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Evolved Living PodcastOccupational Therapist, occupational scientist & open citizen science advocate co-creating liberatory, ecological, & collaborative solutions beyond institutional systems through art, wisdom & applied science. Author: Dr. Josie Jarvis OT
The Evolved Living Podcast with Dr. Josie Jarvis, PP-OTD, MA-OTR/L, BA, BS Hosted by occupational therapist, occupational scientist, and open citizen science advocate Dr. Josie Jarvis, The Evolved Living Podcast explores how we can bridge art, science, and wisdom to co-create more liberatory, ecological, and collaborative systems of care. Each episode invites critical yet compassionate dialogue across disciplinesconnecting practitioners, educators, researchers, and community members who are working toward holistic, trauma-informed, and life-affirming change. Together, we translate occupational science into real-world practice and collective wellbeing through honest, inclusive, and transformative conversations. josiejarvisot.substack.com Language: en Genres: Life Sciences, Science, Social Sciences Contact email: Get it Feed URL: Get it iTunes ID: Get it |
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I wrote to CMS. But this is about more than policy.
Wednesday, 16 September, 2026
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 therapyOccupational 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 dimensionsAs 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?This Substack is reader-supported. To receive new posts and support my work, consider becoming a free or paid subscriber.Then I started asking what those conditions were doing to usLast 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 backOn 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 beginsI created From Adaptation to Authorship for the practitioner sitting in that Tuesday afternoon meeting.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 in three months.What I want to help change is something different.I want you to be able to walk into the same Tuesday afternoon and locate yourself 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, you have somewhere to stand.You can 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.But either way, I want you to understand the conditions and costs well enough that the decision feels more like yours.You do not have to abandon yourself in order to belong. And authorship does not require you to stop belonging.What we’ll actually doOver three months, we’ll investigate your real professional environment.You’ll create an Agency + Participation Map so the giant wall called “the system” starts becoming more legible.You’ll examine what is structural, what is policy, what is organizational culture, what belongs to someone else’s authority, where you have influence, where you need allies, and where you may need protection.Then we’ll create your Epistemic Quilt.We’ll examine the knowledge informing your practice: evidence, occupational science, professional expertise, clinical reasoning, lived and embodied experience, cultural knowledge, creativity, and other forms of knowing.Not because every form of knowledge is interchangeable.Because if you’re going to stand behind what you know, you need to understand how you know it and where it came from.Authorship requires provenance.Then you’ll design a 90-Day Authorship Experiment.Not a plan to fix healthcare.One meaningful way to participate differently in what becomes possible next.The founding cohort$777 for three months. We begin October 13. Space is intentionally limited (payment plans and sliding scale options available).I’m keeping this founding cohort small because I want room for actual inquiry, experimentation, conversation, and co-construction.This is not about escaping traditional OT.It isn’t a business program.It isn’t about everyone becoming a lobbyist or activist.And it is absolutely not another demand that exhausted practitioners work harder to compensate for systems that aren’t working.You might stay exactly where you are.But I want staying to feel different because you know where you stand.You know what you see.You know what you know and where that knowledge comes from.You know what you don’t know.You can better distinguish policy from interpretation, organizational norms from actual requirements, structural constraints from places where you have meaningful agency.And you have practiced making a move from that place.The system may still be there.There will be load-bearing pieces you cannot move alone.There will be places where you need protection.There will be people you can work with.There may be doors you didn’t recognize before.There may even be places where you can begin building something adjacent.But you don’t have to keep abandoning your 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, reply to this email.Tell me where you are in your practice right now.Tell me what you keep noticing.Tell me what feels constrained.Tell me what you wish could be different.No polished application.No sales performance.Just a conversation.We’ll start there.JosieDr. Josephine Jarvis, PP-OTD, MA-OTR/L, BA, BSOccupational Therapist | Applied Occupational Scientist | Educator & Scholar-PractitionerEvolved LivingFrom adaptation to authorship.This Substack is reader-supported. To receive new posts and support my work, consider becoming a free or paid subscriber. Get full access to Dr. Josie Jarvis OT at josiejarvisot.substack.com/subscribe
