I wrote to CMS. But this is about more than policy.

It’s Tuesday afternoon…

You’re sitting in a care conference, IEP meeting, team meeting, or nursing station listening to someone explain why your client doesn’t need OT.

You know what you have observed.

You know what the client has told you.

You know there is more happening here than what fits neatly into the criteria being used to make the decision.

Maybe a discharge plan is being made and you weren’t included.

Maybe someone in the district is telling you why a student no longer requires your involvement.

Maybe someone in the nursing facility has already decided what happens next.

Maybe the person making the decision simply has more organizational authority than you do.

Your client wants something different.

You see something that isn’t being discussed.

And you can already feel the cost of being the person who says so.

So you sit there doing the calculation.

Do I say something?

How hard do I push?

Am I overstepping?

Is this actually policy, or just how this organization does things?

Will I be labeled difficult?

Will speaking up change anything?

What will it cost me if I do?

What will it cost my client if I don’t?

You want to be respected.

You want to be collaborative.

You also want to practice with integrity.

And increasingly, those things can feel like they are pulling you in opposite directions.

So you walk on eggshells.

You notice how the system is affecting the client.

You notice how it is affecting your colleagues.

You notice how it is affecting you.

But there is enormous pressure not to talk about any of it.

Eventually, that constant calculation becomes exhausting.

I think a lot of what we call burnout contains something more specific:

Moral fatigue from seeing what is happening while feeling increasingly powerless to change it.

I know that feeling.

And I have been following the questions underneath it for a very long time.

I didn’t find policy through occupational therapy

Occupational therapy gave me language for questions I had been carrying much longer.

I grew up in rural America with a mixed-race cousin who had a severe chromosomal disorder.

I watched someone I loved encounter structural barriers to receiving care that recognized the fullness of her humanity.

And somewhere inside that experience, I began imagining something different.

I dreamed of a world where she and I could grow older together.

Where disability did not automatically mean separation.

Where the services someone needed could come to them.

Where community, relationship, dignity, care, and belonging could be organized around a person’s life rather than requiring a person’s life to be organized around the limitations of a system.

I didn’t have language like aging in place, community-based care, occupational justice, implementation science, or structural determinants yet.

I just knew I wanted a world where we could age in place together.

There was another story in my family, too.

Before I was born, an uncle who was suspected of being autistic was institutionalized.

He later died in circumstances my family understood in relation to neglect and the deterioration of social supports surrounding people like him.

I inherited that story before I ever entered a policy classroom.

Before I knew what an occupational therapist was.

Before I knew how reimbursement worked.

Before I understood that decisions made in legislatures, agencies, institutions, school districts, hospitals, insurance systems, and organizations could eventually determine extraordinarily intimate things:

Where someone gets to live.

Who gets to remain with their family.

Who receives care.

Whose needs are considered too complicated.

Whose knowledge is believed.

Who gets included in decisions.

What support is considered worth paying for.

And what kinds of lives our systems are willing to make possible.

That is probably where my interest in policy actually began.

Not in Washington, D.C.

Not in a professional association.

Not with CMS.

At home.

Eventually, I learned that these intimate experiences had structural dimensions

As an undergraduate, I found student advocacy and lobbying alongside campaign and labor organizing work and study.

Later came occupational therapy.

School-based practice.

Outpatient pediatrics.

Acute care.

Home health.

Post-acute care.

Mobile outpatient services.

State and federal advocacy and policy work, including work related to shaping applied behavior analysis policy in Washington State, partnership with AOTA, AOTPAC-related involvement, and leadership development.

Then occupational science, education, scholarship, and my growing inquiry into agency-centered, critical, and co-constructive implementation science.

The settings changed.

The scale changed.

My language became more sophisticated.

But I am not sure the underlying question ever changed:

Who gets to participate in authoring what becomes possible for a human life?

My clinical work kept giving me different views of that question.

School-based practice showed me how policy, eligibility, institutional interpretation, educational priorities, and family realities shape participation.

Outpatient pediatrics showed me children and families trying to integrate recommendations into lives much bigger than the clinic.

Acute care showed me how quickly decisions about function, safety, discharge, and someone’s next stage of life are made inside complex institutional systems.

Home health showed me what happens when those decisions arrive at someone’s front door.

Post-acute practice made staffing, transitions, reimbursement, productivity, and interdisciplinary coordination impossible to separate from care.

Mobile outpatient practice showed me what becomes visible when care moves closer to where occupation actually happens.

Different settings.

Different populations.

Different payment structures.

Same human lives.

Same question:

What becomes possible under these conditions?

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Then I started asking what those conditions were doing to us

Last year, I wrote Therapy Isn’t Just Biomechanical: Reclaiming the Psychosocial Heart of OT.

It came out of a conversation about why occupational therapy practitioners can sometimes feel almost “naughty” for bringing psychosocial reasoning into supposedly traditional OT settings.

That word stayed with me.

Why would an occupational therapist feel as though practicing expansively requires permission?

What happens when an organization’s operational version of OT becomes smaller than the occupational lens we were educated to use?

And what happens when we adapt to that version for so long that we stop recognizing the adaptation?

Later, writing about school-based practice pushed me further into the relationship between occupation and policy.

I started putting language around something I had witnessed across settings:

Policy mediates occupation.

And then another realization followed.

Practitioners are occupational beings, too.

We spend our careers examining how environments shape someone else’s participation.

But we have environments.

Policy is part of our environment.

Reimbursement is part of it.

Productivity is part of it.

Documentation systems are part of it.

Staffing is part of it.

Hierarchy is part of it.

Organizational culture is part of it.

Professional identity is part of it.

The stories we’ve inherited about what “counts” as OT are part of it.

This matters because I don’t want to individualize structural problems.

You cannot mindset your way out of inadequate staffing.

You cannot personally fix reimbursement.

You cannot positive-think your way around an inaccessible service model.

But I don’t think the only alternative is powerlessness.

There is a territory between:

“This is all my responsibility.”

and

“There is nothing I can do.”

That territory has become increasingly important to me.

This month, I wrote back

On September 14, I submitted an 11-page public comment in response to the CY 2027 Medicare Physician Fee Schedule Proposed Rule.

Listen to the CMS Comment here:

This wasn’t my introduction to advocacy.

It was another iteration of the question I have been carrying across my life and career:

What kinds of care are our systems actually making possible?

My comment addresses therapy coding and valuation, clinical reasoning, care coordination, interdisciplinary overlap, complexity, technology, mobile and home-based care, staffing and productivity pressures, access, and the risks of both overutilization and systematic underutilization of rehabilitation.

But underneath the 12 recommendations is something larger.

Some of the most consequential clinical work does not fit neatly inside the minutes spent performing a discrete intervention.

We review records.

We synthesize information.

We recognize changes in function and risk.

We communicate with caregivers and other clinicians.

We modify plans.

We coordinate transitions.

We connect pieces of someone’s life that the healthcare system has separated into different disciplines, encounters, codes, and records.

That work matters.

And writing the comment brought me back to an idea that has become increasingly important in my scholarship:

Payment systems are implementation systems.

Payment policy eventually becomes staffing.

Workflow.

Caseload.

Documentation.

Technology.

Service availability.

Interdisciplinary communication.

What clinicians have enough capacity to notice.

And eventually:

Policy becomes occupation.

Because people don’t experience healthcare as a collection of codes.

They experience a life.

The question I ultimately asked CMS was:

Does the payment system create the conditions for beneficiaries, caregivers, and clinicians to participate meaningfully in developing, coordinating, and adapting care around the realities of everyday life?

I want you to read the comment.

Not because you have to agree with me.

Read it as a practitioner.

What gives language to something you have experienced?

Where do you disagree?

What does your practice setting allow you to see that mine doesn’t?

What assumptions have you been treating as policy?

What would you have said differently?

What do you know because you have actually been there?

And notice if another question appears:

Wait. Am I allowed to have an opinion about this?

That question matters.

Your experience doesn’t automatically make your interpretation correct.

Authorship is not certainty.

It is learning to understand what you know, how you know it, what you don’t know, what conditions are operating around you, and where you can responsibly participate.

That is where From Adaptation to Authorship begins

I cannot make the administrator disappear.

I cannot change your district for you.

I cannot guarantee your facility will suddenly include you in discharge planning.

I cannot eliminate hierarchy, reimbursement pressures, productivity expectations, or institutional politics.

What I am interested in is something different.

I want us to become better at walking into the same Tuesday afternoon and locating ourselves differently inside it.

Someone says your client doesn’t need OT.

Instead of immediately collapsing into anger, silence, self-doubt, or an exhausting internal argument, maybe we learn to ask:

What is actually happening here?

What authority does this person hold?

What is genuinely policy?

What is interpretation?

What is simply “how we’ve always done it”?

What do I know?

How do I know it?

What does the client want?

What can I document?

What can I question?

Who could I collaborate with?

Where is there room for negotiation?

What is genuinely immovable today?

What am I willing to risk?

What am I not willing to risk?

And what is not mine to carry home?

That is the transformation I care about.

Discernment where there used to be diffuse powerlessness.

Sometimes authorship is speaking.

Sometimes it is documenting differently.

Sometimes it is asking the question nobody has asked.

Sometimes it is bringing the client back into a conversation happening around them.

Sometimes it is reading the policy instead of accepting “that’s just how we do it.”

Sometimes it is finding an ally.

Sometimes it is trying a small experiment.

Sometimes it is deciding:

This is not the hill I am going to die on today.

And sometimes:

Actually, this one is.

Sometimes authorship is staying.

Sometimes it is leaving.

Sometimes it is recognizing that the problem was never yours to solve individually in the first place.

But either way, I want us to understand the conditions and costs well enough that our choices can become more genuinely our own.

You do not have to abandon yourself in order to belong. And authorship does not require you to stop belonging.

This is part of why I built the Evolved Living Collaborative

I have become increasingly interested in what happens when practitioners have somewhere to think together outside the pressures of productivity, institutional hierarchy, professional performance, and the demand to immediately arrive at the correct answer.

The Evolved Living OT/OS Collaborative is the space I am building for that.

It is a free community for occupational therapists, occupational therapy assistants, students, educators, researchers, occupational scientists, and interdisciplinary collaborators who want to think more deeply about occupation, practice, knowledge, power, participation, and what becomes possible when we take our own professional reasoning seriously.

It is not therapy.

It is not clinical supervision.

It is not a place where I tell you what to think or what to do.

It is a place where we can practice asking better questions together.

Inside the Collaborative, I am building an evolving library of resources around occupational science, occupation-centered practice, professional autonomy, critical knowledge translation, reflective practice, and the questions underneath essays like this one.

There are journal clubs, conversations, community gatherings, educational resources, recordings from consenting participants, and opportunities to encounter ideas that may never fit neatly inside a productivity unit, continuing education checkbox, or institutional training module.

I think of it increasingly as an epistemic quilting guild: a place where different forms and lineages of knowledge can be brought into relationship without pretending they are identical.

A place to examine not only what we know, but how we know it, where that knowledge came from, whose knowledge has been privileged, what has been excluded, and what happens when knowledge meets the complexity of actual practice.

Because authorship requires provenance.

And none of us develops that kind of discernment entirely alone.

You are welcome to come think with us

If something in this essay has been sitting with you, you are welcome to continue the conversation with us.

The Evolved Living Collaborative is free to join, and I intend to keep the core community, educational resources, and journal club recordings from consenting participants accessible there.

If community participation is not what you are looking for right now, you can also subscribe to my Substack, where I continue writing about occupational therapy, occupational science, professional autonomy, critical knowledge translation, implementation, and the strange gray spaces where policy meets actual human practice.

My hope is to keep creating places where practitioners can encounter ideas, question assumptions, find collaborators, deepen their own discernment, and participate more intentionally in the systems we inhabit.

Because the system may still be there.

There will be load-bearing pieces we cannot move alone.

There will be places where we need protection.

There will be people we can work with.

There may be doors we did not recognize before.

There may even be places where we begin building something adjacent.

But we do not have to keep abandoning our own perception just to survive the room.

This is happening around me, but I no longer have to let it author me.

If that sentence landed somewhere deep, come find us.

Bring what you are noticing.

Bring what you are questioning.

Bring what you know.

Bring what you are no longer sure you know.

We can start there.

Josie

Dr. Josephine Jarvis, PP-OTD, MA-OTR/L, BA, BSOccupational Therapist | Applied Occupational Scientist | Educator & Scholar-PractitionerEvolved Living

From adaptation to authorship.

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