Occupational Therapy Example of Prevention (with CPT and ICD 10 codes!)

Alyson Stover, MOT, JD, OTR/L, BCP

2025-06-30 21:59:00

~60 Minutes

On the surface, the concept of occupational therapy is simple.

We help clients change their habits to change their health. We do this through goal-setting, problem-solving, education, and more. Part of what has made our treatment approach so successful over the years is that we focus on the changes we can make at the person level, to the task itself, and within the environment.

Occupational Therapy Example of Prevention text graphic over a designed background

Historically, the occupational therapy process has been applied AFTER a major health incident. For example, a patient may see an OT after having a stroke or receiving a major diagnosis like autism.

But, as the science of prevention progresses, we need to shift with it.

In our recent OT Potential podcast episode on OT and Prevention, Sarah Lyon and I explored the urgent need for occupational therapy to move upstream—beyond reactive care and into proactive, prevention-centered practice.

This change sounds simple and necessary.

But, the reality is that the systems we work in as OTs are complex. So, to make this shift, we must pay special attention to:

How we can get referrals sooner,
What those referrals entail, and
What occupational therapy coding and treatment would look like to achieve the desired outcomes.

Which leads us to this example…

An example of occupational therapy across the lifespan, with a focus on preventing adverse health effects

To make this example as concrete as possible, we are zooming in on a specific place—a community with real concerns about the high incidence of cancer linked to high nitrates in well water—and telling a story about a hypothetical family who lives in said community.

This example highlights exactly how, when, and why occupational therapy can be a frontline intervention for environmental health risks like nitrate-contaminated water. Each section will provide information relevant to:

The role of the referring provider, including:

Red flags that could merit an OT referral,
Corresponding ICD-10 codes (i.e., the diagnostic codes), and
Language to use for the “reason for referral.”

The role of the occupational therapy professional, including:

OT evaluation information,
OT treatment information,
Corresponding CPT codes (i.e., the intervention codes), and
Target outcomes.

Here are the stages of life we will outline in detail:

Prenatal and First Year of Life

Early Childhood Years (2–5 years)

Middle Childhood Years (6–11 years)

Adolescence/Older Childhood Years (12–18 years)

Young Adulthood Years (~20–35 years)

Middle Adulthood Years (~36–64)

Older Adulthood Years (65+ years)

Whether you’re an OT looking to integrate prevention into your practice, an advocate pushing for systems change, or a stakeholder ready to reimagine how we define health and wellness in our communities, this is your blueprint.

We hope this example helps you wrestle with the question:

What if we stopped waiting for things to get worse—and started building systems that keep people well from the very beginning?

Meet the Family: Eleanor and Her Rural Nebraska Roots

Eleanor is an 27-year-old woman living in rural Nebraska as part of a multigenerational farming family. They rely on well water for daily use. She and her husband, both raised in agricultural communities, are expecting their first child. They work long hours on the farm and live modestly, occasionally facing periods of financial strain—something common in middle-class rural households.

Eleanor’s story will remind us how powerful early support, routines, and meaningful daily activity can be across a lifetime.

This case scenario follows Eleanor and her family across multiple generations, highlighting how proactive occupational therapy services along the Prevention Continuum—or the absence thereof—can dramatically influence health outcomes, participation, and well-being.

Prenatal and First Year of Life

Eleanor is a 27-year-old elementary school teacher living on a rural Nebraska farm with her husband, William. Like most families in their area, they rely on a private well. Just weeks after their daughter is born, Eleanor rushes her to the ER when she turns bluish and unresponsive. The baby is diagnosed with methemoglobinemia—caused by high nitrate levels in their drinking water.

Role of Prescribing Provider: Prenatal Care and First Year of Life

Client Population	Screen/”Red Flags”	Referral Information
Prenatal Care	Pregnant person less than 30 weeks gestation¹ Pregnant person lives and/or spends substantial time in one of the following zip codes/areas frequently highlighted for nitrate concerns: • Adams County (e.g., 68901 – Hastings) • Hall County (e.g., 68801 – Grand Island) • Dawson County (e.g., 68850 – Lexington) • York County (e.g., 68467 – York) • Phelps and Fillmore Counties	To: Occupational Therapy Diagnosis: Normal pregnancy, <30 weeks gestation (ICD-10: Z34.81 – Encounter for supervision of other normal pregnancy, first trimester or Z34.82 – second trimester) Reason for Referral: Evaluate and support prenatal routines and environmental health management in the context of nitrate-contaminated water risk. Provide home-based assessment and education focused on maternal roles, health management, safe nutrition, and environmental modifications to reduce fetal health risks.
First Year of Life	See above for zip code/area for environmental red flags Low birth weight (birth weight of less than 2,500 grams (or 5 pounds, 8 ounces))^{13, 14} Preterm birth (at gestational week 20–31)¹³	To: Occupational Therapy Diagnosis: Prematurity (ICD-10: P07.3 – Preterm newborn, gestational age 28–36 completed weeks) and/or Low Birth Weight (ICD-10: P07.1) Reason for Referral: Evaluate and treat for early developmental support and caregiver education. Assess and address environmental factors (e.g., potential nitrate exposure from home water source) that may impact feeding, nutrition, health routines, and caregiver-child occupational engagement. Include home based and caregiver-directed interventions.

Role of Occupational Therapy: Prenatal Care

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT low complexity evaluation to include: • Occupational profile with focus on aspects of Eleanor’s contexts (environmental and personal factors) that support engagement, and what aspects are inhibiting engagement¹ • Well Safety Checklist • Individual and Familial Medical History^{1, 2} with focus on: o Methemoglobinemia (Infants less than 6 months) o Colorectal cancer o Thyroid disease o Neural tube defects o Pediatric brain cancers o Kidney cancer o Bladder cancer o Non-Hodgkin lymphoma o Alzheimer’s disease o Diabetes o Parkinson’s disease • Assessment of diet and eating routines^{1, 2}	Brief history relating to presenting problem 1–3 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Low complexity clinical decision making, limited amount of treatment options, no assessment modification	97165 Occupational therapy evaluation, low complexity Also consider: 99341 Home visit for the evaluation and management of a new patient	Reduced risk of neural tube defects (NTDs) and congenital malformations^1,3,4 Decreased risk of miscarriage^1,5 Prevention of infant methemoglobinemia (“Blue Baby Syndrome”) • Although typically a postnatal issue, early knowledge may prevent use of contaminated well water for infant formula preparation, safeguarding against this often-fatal condition.^1,6,7 Improved maternal health literacy • A structured home assessment with education builds awareness about environmental health risks, enabling more informed decisions during pregnancy and beyond.^8,9 Safer household for other vulnerable Individuals • Education often has ripple elects—encouraging safer water use for other children, elderly, or immunocompromised family members.¹⁰
OT interventions that focus on training and education in: • Home establishment and management • Meal preparation and cleanup • Nutrition management (diets lacking in fruits and vegetables, especially those with limited vitamin C and high in processed meats, can increase the risks associated with nitrates in drinking water^{11, 12})	Educate on nitrate risks, how to access water testing kits, interpret results, and when to use alternative sources (e.g., bottled or filtered water), as well as collaborate with WIC or local food programs to address access to nutritious options as performance skill(s) development and/or progression for applying knowledge and adapting performance. Establish routines for safe water use (e.g., for drinking, cooking, baby formula prep) as performance skill(s) development and/or progression for applying knowledge, adapting performance, and sequencing and timing. Facilitate environmental modifications (e.g., labeling unsafe taps, installing point-of-use filters) as performance skill(s) development and/or progression for applying knowledge and adapting performance. Co-create simple meal prep routines that avoid using nitrate-contaminated water e.g., using bottled water for boiling vegetables or grains) and educate on the protective role of vitamin C (which inhibits the conversion of nitrates to nitrites) and how to integrate fruits like oranges, strawberries, and bell peppers into meals/snacks as ADL for nutrition management and meal prep. Create visual meal guides or grocery lists tailored to budget and access, highlighting high-vitamin-C and low nitrate-risk foods as ADL for nutrition management and meal prep.	97129 Therapeutic interventions that focus on cognitive function (e.g. reasoning, executive function, problem solving) and compensatory strategies to manage the performance of an activity (e.g., managing time or schedules, initiating, organizing, and sequencing tasks). 97530 Therapeutic activities (use of dynamic activities to improve functional performance) 97535 Self-care/home management training Also consider: 96158 Health behavior intervention, individual 96167 Health behavior intervention, family

Role of Occupational Therapy: First Year of Life

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT moderate complexity evaluation Consider also including: • Nitrate exposure risk checklist, addressing source(s) of water used in drinking, cooking, and bathing, outdoor activities for potential exposure to contaminated soil, water, or air, etc. • An environmental health literacy questionnaire and/or interview to assess understanding of nitrates, their health elects, and mitigation strategies • Modified infant nutrition & feeding assessments (i.e. The NeoEAT – Bottle-feeding) to potentially include: o Formula prep practices (e.g., water source, temp) o Symptoms linked to nitrate toxicity (e.g., lethargy, cyanosis) o Household dietary patterns o WIC Nutrition Risk Criteria	Expanded review of therapy/medical records 3–5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Moderate analytical complexity, detailed assessments, minimal to moderate modification of assessments, may have comorbidities	97166 Occupational therapy evaluation, moderate complexity	Reduced risk of Methemoglobinemia (“Blue Baby Syndrome”) Mitigation of long-term toxic stress • Ensures formula and early solids are prepared with safe water, limiting gastrointestinal distress, toxin exposure, and compounding developmental delays. Reducing exposure to harmful environmental factors in infants protects against compounding elects on immune and neuroendocrine systems. Improved achievement of developmental milestones • Early OT involvement enhances sensory, motor, and social development through structured play and responsive caregiving strategies.^{15, 16, 17} Decreased risk of developmental delay or disability • Addressing environmental and caregiving factors early supports neurodevelopmental resilience.^18,19 Safer and more consistent infant care routines • Structured routines for formula prep, feeding, bathing, and cleaning using safe water promote occupational performance and reduce caregiver error or inconsistency. Stronger connection to community and public health resources • OT can serve as a bridge to programs like WIC, Early Intervention, water testing services, and environmental health agencies— creating a network of ongoing support.^{2, 20} Decreased healthcare costs and emergency visits • Preventing waterborne illness and addressing developmental risks early reduces ER visits, hospitalizations, and later-stage interventions.^{21, 22}
Educate caregivers on safe formula prep using clean water; support bottle-feeding routines; address early feeding delays.	Addresses feeding safety, oral-motor coordination, and risk management in infants vulnerable to environmental health issues.	92526 Treatment of swallowing dysfunction and/or oral feeding
Provide interventions for developmental status, facilitate motor, sensory, and cognitive development through age appropriate play and caregiver coaching, as appropriate.	Play-based, goal-directed interventions that promote function and development in daily occupations.	97530 Therapeutic activities
Caregiver support and education through creation of routines for safe infant care (e.g., using bottled water); implement setup modifications.	Creating daily routines for safe infant care, such as preparing bottles with bottled or filtered water, involves training caregivers in task sequencing, environmental setup, and health focused adaptations. Additionally, these tasks are dynamic and functional, requiring real-time decision-making, physical setup, and interaction with the environment (e.g., kitchen, sink area, water storage). The intervention helps prevent harmful exposures while enhancing routine electiveness, consistency, and safety, reducing health risks and supporting medical stability, feeding success, and infant development.	97530 Therapeutic activities Also consider: 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands 97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community

Early Childhood Years (2–5 years)

Wilma is now a toddler, full of personality but still struggling to stack blocks or hold a crayon without frustration. (Yes, she’s named Wilma—no relation to the Wilma West, but Eleanor likes to think some of that OT brilliance might rub off.) Eleanor, balancing motherhood with her classroom job and life on the farm with William, can’t shake the feeling that something’s off. She sees the delays—but between lesson planning, daycare pickups, and no pediatric specialists nearby, she doesn’t know where to start or who to turn to.

Role of Prescribing Provider: Early Childhood Years

Client Population	Screen/“Red Flags”	Referral Information
Early Childhood – Medical	Family uses private well water and has not tested it in the past year Formula or food is prepared using tap water from a potentially contaminated source Caregiver reports child looking “pale” or “blue” around lips after feeding Frequent illnesses, especially respiratory or GI symptoms without clear cause	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; Z13.4 – Encounter for screening for certain developmental disorders in childhood Reason for Referral: Occupational therapy to assess environmental risks, support safe daily care routines, promote developmental progress, and educate caregivers on nitrate mitigation strategies. Child lives in a household identified as at-risk for nitrate-contaminated water and presents with two or more red flags, including [*insert specific concerns—e.g., low birth weight, use of unfiltered well water for formula prep, feeding concerns*].
Early Childhood – Headstart		Child is enrolled in a Head Start program and exhibits multiple risk factors that may impact developmental growth and health due to potential nitrate exposure from contaminated water at home, including: [*insert specific concerns—e.g., low birth weight, use of unfiltered well water for formula prep, feeding concerns*]. Occupational therapy screening and evaluation for potential environmental impact on developmental progress.

Role of Occupational Therapy: Early Childhood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT moderate complexity evaluation; consider also including: • Ages and Stages Questionnaire, 3rd Edition (ASQ-3) or similar evidence based, caregiver-completed tool that captures critical insights into a child’s development across key domains. The ASQ-3 is particularly valuable for children with environmental risk factors—such as nitrate exposure—because it leverages parent observations, identifies concerns within a “monitoring zone” before delays become significant, and supports ongoing developmental tracking. Its accessibility and structured format also promote caregiver engagement and informed, proactive intervention planning. • The PERC-med Detailed Occupational and Environmental Exposure History Questions23 or similar screen for environmental risks	Expanded review of therapy/medical records 3–5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Moderate analytical complexity, detailed assessments, minimal to moderate modification of assessments, may have comorbidities	97166 Occupational therapy evaluation, moderate complexity	Improved achievement of developmental milestones • Early OT involvement enhances sensory, motor, and social development through structured play and responsive caregiving strategies.^{15, 16, 17} Decreased risk of developmental delay or disability • Addressing environmental and caregiving factors early supports neurodevelopmental resilience.^18,19 Occupational therapy plays a critical role in addressing environmental and nutritional risks in children aged 2–5 years by promoting health and development through targeted interventions. Children are uniquely vulnerable to water contamination and dietary risks due to their smaller body size, higher metabolic rate, and developing organ systems, which amplify the elects of toxins such as nitrates.^{24, 25, 26} Early intervention occupational therapy can Improve nutritional safety, especially when families are guided to use safe water sources and reduce nitrate-enhancing dietary risks (e.g., high processed meat consumption, low vitamin C intake).¹⁷With the potential to result in fewer emergency visits and hospitalizations due to GI or respiratory illnesses that may stem from chronic water contamination.²⁵ Increased identification and referral pathways for families with environmental health risks through OT collaboration with Early Intervention, WIC, and primary care. ^{2, 20}
Using colored water, or water with sediment, or water with pungent smell, etc., practice pouring and scooping from clear pitchers into labeled “Safe” and “Unsafe” cups to build sensory and motor skills. Integrate teaching clean vs. contaminated water concepts.	This activity involves a goal-directed, dynamic task requiring the child to perform coordinated movements to complete a purposeful action— transferring water accurately and safely between containers. Additionally, the activity embeds environmental health education relevant to the child’s context (high nitrate risk), making the task personally meaningful and supporting occupational performance in real-life caregiving routines such as feeding and hygiene.	97530 Therapeutic activities Also consider: 97533 Sensory integrative techniques to enhance sensory processing and promote adaptive responses to environmental demands
Set up a child-height clothesline with paper clipped across it. Arrange several small cups of water—some with clear water (representing clean) and others with food colored water (representing dirty). Instruct Wilma to select one cup at a time, dip a clothespin into the water, and then clip it onto the paper using only their thumb and index finger to promote a refined pincer grasp. After each clip, prompt her to identify whether the water was clean or dirty, supporting visual discrimination and environmental health awareness.	This activity targeted isolated strengthening and endurance of specific muscle groups (intrinsics of the hand, thumb, and index finger) and motor control required for functional grasp and release patterns. The repetitive, structured nature of the task with graded resistance from clothespins addresses fine motor deficits through therapist directed, active engagement with measurable physical effort and therapeutic intent.	97110 Therapeutic procedure; therapeutic exercises to develop strength, endurance & flexibility
Set up a small tub with clean water and plastic toy dishes, animals, or pretend clothes. Give Wilma a damp washcloth and encourage her to “wash” the toys using both hands. Instruct her to twist the washcloth with hands moving in opposite directions to wring it out between washes. Use playful cues like, “Let’s make sure we’re using clean water to wash!” or “Twist out the dirty water so we can get fresh water!” to embed concepts of environmental health and safe water use.	This activity targets bilateral coordination, postural control, and proprioceptive input through reciprocal hand movements while seated or standing. The child practiced controlled twisting motions requiring graded force, trunk stability, and midline orientation. Therapist cues supported motor planning and kinesthetic awareness, making 97112 appropriate to address neuromuscular control and functional movement patterns.	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities.

Middle Childhood Years (6–11 years)

By the time Wilma turns eight, Eleanor notices she’s not quite keeping pace with the other kids in her class. She’s quieter, often exhausted after school, and her teacher mentions she’s falling behind in reading. Wilma complains of headaches more than most kids her age, and Eleanor’s gut tells her something deeper is going on. But with the closest specialists two counties over and waitlists months long, the path to answers feels out of reach.

Role of Prescribing Provider: Middle Childhood Years

Client Population	Screen/“Red Flags”	Referral Information
Middle Childhood – Medical	Family uses private well water and has not tested it in the past year Water at home has a metallic taste, sulfur smell, or visible sediment/discoloration Tap water is used regularly for drinking, food prep, or reconstitution of powdered drinks or medications Reports of frequent unexplained illnesses, particularly headaches, fatigue, GI symptoms, or respiratory issues Observed or reported difficulty concentrating, persistent inattention, or irritability Caregiver reports paleness or bluish tinge around lips during or after physical activity Child experiences fatigue or low stamina that seems inconsistent with developmental norms Caregiver or school staff report difficulties in sustaining routines for hygiene, hydration, or nutrition Child shows inconsistent participation in daily self-care or school-related activities Home is located in a ZIP code or county flagged by public health agencies for elevated nitrate levels, AND • Caregiver is unaware of potential risks from nitrate exposure or does not know how to obtain water testing, OR • Family has not been connected to environmental or public health resources, OR • Caregiver expresses confusion, concern, or uncertainty about the child’s nutrition, hydration, or home environment safety	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; Z13.4 – Encounter for screening for certain developmental disorders in childhood; R63.5 – Abnormal weight gain or feeding difficulties (if applicable); F90.0 – Attention deficit hyperactivity disorder, predominantly inattentive type (if applicable); R53.83 – Other fatigue Reason for Referral: Occupational therapy to evaluate and address the impact of potential environmental exposure on daily function, health routines, school participation, and caregiver-child engagement. Child lives in an area with documented nitrate contamination risk and presents with two or more risk indicators, including *[insert relevant indicators, e.g., use of untested private well water, frequent unexplained fatigue or illness, caregiver reports of attention or feeding concerns].*
Middle Childhood – Education		Student resides in a geographic area at high risk for nitrate-contaminated water and demonstrates two or more risk indicators that may be impacting school participation or health. Examples include: • Use of untested private well water at home • Frequent fatigue, poor concentration, or chronic GI symptoms • Difficulties with nutrition/hydration routines at school • Inconsistent performance in classroom tasks • Caregiver concern or limited understanding of water-related health risks Occupational therapy evaluation is requested to assess and support the student’s ability to participate safely and successfully in school routines and activities.

Role of Occupational Therapy: Middle Childhood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT moderate complexity evaluation Consider also including: • Targeted questioning to explore daily routines involving water use, such as hygiene, hydration, and food prep • The PERC-med Detailed Occupational and Environmental Exposure History Questions²³or similar screen for environmental risks • Soma Assessment Interview (SAI)²⁸ or other measure designed to detect functional somatic symptoms in children	Expanded review of therapy/medical records 3–5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Moderate analytical complexity, detailed assessments, minimal to moderate modification of assessments, may have comorbidities.	97166 Occupational therapy evaluation, moderate complexity	Improved attention and learning readiness by addressing fatigue, headaches, or irritability linked to possible low-level nitrate exposure.^{28, 29, 30} Early identification and support for visual-motor, executive function, or sensory processing challenges before they become entrenched barriers to academic participation.^{29, 31} Support for emerging self awareness and interoception, helping children recognize when they are tired, dehydrated, or unwell—critical for self-advocacy and self-regulation. Strengthened daily health routines (e.g., hydration, nutrition) that support cognitive performance and emotional regulation.^{28, 32, 33} Increased engagement in classroom activities through tailored environmental and task adaptations that reduce cognitive load and physical fatigue.^{34, 35} Decreased risk of long-term effects of nitrate exposure, such as methemoglobinemia or delayed growth, through caregiver and child education on safe water practices.³⁶ Data-informed advocacy and systems change, as OT documentation and observations can contribute to awareness of environmental health risks impacting children’s occupational performance.²⁸ Cost-elective early support that can prevent later-stage academic failure, medical complications, or social-emotional diliculties.^{22, 29, 31, 32}
Use a body outline worksheet and visual emotion/sensation cards. Guide Wilma in identifying where she feels sensations (e.g., headache, tired, thirsty, hungry) and label them. Incorporate a discussion on water intake and “listening to your body” when it needs clean water, rest, or food. Use this time to explain that some headaches or tiredness might come from not having enough clean water and build a simple visual hydration tracker.	Addresses body awareness and regulation through guided, repetitive sensory identification exercises that support posture and physical self regulation.	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Also consider: 97533 Sensory integrative techniques to enhance sensory processing
Use a modified word search or letter hunt across a desk or wall. Hide small “clean water” symbols or high-frequency sight words in cluttered fields. Have Wilma scan, track, and decode, using a finger or stylus to follow. Include hidden visual symbols of “clean” vs. “dirty” water to subtly reinforce health concepts while strengthening reading skills.	Uses visual-motor integration and task-oriented searching that directly transfers to reading fluency and classroom function.	97530 Therapeutic activities
Create a step-by-step daily routine visual for hydration, snack, homework, and rest. Include real images of Wilma’s water bottle and foods from home. Practice sequencing and role-playing parts of her after-school routine. Include safe water icons (e.g., using bottled/filtered water) and reinforce that her water needs to come from a “safe source” to help her feel her best.	Targets the development of functional routines that support energy regulation, hydration habits, and independence in self-care.	97530 Therapeutic activities
Set up a low-impact obstacle path (crawl under, balance, reach) with built-in “rest zones” where Wilma checks in with her body (e.g., “How do you feel? Do you need a break? A drink of water?”). Use symbols to guide her pace. Incorporate “safe water” stops in the course to reinforce understanding of hydration from safe sources and rest as a health behavior.	Supports postural control, motor planning, and proprioceptive awareness with attention to pacing and internal signals (interoception).	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Use slanted surface or clipboard for reading tasks paired with high-interest reading materials at her level. Incorporate colored overlays, visual tracking lines, and chunking strategies with frequent movement breaks or body-based fidgets. Include books or reading cards that subtly introduce topics like clean environments, healthy homes, or safe drinking water.	Targets sustained visual motor coordination and task engagement using functional reading activities with embedded physical support.	97530 Therapeutic activities

Adolescence/Older Childhood Years (12–18 years)

By the time Wilma hits high school, something shifts. The bright, curious little girl who once asked endless questions at bedtime now avoids friends, skips meals, and begs to stay home from school. Eleanor is deeply concerned, but getting an appointment—let alone a full evaluation—feels nearly impossible. Providers focus on the immediate behaviors, but no one is connecting them to Wilma’s earlier health scare as an infant or the chronic fatigue and headaches that never really went away.

Role of Prescribing Provider: Adolescence/Older Childhood Years

Client Population	Screen/“Red Flags”	Referral Information
Adolescence/Older Childhood – Medical	Reports of frequent headaches, fatigue, or lightheadedness, especially after physical activity or school Complaints of difficulty concentrating, “foggy thinking,” or falling behind in schoolwork Episodes of paleness, bluish tint to lips, or shortness of breath during exercise or after meals Notable drop in academic performance or energy level without a known medical explanation Diet includes frequent processed or cured meats (e.g., lunch meats, jerky, hot dogs), and/or limited access to fresh fruits and vegetables (especially those high in vitamin C) which may increase nitrate conversion risks Adolescent regularly drinks or prepares food using tap water Adolescent skips meals or does not maintain consistent hydration routines Home is located in a ZIP code or county flagged by public health agencies for elevated nitrate levels, AND • Caregiver is unaware of potential risks from nitrate exposure or does not know how to obtain water testing, OR • Family has not been connected to environmental or public health resources, OR • Caregiver expresses confusion, concern, or uncertainty about the child’s nutrition, hydration, or home environment safety	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; R63.5 – Abnormal weight gain or feeding difficulties (if applicable); R63.4 – Abnormal weight loss (if applicable); F98.9 – Unspecified behavioral or emotional disorder with onset usually occurring in childhood and adolescence; Z13.4 – Encounter for screening for certain developmental disorders; R53.83 – Other fatigue Reason for Referral: Occupational therapy to evaluate the impact of environmental health risk on functional performance, participation, and self management. Adolescent presents with two or more red flags associated with potential nitrate exposure from untested or unfiltered household water, including *[insert relevant indicators, e.g., frequent headaches, low energy, difficulty concentrating, poor hydration, inconsistent academic performance, household diet high in processed meats]*.
Adolescence/Older Childhood – Education		The student resides in a household at high risk for nitrate-contaminated water and demonstrates two or more red flags potentially impacting health, learning, and participation. These may include: • Chronic fatigue or low stamina • Frequent headaches or GI symptoms without known medical explanation • Difficulty sustaining attention or completing tasks • Poor hydration or nutrition routines Occupational therapy support is requested to evaluate and address functional performance concerns related to these environmental and health-related factors.

Role of Occupational Therapy: Adolescence/Older Childhood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	*Therapeutic Use*	*CPT Code(s)*
OT moderate complexity evaluation Consider also including: • Pediatric Quality of Life Inventory™ (PedsQL™)³⁷, PROMIS® Pediatric Fatigue Instruments (Self- and Parent-report)^{38, 39}, or other screen for impact of fatigue on daily activities, school performance, and energy levels • Other PROMIS® Pediatric Measures^{38, 39}, such as: Life Satisfaction, Psychological Stress Experiences, Pain – Interference, Peer Relationships, etc. • The Comprehensive Assessment of Interoceptive Awareness-3rd Edition • A routine-based interview that has specific questions to assess environmental exposures and functional routines (e.g., hydration, food prep, hygiene)	Expanded review of therapy/medical records 3–5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Moderate analytical complexity, detailed assessments, minimal to moderate modification of assessments, may have comorbidities	97166 Occupational therapy evaluation, moderate complexity	Prevention of academic decline by addressing early signs of cognitive fatigue and participation barriers before they result in failure or disengagement.^{40, 41, 42} Early identification and early mitigation of long-term toxic stress or illness by embedding protective daily habits (e.g., safe water use, energy budgeting, low-nitrate diet) and reduces healthcare burden later in life.^{40, 43, 44} Reduction in emergency visits or specialist referrals by addressing functional signs of nitrate exposure at the behavioral and routine level.^{45, 46, 47}
Use an adolescent-appropriate interoception body map. Guide Wilma to identify and label physical sensations (e.g., tension, tiredness, hunger, headache) and connect them to feelings or environmental cues (e.g., skipped meals, dehydration, noisy classrooms). Integrate a hydration reflection (“Did I drink clean water today? How much?”) to support awareness of internal states related to environmental health.	Supports sensory awareness and graded motor activity through body engagement and somatic tracking for regulation and symptom management.	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities Also consider: 97533 Sensory integrative techniques to enhance sensory processing
Collaboratively build a visual “day in the life” chart with zones for physical, mental, and emotional energy. Identify which routines (e.g., skipping breakfast, not drinking water) drain vs. sustain her, and redesign a sample routine for balance. Emphasize water intake from safe sources and food habits that protect against nitrate-related health risks (e.g., low processed meat, higher vitamin C).	Builds self-awareness and executive function by helping client self-manage energy, routines, and environmental health behavior.	97530 Therapeutic activities
Practice or write out scripts for self advocacy situations: asking a teacher for a break, letting a friend know she’s tired or needs space, or navigating cafeteria overwhelm.	Supports social-emotional skills and communication in dynamic, functional scenarios tied to daily school life.	97530 Therapeutic activities

Young Adulthood Years (~20–35 years)

Now in her early twenties, Wilma is technically an adult—but life hasn’t opened up the way Eleanor once hoped it would for her. She’s constantly exhausted—struggling with irregular cycles, brain fog, and a heaviness that seems to sit in both her body and her spirit. She picks up part-time work at the local library, but planning for anything more feels out of reach. Most days, she just tries to get through without crashing. Eleanor watches from across the kitchen table as her once-curious daughter drifts, unsure of how to help and aching as Wilma’s confidence quietly unravels.

Role of Prescribing Provider: Young Adulthood Years

Client Population	Screen/“Red Flags”	Referral Information
Young Adulthood	Lives in a ZIP code or county identified by health or environmental agencies as having elevated nitrate levels Lives in a household using private well water that has not been tested within the past year Regularly uses tap water to make coffee, protein shakes, or cook meals Reports of chronic fatigue, frequent headaches, or feeling “foggy” without clear cause Difficulty with attention, memory, or executive functioning in school or work tasks Experiences frequent GI or respiratory symptoms without medical explanation New onset of irritability, low motivation, or withdrawal from usual roles and routines Diet includes high levels of processed meats (e.g., deli meats, hot dogs) and low intake of fresh fruits and vegetables, particularly vitamin C-rich foods; inconsistent or poor hydration habits, often drinking unfiltered tap water or not tracking intake	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; R63.5 – Abnormal weight gain or feeding diliculties (if applicable); R63.4 – Abnormal weight loss (if applicable); R53.83 – Other fatigue; F99 – Unspecified mental disorder (for executive function or attention concerns); Z13.9 – Encounter for screening, unspecified Reason for Referral: Occupational therapy to assess the impact of these environmental risks on daily functioning, executive skills, health routines, and occupational engagement, and to provide intervention to build adaptive strategies for sustainable participation in daily life. The patient lives in an area identified as high risk for nitrate contamination in drinking water and presents with two or more environmental or functional risk factors, including *[insert relevant concerns: chronic fatigue, foggy thinking, skipped meals, poor hydration, frequent headaches, and/or unfiltered tap water use]*.

Role of Occupational Therapy: Young Adulthood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT low complexity evaluation; consider assessing: • Energy conservation and fatigue management • Hydration and nutrition routines with environmental health considerations • Executive functioning (e.g., time use, planning, organization) • Environmental health literacy • Routine building and role development • Community resource navigation Consider also including: • Occupational Fatigue Exhaustion/Recovery Scale (OFER)^{48, 49}, PROMIS® Fatigue – Adult Short Form⁵⁰, or other screen for impact of fatigue on daily activities, school/work performance, and energy levels • Other PROMIS® Measures^{50, 51}, such as: Cognitive Function, Spirituality, Mood& Sleep, Gastrointestinal – Belly Pain, Satisfaction with Social Roles and Activities (v2.0), etc. • The Comprehensive Assessment of Interoceptive Awareness-3rd Edition	Brief history relating to presenting problem 1–3 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Low complexity clinical decision making, limited amount of treatment options, no assessment modification	97165 Occupational therapy evaluation, low complexity Also consider: 99341 Home visit for the evaluation and management of a new patient	Direct intervention, education on mitigating environmental toxin exposure, and connection to community resources reduce individual risk of long-term health consequences such as anemia or methemoglobinemia^{52, 53, 54} By increasing environmental health literacy, individuals are better equipped to understand the impact of contaminated water on brain and body function and apply this knowledge to daily routines^{52, 53, 54, 55} These interventions contribute to improved long term health outcomes, particularly in rural and underserved communities where environmental risks like nitrate exposure often go unrecognized until more serious health issues arise^{52, 54} Occupational therapy supports greater engagement in education, work, and community life by addressing fatigue, executive dysfunction, and environmental barriers that often go unrecognized ^{56, 57} Through targeted interventions that build sustainable routines, promote energy pacing, and restore confidence, individuals experience improved participation in valued roles such as student, employee, or partner, ^{56, 57} These efforts also help reduce isolation and emotional withdrawal commonly associated with untreated or misattributed chronic symptoms like fatigue and brain fog ⁵⁸ Cost savings to healthcare systems and families by preventing downstream medical complications and mitigating chronic functional impairment through early occupational therapy intervention focused on environmental risk adaptation, routine development, and self management strategies ^{59, 60}
Energy mapping and pacing routine – Create a color-coded weekly “energy planner” together. Identify energy-draining vs. energy restoring tasks. Build in rest breaks, hydration cues (with safe water), and moments for decision-making without overwhelm. Include icons for hydration, meal prep with safe foods, and nitrate reducing habits like avoiding processed meats and prioritizing vitamin C.	Targets health routine development, energy conservation, and occupational engagement through adaptive planning.	97530 Therapeutic activities
Use library-based simulation tasks (e.g., categorizing, scanning for book titles, organizing based on color or genre) to support visual tracking, sustained attention, and cognitive flexibility. Start with 5–10- minute tasks and monitor for signs of fatigue. Include short hydration breaks, and discuss how cognitive performance may fluctuate with dehydration or nitrate-related symptoms.	Engages attention, visual-motor skills, and endurance through meaningful, work-related task simulation.	97530 Therapeutic activities
Begin with a brief guided body scan or emotion-interoception worksheet (e.g., labeling areas of heaviness, tension, pain, or low energy); use programs such as, Interoception Assessment Tools. Use a mirror or posture photo if helpful. Encourage Wilma to describe how those sensations relate to her hydration, rest, or environment. Use this as an opening to discuss symptoms like fatigue and fog that may be worsened by nitrate exposure or poor hydration.	Enhances body awareness and physical self-monitoring to support regulation and symptom management through sensory engagement.	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Guide Wilma through creating a personalized, sustainable bedtime routine that supports regulation of the sleep–wake cycle. Incorporate interoceptive check-ins (e.g., identifying signs of tiredness, restlessness, or dehydration), calming strategies (e.g., dim lighting, body scan, journaling), and routine anchors such as filtered water intake, light evening movement, or warm showers. Track progress using a simple sleep log or app, and explore how sleep impacts cycle regularity and daily functioning. *Environmental Health Adaptation*: Include education on how nitrate exposure may contribute to fatigue or hormonal disruption and emphasize hydration using safe water sources as part of pre-sleep routines.	This intervention targets functional self care routines related to sleep hygiene and body regulation. It supports the development of independent management of health behaviors and energy patterns, integrating environmental safety and interoceptive awareness into a structured, goal directed task.	97530 Therapeutic activities
Engage Wilma in a structured, discussion based and task-oriented session focused on building environmental health literacy. Use visuals and plain-language resources to explain how nitrate-contaminated water can affect cognitive clarity, energy levels, and hormone regulation. Collaboratively identify daily routines where exposure can be reduced—such as switching to filtered/bottled water for cooking and hydration, increasing intake of vitamin C rich foods, and avoiding processed meats. Support her in integrating these health behaviors into her existing routines using a visual routine tracker or checklist.	This intervention supports home and health management through education and adaptation of personal routines in response to an environmental health risk. It empowers the client to understand and mitigate the impact of nitrate exposure through daily actions, enhancing independence and functional performance.	97530 Therapeutic activities
Caregiver check-in – 5–10 minutes of joint discussion with Eleanor (as appropriate), focused on how to support Wilma without overcompensating. Share strategies to build her self-efficacy and autonomy.	Supports family system integration and environmental consistency in health routines.	97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community

Middle Adulthood Years (~36–64 years)

At 52, after months of brushing off persistent stomach pain and fatigue, Eleanor finally gets the diagnosis: colorectal cancer. The news lands hard. She starts chemo soon after surgery, and the treatment leaves her drained—teaching is out of the question, and William takes on extra work around the farm to keep things afloat. Medical bills pile up faster than they can keep track, and the savings they’d hoped to use for retirement or helping Wilma get on her feet begins to vanish. The physical toll is heavy, but the emotional weight—of worry, of guilt, of what-ifs—is heavier still.

Role of Prescribing Provider: Middle Adulthood Years

Client Population	Screen/“Red Flags”	Referral Information
Middle Adulthood	Lives in a ZIP code or county identified by health or environmental agencies as having elevated nitrate levels Lives in a household using private well water that has not been tested within the past year Reports of chronic fatigue, frequent headaches, or mental fog without clear medical explanation History of anemia, thyroid issues, or reproductive/hormonal disruption Notable decline in daily functioning, such as diliculty sustaining work tasks, managing home routines, or staying organized New or worsening emotional withdrawal, irritability, or low motivation Diliculty managing chronic conditions (e.g., diabetes, cardiovascular issues) due to inconsistent routines or environmental stressors Skipped meals, low water intake, or reliance on processed/cured meats	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; R63.5 – Abnormal weight gain or feeding diliculties (if applicable); R63.4 – Abnormal weight loss (if applicable); R53.83 – Other fatigue; F48.0 – Neurasthenia (chronic fatigue, low energy, concentration diliculties); Z13.9 – Encounter for screening, unspecified Reason for Referral: Occupational therapy to evaluate the impact of environmental exposure on health routines, cognitive function, fatigue management, and occupational participation. Patient lives in a region identified as high risk for nitrate contaminated water and presents with two or more red flags, including *[insert relevant concerns: chronic fatigue, cognitive fog, inconsistent self-care, unfiltered tap water use, or difficulty managing work or home responsibilities]*.

Role of Occupational Therapy: Middle Adulthood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes		Prevention Outcome
	Therapeutic Use	CPT Code(s)
OT low complexity evaluation; consider assessing: • Fatigue management and energy conservation strategies • Hydration, nutrition, and health routines related to environmental risks • Executive functioning, task management, and work/home balance • Interoception development and symptom recognition • Environmental health literacy and behavior adaptation (e.g., safe water use) Consider also including: • PROMIS® Cancer Bank v1.0 – Fatigue ⁶¹, or other screen for impact of fatigue on daily activities, school/work performance, and energy levels • Other PROMIS® Measures ⁵⁰, such as: Cancer Bank v1.1 – Physical Function, Cancer Bank v1.1 – Pain Interference, Self-Efficacy for Managing Chronic Conditions – Manage Emotions • The Comprehensive Assessment of Interoceptive Awareness-3rd Edition	Brief history relating to presenting problem 1–3 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Low complexity clinical decision making, limited amount of treatment options, no assessment modification	97165 Occupational therapy evaluation, low complexity Also consider: 99341 Home visit for the evaluation and management of a new patient	Intervention at this stage supports the restoration of disrupted daily routines, development of energy conservation strategies, and re-engagement in meaningful roles—each critical for preserving independence and quality of life ^{62, 63, 64}. By addressing the functional consequences of chronic exposure (e.g., fatigue, disrupted routines, cognitive fog, and self-care decline), OT helps prevent further health deterioration and promotes adaptive strategies that reduce reliance on acute care services ⁶⁵ Education on safe water use and environmental health literacy equips Eleanor and her family to take preventive actions that mitigate long-term exposure risks ^{52, 55} These services not only improve immediate occupational performance but also reduce the likelihood of future complications, healthcare costs ^{65, 66}, and caregiver burnout ⁶⁷ This approach also strengthens upstream public health capacity by identifying unrecognized environmental risks and helping communities respond through informed routines, resource access, and advocacy. This results in not only improved individual outcomes but also reduced healthcare costs ^{59, 60, 66}, increased community engagement in environmental safety ^{52, 54}, and more equitable access to prevention-based care
Develop a personal “energy envelope” system using a 1–10 scale or color-coded chart. Incorporate a tracker for symptoms (fatigue, GI distress, emotional overwhelm), hydration, and activity levels. Discuss what helps restore her energy and how to predict crashes. Embed nitrate-related symptom awareness (e.g., “When I forget to hydrate or eat, my headache and fog get worse”).	Builds body awareness, pacing, and self-regulation skills to manage post treatment fatigue and environmental exposure risks.	97112 Therapeutic procedure; neuromuscular reeducation of movement, balance, coordination kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
Create a visual or tactile “coping toolbox” with Eleanor that includes personalized emotional literacy tools: grounding techniques, affirmations, sensory items, and routines for checking in with herself emotionally. Use visual scales to label mood, tension, or grief. Connect emotional states to physical symptoms, and help Eleanor recognize when emotional load may impact hydration, rest, or meal intake.	Supports emotional regulation and integration of self-care strategies into functional routines.	97530 Therapeutic activities
“Anchor Tasks” for rebuilding routines – Guide Eleanor in identifying 1–2 daily “anchor” activities (e.g., making tea, checking the garden, calling a friend) that can serve as a grounding part of her routine. Use a simple visual schedule or cue cards to slowly rebuild her sense of time and control. Include hydration and rest as part of the anchor activity (e.g., “drink filtered water while journaling” or “sit in sunlight and stretch”).	Helps re-establish disrupted daily rhythms and promotes occupational engagement within energy limitations.	97530 Therapeutic activities
Provide a focused caregiver education session for William to address: • Energy-saving support techniques (e.g., breaking tasks into parts, prepping meals with filtered water) • How to support Eleanor’s pacing routines without overstepping her autonomy • How to recognize signs of Eleanor’s emotional fatigue and provide presence, not pressure Offer William a simple caregiver tracker	Addresses the home management dynamic and equips caregivers with strategies that improve environmental safety, reduce stress, and promote client-centered care.	97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community

Older Adulthood Years (65+ years)

By her 70s, Eleanor is facing a new set of challenges—early Parkinson’s and memory lapses that sneak up more often than she’d like to admit. She’s taken a couple of tumbles in the past year—nothing catastrophic, but enough to shake her confidence. Still, she’s determined to stay in the farmhouse she and William built a life in. Her days have become smaller—just a few familiar rooms and steady routines—but they’re hers. William, now in his 70s too, does his best to keep up with it all: meds, meals, doctor visits. But behind his quiet steadiness, the cracks are showing. It’s getting harder.

Role of Prescribing Provider: Older Adulthood Years

Client Population	Screen/“Red Flags”	Referral Information
Older Adulthood	Lives in a ZIP code or county identified by health or environmental agencies as having elevated nitrate levels Lives in a household using private well water that has not been tested within the past year Reports of chronic fatigue, shortness of breath, or headaches without known cause History of anemia, cardiovascular disease, or cognitive changes (e.g., increased confusion, memory loss) Difficulty managing daily routines, such as meal prep, medication timing, or hygiene tasks Increased falls or balance issues, potentially linked to poor hydration or stamina Recent hospitalizations or medical complications with unclear etiology Reduced fluid intake due to concerns about water quality or limited access to bottled/filtered options	To: Occupational Therapy Diagnosis: Z77.120 – Contact with and (suspected) exposure to contaminated drinking water; R53.83 – Other fatigue; R63.5 – Abnormal feeding or fluid intake; F02.81 – Dementia in other diseases classified elsewhere with behavioral disturbance (if applicable); R41.3 – Other amnesia (if cognitive symptoms present); Z13.9 – Encounter for screening, unspecified Reason for Referral: Occupational therapy to evaluate the impact of these factors on health, safety, and independence and to support functional adaptation in the home environment. The patient resides in a high-risk area for nitrate contaminated water and presents with two or more red flags, including *[insert relevant concerns: e.g., fatigue, functional decline, recent falls, inconsistent fluid intake, memory concerns, or disorganized routines].*

Role of Occupational Therapy: Older Adulthood Years

OT Intervention	Therapeutic Use of the Intervention & Possible CPT codes			Prevention Outcome
	Therapeutic Use		CPT Code(s)
OT low OR moderate complexity evaluation consider addressing: • Hydration and meal routines using safe water sources • Environmental health literacy (e.g., understanding safe water use and household adaptations) • Caregiver education and support as needed consider also including: • Berg Balance Scale (BBS) • Activities-specific Balance Confidence (ABC) Scale • Short Physical Performance Battery (SPPB) • Performance Assessment of Self Care Skills (PASS)	Brief history relating to presenting problem 1–3 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Low complexity clinical decision making, limited amount of treatment options, no assessment modification	Expanded review of therapy/medical records 3–5 performance deficits relating to physical, cognitive, psychosocial limitations/restrictions Moderate analytical complexity, detailed assessments, minimal to moderate modification of assessments, may have comorbidities	97165 Occupational therapy evaluation, low complexity OR 97166 Occupational therapy evaluation, moderate complexity Also consider: 99341 Home visit for the evaluation and management of a new patient	Occupational therapy services for older adults have implications well beyond individual outcomes. By addressing disrupted routines, environmental health literacy, and mobility challenges, OT directly reduces the risk of falls ⁶⁸, which are among the most common and costly causes of injury-related hospitalization in older adults. Through personalized interventions such as energy conservation, safe pacing, interoception training, and home task adaptation, occupational therapy strengthens an older adult’s ability to safely age in place ^{69, 70} while reducing reliance on emergency and institutional care. OT also supports caregivers through education and task sharing, decreasing burnout ^{71, 72}and sustaining informal care networks critical to community based aging. At a systems level, fall prevention and environmental risk mitigation reduce strain on overburdened healthcare systems, particularly in rural and underserved communities where environmental toxins like nitrates often go unrecognized. By integrating environmental health awareness with functional support, occupational therapy not only addresses individual and household safety—it acts as a catalyst for upstream public health improvement, reducing injury rates, enhancing environmental justice, and promoting long-term cost savings across the healthcare continuum.
Practice a short, safe indoor walking route using visual floor cues, stable furniture landmarks, and seated rest points. Teach Eleanor to pause at hydration “stations” to sip from her filtered water bottle or check her body’s cues. Use color-coded labels to reinforce filtered water vs. unsafe tap sources.	Functional task-oriented movement to improve balance, confidence, and energy pacing.		97110 Therapeutic procedure; therapeutic exercises to develop strength, endurance & flexibility
Simulate a simple task Eleanor does daily (e.g., making tea or oatmeal) with energy-saving modifications: sit-while doing, stable positioning, and filtered water use. Practice sequencing, safety (e.g., kettle use, reaching), and memory recall. Label filtered water pitcher and avoid tasks using tap water. Discuss nitrate-related diet safety.	Supports daily activity performance and home safety in the context of physical and environmental challenges.		97530 Therapeutic activities
Help Eleanor create visual cue cards for daily routines and symptom responses (e.g., “When I feel dizzy → sit down, drink water, call William”). Include visual reminders for medication, filtered water, and movement pacing. Post cards in key areas (kitchen, bathroom, bedside) and include nitrate-safe tips.	Supports cognitive compensatory strategy use and safety-based environmental adaptation.		97530 Therapeutic activities
Practice light home tasks that support routine and motor control—e.g., sorting laundry by color or folding towels—while standing or seated. Use counting, rhythm, or verbal sequencing to reinforce movement timing and memory. Label water sources in the laundry room (e.g., avoid rinsing items using tap water for personal use items).	Promotes occupational performance in familiar tasks while reinforcing rhythm, balance, and cognitive sequencing.		97530 Therapeutic activities
Provide brief training on energy conservation strategies, environmental risk mitigation, and how to monitor Eleanor’s symptoms related to fatigue, cognition, and hydration. Offer a “Caregiver Daily Flow” checklist that reinforces routines without increasing caregiver burden.	Supports caregiver competence and joint problem-solving for environmental and functional health risks.		97550 Caregiver training in strategies and techniques to facilitate the patient’s functional performance in the home or community

Conclusion

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References

1. Bell, J. E. (n.d.). Health concerns with nitrates in drinking water. University of Nebraska Medical Center, Water, Climate and Health Program.

2. American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.) American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010.

3. Blaisdell, J., Turyk, M. E., Almberg, K. S., Jones, R. M., & Stayner, L. T. (2019). Prenatal exposure to nitrate in drinking water and the risk of congenital anomalies. Environmental research, 176, 108553.

4. Stayner, L. T., Jensen, A. S., Schullehner, J., Coffman, V. R., Trabjerg, B. B., Olsen, J., Hansen, B., Pedersen, M., Pedersen, C. B., & Sigsgaard, T. (2022). Nitrate in drinking water and risk of birth defects: Findings from a cohort study of over one million births in Denmark. The Lancet regional health. Europe, 14, 100286.

5. Manassaram, D. M., Backer, L. C., & Moll, D. M. (2006). A review of nitrates in drinking water: maternal exposure and adversereproductive and developmental outcomes. Environmental health perspectives, 114(3), 320–327.

6. Fewtrell L. (2004). Drinking-water nitrate, methemoglobinemia, and global burden of disease: a discussion. Environmental health perspectives, 112(14), 1371–1374.

7. Manassaram, D. M., Backer, L. C., & Moll, D. M. (2006). A review of nitrates in drinking water: maternal exposure and adverse reproductive and developmental outcomes. Environmental health perspectives, 114(3), 320–327.

8. Fazli, G. S., Phipps, E., Crighton, E., Sarwar, A., & Ashley-Martin, J. (2025). Engaging, recruiting, and retaining pregnant people from marginalized communities in environmental health cohort studies: a scoping review. BMC Public Health, 25(1), 908.

9. Payne-Sturges, D. C., Cory-Slechta, D. A., Puett, R. C., Thomas, S. B., Hammond, R., & Hovmand, P. S. (2021). Defining and intervening on cumulative environmental neurodevelopmental risks: introducing a complex systems approach. Environmental Health Perspectives, 129(3), 035001.

10. Payne-Sturges, D. C., Ballard, E., & Dilworth-Bart, J. (2024). Systems approaches for uncovering mechanisms of structural racism impacting children’s environmental health and development. Early Childhood Research Quarterly, 69, S91-S101.

11. van Breda, S. G., Mathijs, K., Sági-Kiss, V., Kuhnle, G. G., van der Veer, B., Jones, R. R., Sinha, R., Ward, M. H., & de Kok, T. M. (2019). Impact of high drinking water nitrate levels on the endogenous formation of apparent N-nitroso compounds in combination with meat intake in healthy volunteers. Environmental health : a global access science source, 18(1), 87.

12.De Roos, A. J., Ward, M. H., Lynch, C. F., & Cantor, K. P. (2003). Nitrate in public water supplies and the risk of colon and rectum cancers. Epidemiology (Cambridge, Mass.), 14(6), 640–649.

13.Clemmensen, P. J., Schullehner, J., Brix, N., Sigsgaard, T., Stayner, L. T., Kolstad, H. A., & Ramlau-Hansen, C. H. (2023). Prenatal Exposure to Nitrate in Drinking Water and Adverse Health Outcomes in the Offspring: a Review of Current Epidemiological Research. Current environmental health reports, 10(3), 250–263.

14. Zheng, S., Cao, Y., Strasser, S., & Wei, H. (2024). Prevalence and risk factors of low birth weight in the United States: An analysis of 2016-2021 data. American journal of human biology : the official journal of the Human Biology Council, 36(4), e24016.

15. Kingsley, K. L., & Clark, G. F. (2020). Occupational Therapy Interventions for Children Ages Birth-5 Years. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 74(5), 7405390010p1–7405390010p4.

16.Case-Smith J. (2013). Systematic review of interventions to promote social-emotional development in young children with or at risk for disability. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 67(4), 395–404.

17. Gronski, M., & Doherty, M. (2020). Interventions Within the Scope of Occupational Therapy Practice to Improve Activities of Daily Living, Rest, and Sleep for Children Ages 0-5 Years and Their Families: A Systematic Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 74(2), 7402180010p1–7402180010p33.

18. Luby, J. L., Herzberg, M. P., Hoyniak, C., Tillman, R., Lean, R. E., Brady, R., Triplett, R., Alexopoulos, D., Loseille, D., Smyser, T., Rogers, C. E., Warner, B., Smyser, C. D., & Barch, D. M. (2024). Basic Environmental Supports for Positive Brain and Cognitive Development in the First Year of Life. JAMA pediatrics, 178(5), 465–472.

19.Britto, P. R., Lye, S. J., Proulx, K., Yousafzai, A. K., Matthews, S. G., Vaivada, T., Perez-Escamilla, R., Rao, N., Ip, P., Fernald, L. C. H., MacMillan, H., Hanson, M., Wachs, T. D., Yao, H., Yoshikawa, H., Cerezo, A., Leckman, J. F., Bhutta, Z. A., & Early Childhood Development Interventions Review Group, for the Lancet Early Childhood Development Series Steering Committee (2017). Nurturing care: promoting early childhood development. Lancet (London, England), 389(10064), 91–102.

20. Seruya, F. M., Feit, E., Tirado, A., Ottomanelli, D., & Celio, M. (2022). Caregiver Coaching in Early Intervention: A Scoping Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 76(4), 7604205070.

21. Ngure, F. M., Reid, B. M., Humphrey, J. H., Mbuya, M. N., Pelto, G., & Stoltzfus, R. J. (2014). Water, sanitation, and hygiene (WASH), environmental enteropathy, nutrition, and early child development: making the links. Annals of the New York Academy of Sciences, 1308, 118–128.

22. Tofail, F., Fernald, L. C., Das, K. K., Rahman, M., Ahmed, T., Jannat, K. K., Unicomb, L., Arnold, B. F., Ashraf, S., Winch, P. J., Kariger, P., Stewart, C. P., Colford, J. M., Jr, & Luby, S. P. (2018). Effect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trial. The Lancet. Child & adolescent health, 2(4), 255–268.

23. PERC-med. (n.d.). Detailed occupational and environmental exposure history questions. National Pesticide Information Center.

24.Bantol, K. E. A., Brumberg, H. L., Shah, S. I., & Javier, J. R. (2020). Perspectives from the Society for Pediatric Research: contaminants of water and children’s health: Can we do better?. Pediatric research, 88(4), 535–543

25. Shittu, E., Lakhanpaul, M., Vigurs, C., Sarkar, K., Koch, M., Parikh, P., & Campos, L. C. (2023). A rapid systematic scoping review of research on the impacts of water contaminated by chemicals on very young children. The Science of the total environment, 891, 164604.

26.Mielech, A., Puścion-Jakubik, A., & Socha, K. (2021). Assessment of the Risk of Contamination of Food for Infants and Toddlers. Nutrients, 13(7), 2358.

27.Rask, C. U., Christensen, M. F., Borg, C., Søndergaard, C., Thomsen, P. H., & Fink, P. (2009). The Soma Assessment Interview: new parent interview on functional somatic symptoms in children. Journal of psychosomatic research, 66(5), 455–464.

28. Riley, B. R. W., & de Sam Lazaro, S. L. (2021). Role of Occupational Therapy in Pediatric Primary Care: Promoting Childhood Development. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 75(6), 7506090010.

29. Grajo, L. C., Candler, C., & Sarafian, A. (2020). Interventions Within the Scope of Occupational Therapy to Improve Children’s Academic Participation: A Systematic Review. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 74(2), 7402180030p1–7402180030p32.

30. Sun, W., Yu, M., & Zhou, X. (2022). Effects of physical exercise on attention deficit and other major symptoms in children with ADHD: A meta-analysis. Psychiatry research, 311, 114509.

31.Beisbier, S., & Laverdure, P. (2020). Occupation- and Activity-Based Interventions to Improve Performance of Instrumental Activities of Daily Living and Rest and Sleep for Children and Youth Ages 5-21: A Systematic Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 74(2), 7402180040p1–7402180040p32.

32.Cahill, S. M., Egan, B. E., & Seber, J. (2020). Activity- and Occupation-Based Interventions to Support Mental Health, Positive Behavior, and Social Participation for Children and Youth: A Systematic Review. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 74(2), 7402180020p1–7402180020p28.

33. Pfeiffer, B., Clark, G. F., & Arbesman, M. (2018). Effectiveness of Cognitive and Occupation-Based Interventions for Children With Challenges in Sensory Processing and Integration: A Systematic Review. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 72(1), 7201190020p1–7201190020p9.

34.Meuser, S., Piskur, B., Hennissen, P., & Dolmans, D. (2023). Targeting the school environment to enable participation: A scoping review. Scandinavian Journal of Occupational Therapy, 30(3), 298-310.

35.Bodison, S. C., & Parham, L. D. (2018). Specific sensory techniques and sensory environmental modifications for children and youth with sensory integration difficulties: A systematic review. The American Journal of Occupational Therapy, 72(1), 7201190040p1-7201190040p11.

36. Gupta, S. K., Gupta, R. C., Gupta, A. B., Seth, A. K., Bassin, J. K., & Gupta, A. (2000). Recurrent acute respiratory tract infections in areas with high nitrate concentrations in drinking water. Environmental health perspectives, 108(4), 363–366.

37.Varni, J. W., Beaujean, A. A., & Limbers, C. A. (2013). Factorial invariance of pediatric patient self-reported fatigue across age and gender: a multigroup confirmatory factor analysis approach utilizing the PedsQL™ Multidimensional Fatigue Scale. Quality of Life Research, 22, 2581-2594.

38. Lai, J. S., Stucky, B. D., Thissen, D., Varni, J. W., DeWitt, E. M., Irwin, D. E., … & DeWalt, D. A. (2013). Development and psychometric properties of the PROMIS® pediatric fatigue item banks. Quality of Life Research, 22, 2417-2427.

39.Varni, J. W., Thissen, D., Stucky, B. D., Liu, Y., Gorder, H., Irwin, D. E., DeWitt, E. M., Lai, J. S., Amtmann, D., & DeWalt, D. A. (2012). PROMIS® Parent Proxy Report Scales: an item response theory analysis of the parent proxy report item banks. Quality of life research: an international journal of quality of life aspects of treatment, care and rehabilitation, 21(7), 1223–1240.

40.Dubuc, M. M., Aubertin-Leheudre, M., & Karelis, A. D. (2019). Lifestyle Habits Predict Academic Performance in High School Students: The Adolescent Student Academic Performance Longitudinal Study (ASAP). International journal of environmental research and public health, 17(1), 243.

41. Faught, E. L., Qian, W., Carson, V. L., Storey, K. E., Faulkner, G., Veugelers, P. J., & Leatherdale, S. T. (2019). The longitudinal impact of diet, physical activity, sleep, and screen time on Canadian adolescents’ academic achievement: An analysis from the COMPASS study. Preventive medicine, 125, 24–31.

42.Adelantado-Renau, M., Jiménez-Pavón, D., Beltran-Valls, M. R., & Moliner-Urdiales, D. (2019). Independent and combined influence of healthy lifestyle factors on academic performance in adolescents: DADOS Study. Pediatric research, 85(4), 456–462.

43. HoEman, J. B., Petriello, M. C., & Hennig, B. (2017). Impact of nutrition on pollutant toxicity: an update with new insights into epigenetic regulation. Reviews on environmental health, 32(1-2), 65–72.

44. HoEman, J. B., & Hennig, B. (2017). Protective influence of healthful nutrition on mechanisms of environmental pollutant toxicity and disease risks. Annals of the New York Academy of Sciences, 1398(1), 99–107.

45.Centers for Disease Control and Prevention (CDC) (2011). School health guidelines to promote healthy eating and physical activity. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports, 60(RR-5), 1–76.

46. Szyszkowicz, M., Zemek, R., Colman, I., Gardner, W., Kousha, T., & Smith-Doiron, M. (2020). Air Pollution and Emergency Department Visits for Mental Disorders among Youth. International journal of environmental research and public health, 17(12), 4190.

47. Essien, E. E., Said Abasse, K., Côté, A., Mohamed, K. S., Baig, M. M. F. A., Habib, M., Naveed, M., Yu, X., Xie, W., Jinfang, S., & Abbas M. (2022). Drinking-water nitrate and cancer risk: A systematic review and meta-analysis. Archives of environmental & occupational health, 77(1), 51–67.

48.Winwood, P. C., Winefield, A. H., Dawson, D., & Lushington, K. (2005). Development and validation of a scale to measure work related fatigue and recovery: the Occupational Fatigue Exhaustion/Recovery Scale (OFER). Journal of occupational and environmental medicine, 47(6), 594–606.

49.Winwood, P. C., Lushington, K., & Winefield, A. H. (2006). Further development and validation of the Occupational Fatigue Exhaustion Recovery (OFER) scale. Journal of occupational and environmental medicine, 48(4), 381–389.

50.Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., … & PROMIS Cooperative Group. (2010). The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of clinical epidemiology, 63(11), 1179-1194.

51.Bevans, M., Ross, A., & Cella, D. (2014). Patient-Reported Outcomes Measurement Information System (PROMIS): efficient, standardized tools to measure self-reported health and quality of life. Nursing outlook, 62(5), 339-345.

52. Irvin, V. L., Kile, M. L., Lucas-Woodruff, C., Cude, C., Anderson, L., Baylog, K., Hovell, M. F., Choun, S., & Kaplan, R. M. (2024). An overview of the Be Well Home Health Navigator Program to reduce contaminants in well water: Design and methods. Contemporary clinical trials, 140, 107497.

53.MacDonald, K., & Tippett, M. (2020). Reducing public exposure to common, harmful well water contaminants through targeted outreach to highly susceptible neighborhoods as a method of increasing the likelihood of testing and treatment of water from private wells. Journal of water and health, 18(4), 522–532.

54. Kreutzwiser, R., de Loë, R., Imgrund, K., Conboy, M. J., Simpson, H., & Plummer, R. (2011). Understanding stewardship behaviour: factors facilitating and constraining private water well stewardship. Journal of environmental management, 92(4), 1104–1114.

55. Hocking, C., & Kroksmark, U. (2013). Sustainable occupational responses to climate change through lifestyle choices. Scandinavian journal of occupational therapy, 20(2), 111–117.

56. Lambdin-Pattavina, C., & Pyatak, E. (2022). Occupational Therapy’s Role in Chronic Conditions. The American journal of occupational therapy: official publication of the American Occupational Therapy Association, 76(Supplement_3), 7613410220.

57. Role of Occupational Therapy in Primary Care. (2020). The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 74(Supplement_3), 7413410040p1–7413410040p16.

58. ProEitt, R., Boone, A., Hunter, E. G., Schaffer, O., Strickland, M., Wood, L., & Wolf, T. J. (2022). Interventions to improve social participation, work, and leisure among adults poststroke: A systematic review. The American Journal of Occupational Therapy, 76(5), 7605205120.

59.Mathewson, P. D., Evans, S., Byrnes, T., Joos, A., & Naidenko, O. V. (2020). Health and economic impact of nitrate pollution in drinking water: a Wisconsin case study. Environmental monitoring and assessment, 192(11), 724.

60. Temkin, A., Evans, S., Manidis, T., Campbell, C., & Naidenko, O. V. (2019). Exposure-based assessment and economic valuation of adverse birth outcomes and cancer risk due to nitrate in United States drinking water. Environmental research, 176, 108442.

61. Xu, C., Sidey-Gibbons, C., & Lacourt, T. E. (2024). Development of a PROMIS multidimensional cancer-related fatigue (mCRF) form using modern psychometric techniques. Quality of Life Research, 33(9), 2361–2373.

62. Pergolotti, M., Williams, G. R., Campbell, C., Munoz, L. A., & Muss, H. B. (2016). Occupational Therapy for Adults With Cancer: Why It Matters. The oncologist, 21(3), 314–319.

63. Yang, S. Y., Wang, J. D., & Chang, J. H. (2020). Occupational therapy to improve quality of life for colorectal cancer survivors: a randomized clinical trial. Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer, 28(3), 1503–1511.

64. Loh, S. Y., Sapihis, M., Danaee, M., & Chua, Y. P. (2021). The role of occupational-participation, meaningful-activity and quality-of-life of colorectal cancer survivors: findings from path-modelling. Disability and rehabilitation, 43(19), 2729–2738.

65.McNichols, C., Peterson, A., & Reynolds, S. (2025). Utilization of Occupational Therapy Services for Patients with Cancer in an Acute Care Setting and Effects on Readmission. Archives of Physical Medicine and Rehabilitation, 106(4), e27–e28.

66.Jacobsen, B. H., Hansen, B., & Schullehner, J. (2024). Health-economic valuation of lowering nitrate standards in drinking water related to colorectal cancer in Denmark. The Science of the total environment, 906, 167368.

67. Fields, B., Rodakowski, J., Jewell, V. D., Arthanat, S., Park, M., Piersol, C. V., Schepens Niemiec, S. L., Womack, J., & Mroz, T. M. (2021). Unpaid Caregiving and Aging in Place in the United States: Advancing the Value of Occupational Therapy. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 75(5), 7505347010.

68.Chase, C. A., Mann, K., Wasek, S., & Arbesman, M. (2012). Systematic review of the effect of home modification and fall prevention programs on falls and the performance of community-dwelling older adults. The American journal of occupational therapy : official publication of the American Occupational Therapy Association, 66(3), 284–291.

69.Brown, T., Kidwell, H., Priest, P., Sellers, A., Serino, A., & Spencer, B. (2020). Occupational therapy interventions to support aging in place: A rapid systematic review.

70.Breysse, J., Dixon, S., Wilson, J., & Szanton, S. (2022). Aging gracefully in place: An evaluation of the capability of the CAPABLE© approach. Journal of Applied Gerontology, 41(3), 718-728.

71.Raj, S. E., Mackintosh, S., Fryer, C., & Stanley, M. (2021). Home-based occupational therapy for adults with dementia and their informal caregivers: A systematic review. The American Journal of Occupational Therapy, 75(1), 7501205060p1-7501205060p27

72.Micklewright, K., & Farquhar, M. (2023). Occupational therapy interventions for adult informal carers and implications for intervention design, delivery and evaluation: A systematic review. British Journal of Occupational Therapy, 86(2), 90-100.

Contributors

Alyson Stover

MOT, JD, OTR/L, BCP

A childhood family trauma introduced Alyson to the power of occupational therapy. A subsequent lifetime of study and practice convinced her that consumer advocacy was every bit as essential as her technical practice of occupational therapy. Now, Alyson and her husband own a private outpatient pediatric practice in a rural county in Pennsylvania and co-founded a non-profit organization that uses occupation to address community, societal and population needs. She currently serves as the Director of Clinical Services and continues to practice as an occupational therapist at Capable Kids and lead clinical consultant for Capable Families. Alyson's areas of expertise include pediatrics and holistic, occupation-centric approaches to substance misuse and trauma. Additionally she consults in various capacities, including clinical as well as systems, bringing expert program development knowledge, change at the micro, meso, and macro levels, sustainability, and business resilience/staff wellness. Alyson also is committed to promotion of occupational therapy through grassroots advocacy initiatives and development of community collaborations to support community wellness. She has partnered with many organizations in her hometown to implement innovative, interdisciplinary programs through community grant funding and state funds. She is AOTA Board Certified in Pediatrics. Additionally, Alyson is an associate professor in the Department of Occupational Therapy at the University of Pittsburgh where she also obtained her juris doctorate in law with a post-graduate certificate in health law. Her interests include using occupational therapy as a powerful driving-force for larger health care change, advancing occupational therapy’s national and global relevance and occupational therapy’s role as a leader in policy development and implementation. Alyson is humbled and honored to serve as the President of the American Occupational Therapy Association (AOTA), and is eager to hear the voices of all members of the occupational therapy community.