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Evolved Living Podcast

Evolved Living Podcast

By: Dr. Josie Jarvis OT
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🎙️ 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 disciplines—connecting 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.

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Episodes
  • Hearsay wearing a lab coat

    Hearsay wearing a lab coat
    Sep 23 2026
    You asked a careful question about your scope and got an answer delivered with total certainty and no source. Maybe it came in a comment thread, maybe in a team meeting, and you felt yourself shrink a little inside a profession you spent years training for. If that has happened to you, this essay is for you, and so is the free journal club I’m hosting this Saturday.Details are at the end, or you can join the Evolved Living Collaborative here now and meet us there Saturday.I see some version of this exchange nearly every week, in practice groups, in team meetings and in hallways outside treatment rooms. I’ve de-identified it, since what matters is how it works and nobody in particular.A practitioner asks whether OTs can perform digital stimulation as part of a bowel program for a client with a spinal cord injury. She has already checked her state practice act and the AOTA materials, found nothing explicit either way, and is asking before she proceeds. That’s exactly what a careful clinician should do.Someone answers in two words.Absolutely not.They cite no statute, regulation or professional standard, and often give no sign that they hold the credential they’re ruling on.That answer will land on somebody’s practice. Maybe not hers, since she was already reading the source documents. Somebody watching, though, will absorb “OTs can’t do that” and carry it into a team meeting six months from now, where a person who no longer remembers where they heard it will repeat it as fact.A scope shrinks one confident, unsourced sentence at a time, repeated until it hardens into something that feels like law.The missing-sentence fallacyThe reasoning under that two-word answer goes like this: I can’t find this intervention named in an OT document, so it must be prohibited.Our own professional resources ask for a much fuller process. That process includes checking whether applicable documents actually contain language prohibiting the practice (American Occupational Therapy Association [AOTA], n.d.-c), and I’ll lay out the whole sequence below.AOTA describes occupational therapy as a dynamic and evolving profession responsive to societal needs, system changes, emerging knowledge, research and technology. It also makes clear that professional documents do not supersede state laws and regulations governing practice (AOTA, 2021). Silence in a document tells you the document is finite, and by itself it proves nothing about prohibition.Sometimes that silence tells us something more hopeful. A practice that has not been extensively codified may simply be an area where the profession has not yet developed the evidence, competency infrastructure, educational resources or policy language practitioners need. People may already be doing pieces of that work in clinical programs and communities, while much of their knowledge stays in clinical reasoning, local outcomes and conversations with one another.That gap is an invitation to build, responsibly. When practitioners pool what they have learned, document outcomes, collaborate with researchers and communities, develop competencies, and bring that evidence into professional and regulatory conversations, today’s missing sentence can become tomorrow’s resource.I’m doing exactly that right now, working on a paper with Dr. Tim Dionne and Dr. Susan Burwash, and I’ll come back to it at the end.So when you can’t find a practice named anywhere, one question is absolutely whether you are permitted and competent to do this now. Another is who ought to be developing the evidence and infrastructure this area still needs, and sometimes the answer to that second question might include you.Where our certainty actually comes fromI’ve been watching how scope gets argued online for a long time, and the pattern is remarkably consistent. People who answer scope questions with total conviction are often drawing on something far more local than they realize.They’re drawing on when and where they went to school, and on what the curriculum emphasized in that particular decade. A clinician trained twenty years ago and one trained last spring can hold very different pictures of the same profession, and each may describe theirs as simply “what OT is.”They’re also drawing on the traditions of the agencies they’ve worked in, meaning the way a department has always done things and the precedent nobody has questioned since the manager before last.Very often they’re drawing on their own personal boundaries as well. “I would never do that” is a legitimate thing for a clinician to feel, and “I have not developed competence to do that safely” is an important professional judgment. Delivered as a statement about an entire licensed profession, however, that individual boundary can become personal preference dressed up as policy.Six things we collapse into oneMost scope arguments in our profession are really six different conversations wearing one label. Untangling them...
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    34 mins
  • I wrote to CMS. But this is about more than policy.

    I wrote to CMS. But this is about more than policy.
    Sep 16 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...
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    20 mins
  • CMS Payment Reform: Your Voice Is Needed by September 14

    CMS Payment Reform: Your Voice Is Needed by September 14
    Sep 9 2026
    What happens when the people delivering healthcare actually participate in deciding how that care is valued?Right now, we have an opportunity to do exactly that.CMS is accepting public comments on the CY 2027 Medicare Physician Fee Schedule proposed rule, and the deadline is September 14, 2026.If you are a U.S.-based occupational therapist, physical therapist, speech-language pathologist, or another rehabilitation or allied health provider, this is a moment to pay attention and participate.Read the CMS CY 2027 Medicare Physician Fee Schedule proposed ruleSubmit a public comment through Regulations.govSearch for CMS-1848-P when submitting your comment.Why this mattersPayment policy is about much more than reimbursement rates. It influences what healthcare systems prioritize, how services are structured, what work is considered valuable, and what kinds of care are realistically available to patients.For rehabilitation providers, there can be a significant gap between the work that actually produces meaningful outcomes and what can be easily represented through a billing code.Think about what goes into a complex rehabilitation encounter. There is the assessment itself, but also the clinical reasoning behind it. There is communication with caregivers and other providers, environmental analysis, education, risk management, adapting interventions to the individual, coordinating care, and making decisions based on information that may not be captured by a single diagnosis or procedure code.For many of us, these are not extras added onto the work.They are the work.That makes this comment period important.Rather than simply saying that reimbursement is too low, we have an opportunity to explain what current payment structures fail to capture and what that means for patients, providers, and the healthcare system.What is changing?The CY 2027 proposed rule includes changes and requests for input related to how Medicare services are coded and valued, including the Practice Expense methodology and aspects of care management and remote monitoring.These are technical policy issues, but the questions underneath them are surprisingly practical:What does it actually take to provide good care?What resources are required?What kinds of clinical work happen outside the most visible portion of an encounter?How should payment systems recognize complexity, coordination, clinical reasoning, and the resources required to manage patients over time?These are questions rehabilitation providers have direct experience answering.OT Potential’s Sarah Lyon and colleagues have been particularly active in bringing OT and PT perspectives into this conversation. Their proposed recommendations include better differentiation in reimbursement for evaluation complexity and consideration of non-time-based therapist management codes to recognize some of the ongoing clinical work that occurs throughout an episode of care.You do not have to agree with every recommendation to see the value in participating.In fact, this is one of the things I appreciate about the public comment process. It gives us an opportunity to respond to what is actually being proposed, identify what we think is missing, describe unintended consequences, and offer alternatives based on what we see in practice.Start with Sarah Lyon’s episodeIf you want some context before diving into the policy language, I recommend starting with Sarah Lyon’s recent OT Potential episode on this issue.Listen to the OT Potential episode on YouTubeThe episode provides a useful overview of the current opportunity and the work underway to bring rehabilitation perspectives into the Medicare payment conversation.OT Potential has also created a 2027 CMS Comment Template for OT and PT care, which makes the process considerably easier if you are staring at Regulations.gov wondering where to begin.Access the OT Potential CMS Comment TemplateThe template provides language you can adapt, along with references and guidance for submitting your comment. I would encourage you to personalize it rather than simply submitting the exact same language as everyone else.Your own experience is what makes the comment valuable.What can you contribute?Start with the part of the system you know.Maybe you work with patients whose needs are more complex than the evaluation code adequately communicates. Maybe much of your clinical expertise involves adapting care to cognition, environment, caregiver capacity, health literacy, routines, transportation, safety, or other contextual factors.Maybe you spend substantial time coordinating with other disciplines and caregivers. Maybe your work involves preventing a problem rather than treating the consequences after it happens.Maybe you have watched a patient avoid an emergency department visit because someone identified a risk early. Maybe you have helped a family safely manage a transition home. Maybe your interdisciplinary team caught something that would have otherwise ...
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    3 mins
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