Population Support — Apply evidence-informed programming to support population health outcomes - Nbcot Certified Occupational Therapy Assistant Cota

SECTION 1

Historical Context & Motivation

Occupational therapy has historically centered on the individual client — assessing a single person's capacities, designing tailored interventions, and measuring outcomes one case at a time. While this model remains foundational, the profession has increasingly recognized that many determinants of health operate at the community and population level, making individual-only approaches insufficient for addressing widespread occupational injustice, chronic disease burden, and health disparities. The shift toward population-based practice in occupational therapy reflects a broader movement across all health professions to integrate evidence-informed programming — systematically using the best available research, clinical expertise, and community data to design interventions that improve health outcomes for groups rather than solely for individuals.

The concept of evidence-based practice (EBP) in healthcare emerged in the early 1990s from the work of physicians at McMaster University in Canada, who argued that clinical decisions should be grounded in rigorous research rather than tradition or authority alone. Occupational therapy adopted and adapted this framework, adding a crucial emphasis on client values and occupational context. Over time, the language evolved from "evidence-based" to evidence-informed to acknowledge that research evidence is one input among many — including cultural considerations, stakeholder preferences, and practical feasibility — when making programming decisions for entire populations.

1917 • Founding of OT Profession

The National Society for the Promotion of Occupational Therapy is established, initially focusing on individual rehabilitation for soldiers and persons with mental illness, with programming based largely on clinical intuition and tradition.

1986 • Ottawa Charter for Health Promotion

The World Health Organization publishes the Ottawa Charter, formally recognizing that health is shaped by social, economic, and environmental conditions. This document lays the groundwork for population-level health programming across all professions, including rehabilitation sciences.

1992 • Evidence-Based Medicine Movement

Gordon Guyatt and colleagues at McMaster University coin the term "evidence-based medicine," catalyzing a paradigm shift across healthcare disciplines. Occupational therapy begins integrating systematic literature review into clinical decision-making.

2008 • AOTA Centennial Vision

The American Occupational Therapy Association articulates a vision of OT as a science-driven, evidence-based profession meeting society's occupational needs. Population health and community-based practice gain formal recognition as essential domains of OT service delivery.

2020 • AOTA Vision 2025 & COVID-19

AOTA's Vision 2025 emphasizes health equity and population health as professional imperatives. The COVID-19 pandemic dramatically underscores the need for evidence-informed, population-level OT programming to address widespread occupational disruption.

The central question that evidence-informed population programming addresses is: How can COTAs move beyond treating one client at a time and instead design, implement, and evaluate programs that systematically improve occupational participation for defined populations? This question sits at the intersection of public health science, occupational science, and professional ethics — and answering it is now an explicit competency expectation for certified occupational therapy assistants.

SECTION 2

Core Principles of Evidence-Informed Population Programming

Evidence-informed programming in occupational therapy rests on several foundational principles that distinguish it from both traditional one-on-one clinical practice and from generic public health interventions. Understanding these principles is essential for COTAs who are expected to contribute meaningfully to population-level service delivery under the direction of an occupational therapist (OTR). The COTA's role in this process is collaborative and implementation-focused: COTAs gather data, deliver evidence-informed interventions, monitor outcomes, and communicate findings to the supervising therapist and broader team.

Integration of Best Available Evidence

Programming decisions are grounded in systematic reviews, randomized controlled trials, clinical practice guidelines, and practice-based evidence. The COTA appraises research quality and applicability to the target population rather than relying solely on tradition or anecdotal experience.

Population-Level Thinking

Instead of focusing exclusively on individual deficits, the practitioner considers shared occupational challenges across a defined group — such as older adults at risk for falls in a community, or children in a school district with sensory processing difficulties — and designs programs that address common needs efficiently.

Social Determinants of Health

Evidence-informed programs account for the social, economic, and environmental factors — housing stability, food access, transportation, and systemic discrimination — that shape occupational participation. Effective population programming addresses upstream determinants, not just downstream symptoms.

Continuous Quality Improvement

Programs are designed with built-in outcome measurement from the outset. Data on participation, satisfaction, and health outcomes are collected systematically and used to refine programming through iterative Plan-Do-Study-Act (PDSA) cycles.

Cultural Responsiveness & Stakeholder Engagement

The "informed" aspect of evidence-informed practice means that community values, cultural practices, and stakeholder input are weighted alongside research findings. Programs designed without authentic community engagement risk poor uptake and perpetuation of health inequities.

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KEY TAKEAWAY

Think of evidence-informed population programming like planning a city's public transit system rather than giving one person driving directions. You study ridership data (research evidence), survey the neighborhoods (community needs assessment), consult local residents (stakeholder engagement), and then design routes that serve the greatest number of people efficiently. Just as a transit planner wouldn't ignore a neighborhood's geography or culture, a COTA must integrate evidence with the real-world context of the population being served.

SECTION 3

The Evidence-Informed Programming Cycle

The process of developing and implementing evidence-informed population health programming follows a cyclical model. Unlike a linear workflow with a definitive endpoint, this cycle emphasizes ongoing assessment, adaptation, and improvement. The following diagram illustrates how the Evidence-Informed Programming Cycle operates in practice, from initial population needs assessment through program evaluation and refinement. Each phase draws on different types of evidence and involves specific COTA competencies.

The six-phase cycle begins with identifying population needs (Phase 1) and searching the best available evidence (Phase 2). The COTA then collaborates with the OTR to design the program (Phase 3), implements the intervention (Phase 4), evaluates outcomes using measurable data (Phase 5), and refines the program based on findings (Phase 6). The cycle then repeats, reflecting the Plan-Do-Study-Act approach to continuous quality improvement.

Notice that the cycle does not terminate after evaluation. Phase 6 — Refine feeds directly back into Phase 1 as the practitioner reassesses population needs in light of new outcome data. This iterative structure ensures that programs remain responsive to changing demographics, emerging research, and evolving community priorities. For the COTA specifically, competency in this cycle means being able to collect and report data that supports ongoing program refinement, implement modifications directed by the supervising OTR, and communicate outcomes to interdisciplinary team members and stakeholders.

SECTION 4

How Evidence-Informed Programming Works in Practice

Levels of Evidence in OT Population Programming

A critical competency for COTAs is understanding the hierarchy of evidence that guides programming decisions. Not all evidence carries equal weight: a well-designed systematic review of randomized controlled trials provides stronger support for an intervention than a single case study or expert opinion. However, in population health contexts, COTAs must also value practice-based evidence — data gathered from real-world program implementation — because controlled laboratory conditions rarely capture the complexity of community settings. The hierarchy should be viewed as a guide for weighting evidence rather than as a rigid gate-keeping mechanism.

Level	Type of Evidence	Example in OT Population Practice
I	Systematic reviews / meta-analyses of RCTs	Cochrane review showing fall prevention programs reduce hip fractures in community-dwelling older adults by 30%
II	Randomized controlled trials (RCTs)	An RCT demonstrating that a group-based self-management program improves ADL independence in adults with diabetes
III	Cohort studies / quasi-experimental designs	A pre-post study of a school-based handwriting program showing improved legibility across 200 kindergarteners
IV	Case series / qualitative research	Qualitative interviews with caregivers revealing barriers to participation in a community wellness program
V	Expert opinion / clinical guidelines	AOTA practice guidelines recommending occupation-based programming for community-dwelling adults with mild cognitive impairment

Hierarchy of Evidence Applied to OT Population Programming

The Three-Pillar Decision Framework

Evidence-informed programming decisions rest on three equally important pillars: research evidence, clinical expertise, and population values and context. When these three pillars converge, the resulting program has the strongest foundation. When they conflict — for instance, when the strongest research evidence recommends an intervention that the target population finds culturally unacceptable — the COTA and OTR must negotiate a balanced approach. The NBCOT expects COTAs to recognize that privileging any one pillar at the expense of the others leads to suboptimal programming: research without clinical judgment may be impractical; clinical judgment without research may perpetuate ineffective practices; and ignoring population values undermines engagement and sustainability.

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COTA SCOPE OF PRACTICE NOTE

Under AOTA guidelines, the COTA contributes to evidence-informed programming under the supervision of an OTR. The COTA may collect needs assessment data, search for and summarize relevant literature, implement program components, gather outcome data, and report findings. The OTR retains responsibility for interpreting evaluation results, making final programming decisions, and establishing the overall plan of care. Understanding this collaborative relationship is essential for the NBCOT examination.

SECTION 5

Population Health Frameworks & OT Models

Effective population programming requires a conceptual framework that organizes thinking about who is being served, what outcomes are targeted, and how interventions are structured. Several frameworks from both public health and occupational therapy inform this work. The Occupational Therapy Practice Framework (OTPF) provides the profession-specific lens, while models from public health — particularly the Social-Ecological Model and the Healthy People Framework — supply the population-level structure. The integration of these models is what makes OT population programming distinct from generic public health programming: it maintains the profession's unique focus on meaningful occupation while operating at the scale of communities and populations.

The Social-Ecological Model shows how health is shaped at five nested levels. Traditional OT practice (left box) operates primarily at the individual level, while population-level OT programming (right box) addresses organizational, community, and policy levels. Evidence-informed COTAs must understand how interventions at outer levels create conditions that support individual occupational performance.

Key OT Population Programming Approaches

Approach	Target Level	Description	COTA Role
Health Promotion	Community / Population	Proactive programming to enhance wellness and prevent disease (e.g., ergonomic workshops for office workers)	Deliver group sessions, collect pre/post data, distribute educational materials
Disease Prevention	At-risk groups	Targeted interventions for populations with identified risk factors (e.g., fall prevention for older adults with osteoporosis)	Administer screenings, lead exercise groups, track fall incident data
Community-Based Rehabilitation	Underserved communities	Programs embedded in community settings to improve access and participation (e.g., mobile therapy services in rural areas)	Provide direct services in community settings, train community health workers, document outcomes
Advocacy & Policy	Systems / Policy	Using outcome data to advocate for policy changes that support occupational participation (e.g., ADA compliance initiatives)	Compile data reports, participate in community coalitions, communicate outcomes to decision-makers

Population-Level OT Programming Approaches and COTA Roles

SECTION 6

Worked Example: Developing a Community Fall Prevention Program

Consider a scenario in which a COTA working at a community health center is asked to assist in developing a fall prevention program for older adults in a rural county. The county has a disproportionately high rate of fall-related emergency department visits among adults aged 65 and older, and the supervising OTR has directed the COTA to assist in creating an evidence-informed group intervention. The following worked example walks through each phase of the Evidence-Informed Programming Cycle as it would unfold in practice.

Designing an Evidence-Informed Fall Prevention Program

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Step 1 — Identify Population Needs

The COTA collaborates with the OTR to conduct a community needs assessment. The team reviews county health department data showing that adults aged 65+ had 340 fall-related ED visits in the past year — a rate 1.8× the state average. The COTA administers brief surveys at three senior centers, finding that 72% of respondents report fear of falling and 58% have reduced their community participation due to fall concerns. Environmental audits of senior housing reveal poor lighting and lack of grab bars in 45% of units inspected.

Identified need: High fall rate and fear of falling among rural older adults, exacerbated by environmental hazards and reduced participation.
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Step 2 — Search for Best Available Evidence

The COTA, guided by the OTR, searches OTseeker, PubMed, and AOTA's Evidence Exchange. They locate a Level I systematic review (Cochrane, 2022) demonstrating that multicomponent fall prevention programs combining exercise, home modification, and education reduce fall rates by approximately 24% in community-dwelling older adults. They also find Level II evidence supporting the Stepping On program — a 7-week group intervention with strong evidence for reducing falls by 31% over 14 months. Additionally, qualitative research (Level IV) from similar rural communities suggests that programs must be held at familiar community sites with transportation assistance to achieve adequate participation.

Evidence supports multicomponent group intervention (Stepping On) delivered in community settings with transportation support.
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Step 3 — Design the Program

The OTR and COTA design a 7-week program adapted from the Stepping On protocol. Sessions are 2 hours each and include balance and strength exercises, home safety education, medication review coordination with the local pharmacy, and vision screening referrals. Based on community input, sessions are scheduled at three rural senior centers on rotating days, and the team arranges volunteer driver transportation. The COTA selects standardized outcome measures: the Timed Up and Go (TUG) test for mobility, the Falls Efficacy Scale-International (FES-I) for fear of falling, and a participation tracking form to measure community engagement.

Program design: 7-week Stepping On adaptation with exercise, education, and environmental components delivered at 3 community sites.
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Step 4 — Implement the Program

The COTA leads the weekly group sessions under OTR supervision, facilitating exercises, delivering educational content on home hazards, and conducting home safety assessments for participants who request them. The COTA administers the TUG and FES-I at baseline (Week 1) and post-intervention (Week 7). A total of 42 older adults enroll across the three sites, with an average attendance rate of 81%. The COTA documents session notes, tracks attendance, and records any adverse events.

Implementation: 42 participants, 81% attendance, all baseline and post-intervention measures collected.
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Step 5 — Evaluate Outcomes & Refine

Post-program data analysis shows that mean TUG scores improved from 14.2 seconds to 11.8 seconds (a clinically meaningful 2.4-second improvement), and FES-I scores decreased from 32.1 to 24.7, indicating reduced fear of falling. Participant satisfaction surveys reveal 91% would recommend the program to peers, but several participants note that the 2-hour sessions were too long. The COTA compiles these data into a report for the OTR, who decides to continue the program with sessions shortened to 90 minutes and to add a 3-month follow-up TUG assessment. The COTA also presents findings to the county health department to advocate for continued funding.

Outcomes: Clinically meaningful improvement in mobility and fear of falling. Program refined based on participant feedback and data.

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KEY TAKEAWAY

This worked example illustrates that the COTA's contribution to evidence-informed programming is both practical and intellectual. The COTA does not merely follow instructions — they actively collect data, search literature, deliver evidence-based interventions, and generate outcome reports that drive program improvement. The NBCOT expects COTAs to demonstrate competency in each phase of this cycle, always within the scope of practice and under OTR supervision.

SECTION 7

Strengths and Limitations of Population-Level OT Programming

Population-level evidence-informed programming offers significant advantages over exclusively individual approaches, but it also carries inherent limitations that COTAs must understand to practice effectively and ethically. Recognizing these trade-offs is essential for clinical reasoning and for communicating the value and boundaries of OT programming to stakeholders.

Strengths	Limitations
Reaches larger numbers of people with fewer resources per capita, improving cost-effectiveness and equity of service delivery	Individual needs may be overlooked when programs are designed for group averages; some participants may require more intensive, individualized intervention
Addresses upstream social determinants of health (e.g., environmental barriers, community access), which individual treatment alone cannot change	Requires substantial initial investment in needs assessment, literature review, and program design before any services are delivered
Generates population-level outcome data that can be used to justify funding, advocate for policy change, and demonstrate OT's value in public health	Outcome measurement at the population level is methodologically challenging; confounding variables make it difficult to attribute changes solely to the OT program
Promotes interprofessional collaboration and positions OT within broader public health and community development teams	Research evidence for population-level OT interventions is still growing; fewer RCTs exist for community-based OT programs compared to individual clinical interventions
Supports preventive and health-promoting approaches that reduce downstream healthcare costs and improve quality of life	Cultural, linguistic, and socioeconomic diversity within a population makes one-size-fits-all programming risky; adaptation requires ongoing community engagement

Strengths and Limitations of Population-Level OT Programming

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KEY TAKEAWAY

Population programming and individual intervention are not competing approaches — they are complementary levels of the same profession's scope. Think of it like healthcare's version of weather versus climate: an individual therapy session is like today's weather forecast for one city, while population programming is like a climate model for an entire region. Both are necessary, both require different data and methods, and effective COTAs must be competent in contributing to both.

SECTION 8

Connecting Population Support to Advanced OT Practice & Policy

Evidence-informed population programming does not exist in isolation — it connects directly to larger professional and societal movements that are reshaping occupational therapy's role in healthcare. Understanding these connections positions the COTA not only for the NBCOT examination but also for a career trajectory that increasingly values population health competencies.

Concept in This Lesson	Advanced / Related Concept	Connection
Evidence-informed programming cycle	Implementation Science	An emerging discipline studying how evidence-based interventions are adopted, adapted, and sustained in real-world settings — directly extends the Refine phase of the programming cycle
Social determinants of health	Occupational Justice	An occupational science framework arguing that all people have a right to meaningful occupation; extends SDOH thinking by centering occupation as both a determinant and an outcome of health
Continuous quality improvement	Value-Based Care Models	Healthcare payment models that reimburse based on outcomes rather than volume of services; population-level outcome data generated by COTAs directly supports OT reimbursement under these models
Community needs assessment	Community-Based Participatory Research (CBPR)	A research methodology in which community members are equal partners in defining problems and designing studies; represents the most rigorous form of stakeholder engagement
Hierarchy of evidence	Knowledge Translation (KT)	The process of moving research findings into practice; KT science addresses the well-documented gap between what evidence shows and what practitioners actually do

Connections to Advanced Theory and Practice

As healthcare systems worldwide shift toward preventive, community-based, and value-driven models of care, the demand for COTAs who can contribute to evidence-informed population programming will continue to grow. The competencies described in this lesson — needs assessment, evidence appraisal, program implementation, outcome measurement, and stakeholder engagement — are foundational skills that scale upward into advanced practice roles such as program management, quality improvement coordination, and community health leadership. By mastering these skills now, you are preparing not only for the NBCOT examination but for the future trajectory of the profession.

SECTION 9

Practice Problems

Question 1: CONCEPTUAL

A COTA is explaining to a community partner why the occupational therapy team uses the term "evidence-informed" rather than "evidence-based" when describing their population health programming. Which of the following best captures the distinction between these two terms in the context of population-level OT practice?

Show answer

The term "evidence-informed" acknowledges that research evidence is one critical input among several — including clinical expertise, population values, cultural context, and practical feasibility — when making programming decisions. While "evidence-based" can sometimes be interpreted as implying that randomized controlled trial evidence alone should drive decisions, "evidence-informed" explicitly recognizes that population health interventions must be adapted to the unique characteristics, preferences, and circumstances of the community being served. In OT population practice, this distinction is particularly important because community contexts vary widely, and rigid adherence to a research protocol without cultural adaptation can undermine engagement, sustainability, and ultimately health outcomes. The COTA should communicate that the team values rigorous research but also integrates community input and professional judgment to create the most effective and equitable programming possible.

Question 2: BASIC APPLICATION

A COTA is conducting a literature search to support the development of a community-based diabetes self-management program. The COTA locates the following sources: (A) a Cochrane systematic review of group-based self-management interventions, (B) a single case study of an OT-led program for one patient, (C) an AOTA practice guideline, and (D) an RCT comparing group OT to usual care for adults with Type 2 diabetes. Rank these four sources from strongest to weakest level of evidence using the hierarchy of evidence.

Show answer

Using the five-level hierarchy of evidence described in this lesson, the ranking from strongest to weakest is: (A) Cochrane systematic review — Level I, as it synthesizes multiple RCTs and provides the highest level of aggregate evidence; (D) RCT — Level II, as a single well-designed randomized controlled trial provides strong experimental evidence but represents only one study; (B) single case study — Level IV, as case-level data can be informative but is not generalizable to populations; and (C) AOTA practice guideline — Level V, as expert-developed guidelines are valuable but represent synthesized expert opinion rather than original experimental data. The COTA would report these findings to the supervising OTR, noting that the systematic review and RCT provide the strongest support for designing the program, while the case study and practice guideline offer supplementary clinical insight.

Question 3: INTERMEDIATE

A COTA is helping to evaluate a 12-week occupational therapy wellness program for adolescents with anxiety in a school district. At baseline, the mean score on the Canadian Occupational Performance Measure (COPM) satisfaction scale for the 60 participants was 3.2 (out of 10). After the program, the mean satisfaction score rose to 5.8. The literature identifies a 2.0-point change on the COPM as the minimal clinically important difference (MCID). The school board is asking whether the program "worked." How should the COTA interpret and communicate these results, and what additional information would strengthen the evaluation?

Show answer

The COTA should report that the observed improvement of 2.6 points on the COPM satisfaction scale exceeds the established MCID of 2.0, suggesting a clinically meaningful change in participants' satisfaction with their occupational performance. However, the COTA must be transparent about limitations: without a comparison or control group, the team cannot definitively attribute the improvement solely to the program — maturation, other school-based interventions, seasonal effects, or regression to the mean could contribute. To strengthen the evaluation, the COTA could recommend adding a control group in the next cohort, collecting follow-up data at 3 and 6 months to assess sustainability of gains, gathering qualitative data from students and teachers about perceived changes, and tracking school attendance and academic performance as secondary outcome measures. The COTA would communicate these findings and limitations honestly to the school board while emphasizing that the results are promising and warrant continued investment with enhanced evaluation methods.

Question 4: APPLIED

A rural health clinic serves a population of migrant agricultural workers who experience high rates of musculoskeletal injuries and limited access to rehabilitation services. The supervising OTR asks the COTA to assist in developing an evidence-informed injury prevention and ergonomic training program for this population. Describe how the COTA would apply each of the three pillars of evidence-informed decision-making (research evidence, clinical expertise, and population values/context) and identify at least two potential barriers to successful implementation.

Show answer

For the research evidence pillar, the COTA would search databases such as PubMed and OTseeker for systematic reviews and RCTs on workplace ergonomic interventions and musculoskeletal injury prevention programs for agricultural workers, identifying evidence for stretching protocols, body mechanics training, and ergonomic tool modifications. For clinical expertise, the COTA would draw on their knowledge of musculoskeletal anatomy, activity analysis, and adaptive strategies, as well as the OTR's experience with similar populations, to select and adapt evidence-based techniques for the specific physical demands of agricultural work. For population values and context, the COTA would conduct surveys and focus groups with workers (using interpreters as needed) to understand their occupational routines, cultural beliefs about health and injury, language preferences, literacy levels, and scheduling constraints — ensuring the program is accessible, culturally responsive, and delivered at times and locations that do not conflict with work schedules. Potential barriers include: (1) language and literacy barriers requiring materials in Spanish or other languages with visual rather than text-heavy formats; (2) workers' fear of employer retaliation for reporting injuries or attending health programs, necessitating confidentiality assurances; (3) transient population making follow-up and outcome tracking difficult; and (4) limited research evidence specifically addressing OT interventions for migrant agricultural populations, requiring thoughtful extrapolation from related literature.

Question 5: CRITICAL THINKING

A county health department has funding for only one new program and must choose between two proposals: (A) an evidence-informed OT population health program targeting fall prevention for 200 older adults, supported by Level I evidence showing a 24% reduction in fall rates, or (B) a novel OT community mental health program for 50 adults with serious mental illness, supported by Level III evidence showing improved community participation. The county's fall-related ED costs are $1.2 million per year, and mental health-related costs are $800,000 per year. Using principles from this lesson, construct an argument for each proposal, and then explain how the three-pillar framework helps navigate this decision.

Show answer

Argument for Proposal A: The fall prevention program is supported by the strongest available evidence (Level I), reaches a larger population (200 vs. 50), targets the county's highest-cost health issue ($1.2 million), and the 24% expected reduction could prevent approximately 48 falls, potentially saving the county $288,000 annually while reducing suffering and loss of independence among older adults. The stronger evidence base also makes it more defensible to funders and policymakers. Argument for Proposal B: Although supported by Level III evidence, the mental health program addresses a severely underserved population with limited existing services, and the 50 participants may experience transformative improvements in occupational participation, social integration, and quality of life. The $800,000 in mental health costs may underestimate the broader societal costs (housing instability, criminal justice involvement, lost productivity), and investing in this population aligns with health equity principles. The three-pillar framework helps navigate this decision by requiring decision-makers to weigh not only research evidence strength (favoring A) but also clinical expertise about unmet needs and population values and context — the mental health population may face greater occupational injustice and have fewer alternative services available. The framework prevents a purely utilitarian calculation and demands consideration of equity, community voice, and professional values. Ultimately, the decision may involve stakeholder input from both populations, analysis of whether alternative funding sources could support the other program, and consideration of whether elements of both programs could be combined. The COTA's role is to present the evidence clearly and honestly, not to make the final funding decision, while advocating for the populations being served.

SUMMARY

Lesson Summary

Summary

This lesson explored how COTAs apply evidence-informed programming to support population health outcomes — a core competency within NBCOT Domain 3. We traced the historical evolution from individual-focused OT practice to population-level thinking, grounded in the evidence-based medicine movement and major public health frameworks. Five core principles guide this work: integration of best available evidence, population-level thinking, attention to social determinants of health, continuous quality improvement, and cultural responsiveness with stakeholder engagement.

The Evidence-Informed Programming Cycle — Identify, Search, Design, Implement, Evaluate, Refine — provides a structured process that COTAs follow under OTR supervision. Programming decisions are anchored in the three-pillar framework (research evidence, clinical expertise, and population values/context) and informed by the hierarchy of evidence. The Social-Ecological Model reminds us that health is shaped at individual, interpersonal, organizational, community, and policy levels — and that effective OT population programming must address multiple levels simultaneously. As the profession moves toward value-based care, occupational justice, and implementation science, the competencies described in this lesson will become even more central to COTA practice.