also play a role in palliative and hospice care. the goal at this stage of life is to ensure that the roles and occupations that the individual finds meaningful continue to be meaningful. if the person is no longer able to perform these activities, the occupational therapist can offer new ways to complete these tasks while taking into consideration the environment along with psychosocial and physical needs. not only do occupational therapists work with older adults in traditional settings, they also work in senior centre's and alfs. visual impairment visual impairment is one of the top 10 disabilities among american adults. occupational therapists work with other professions, such as optometrists, ophthalmologists, and certified low vision therapists, to maximize the independence of persons with a visual impairment by using their remaining vision as efficiently as possible. aota's promotional goal of "living life to its fullest" speaks to who people are and learning about what they want to do, particularly when promoting the participation in meaningful activities, regardless of a visual impairment. populations that may benefit from occupational therapy includes older adults, persons with traumatic brain injury, adults with potential to return to driving, and children with visual impairments. visual impairments addressed by occupational therapists may be characterized into two types including low vision or a neurological visual impairment. an example of a neurological impairment is a cortical visual impairment (cvi) which is defined as "...abnormal or inefficient vision resulting from a problem or disorder affecting the parts of brain that provide sight". the following section will discuss the role of occupational therapy when working with the visually impaired. occupational therapy for older adults with low vision includes task analysis, environmental evaluation, and modification of tasks or the environment as needed. many occupational therapy practitioners work closely with optometrists and ophthalmologists to address visual deficits in acuity, visual field, and eye movement in people with traumatic brain injury, including providing education on compensatory strategies to complete daily tasks safely and efficiently. adults with a stable visual impairment may benefit from occupational therapy for the provision of a driving assessment and an evaluation of the potential to return to driving. lastly, occupational therapy practitioners enable children with visual impairments to complete self care tasks and participate in classroom activities using compensatory strategies. adult rehabilitation occupational therapists address the need for rehabilitation following an injury or impairment. when planning treatment, occupational therapists address the physical, cognitive, psychosocial, and environmental needs involved in adult populations across a variety of settings. occupational therapy in adult rehabilitation may take a variety of forms: working with adults with autism at day rehabilitation programs to promote successful relationships and community participation through instruction on social skills increasing the quality of life for an individual with cancer by engaging them in occupations that are meaningful, providing anxiety and stress reduction methods, and suggesting fatigue management strategies coaching individuals with hand amputations how to put on and take off a myoelectrically controlled limb as well as training for functional use of the limb pressure sore prevention for those with sensation loss such as in spinal cord injuries. using and implementing new technology such as speech to text software and nintendo wii video games communicating via telehealth methods as a service delivery model for clients who live in rural areas working with adults who have had a stroke to regain their activities of daily living assistive technology occupational therapy practitioners, or occupational therapists (ots), are uniquely poised