Adapting Lifestyle Redesign^®: Navigating Fidelity and Contextual Fit Across Four Case Examples

Abstract

Background.

Lifestyle Redesign^® occupational therapy (LR-OT) originated in the Well Elderly studies as a preventive intervention for older adults, demonstrating positive health and cost outcomes. While LR-OT later expanded to chronic condition management and inspired numerous program adaptations for different contexts and populations, systematic reporting of intervention modifications remains scarce. This gap extends beyond OT, reflecting a broader movement in implementation science.

Purpose.

This study applies the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to systematically document adaptations across four LR-OT programs. Additionally, we examine fidelity-consistency by mapping program components to the Well Elderly program and core LR-OT elements.

Methods.

Four teams implementing adapted programs—diabetic foot ulcer self-management, primary care chronic condition management, Remodeler sa Vie for French-Canadian older adults, and LR weight management—participated in a structured mapping exercise to align programs with FRAME and LR-OT principle components.

Results.

Adaptation approaches varied from highly structured to loosely standardized methods. Despite numerous modifications, all programs strongly aligned with LR-OT’s core characteristics and domains.

Conclusion.

This study highlights LR-OT’s adaptability across diverse contexts while maintaining fidelity to its foundational framework. Findings contribute to implementation research, providing a model for systematically documenting and characterizing adaptations made to client-centred, evidence-based OT programs.

Introduction

Adaptation of Evidence-based Programs and Practices

Research documents a growing interest in the science and methods of adapting evidence-based programs and practices (EBPs) for implementation in new contexts (Stirman et al., 2019; Escoffery et al., 2019). Adaptation is the process of making changes, planned or unplanned, to an intervention or program design (e.g., content, dosage, procedure) to fit the needs of a population or context (Stirman et al., 2013). Modifying interventions can improve acceptability and outcomes for a target population and address healthcare inequities that limit accessibility and effectiveness of interventions in under-resourced communities (Chambers, Glasgow, & Stange, 2013). In contrast, failing to adapt interventions ignores the critical influence that context has on the success and sustainability of intervention implementation.

Although adaptation is foundational to the translation of EBPs, ensuring that adapted interventions simultaneously remain true to the core components of the original intervention framework is vital (Stirman et al., 2019), as altering essential elements of an EBP may compromise its effectiveness and ability to meet population needs (Pérez et al, 2015). Mejia and team (2017) note that a “both-and” approach is possible, such that one can both adapt an intervention to ensure cultural relevance and maintain fidelity to its original framework. Thus, while adaptation is critical to ensure contextual relevance and equity, fidelity to an intervention’s core elements anchors its effectiveness. This dynamic interplay between fidelity and adaptation frames the present analysis of Lifestyle Redesign^® Occupational Therapy (LR-OT).

There is a dearth of systematic documentation of adaptations made to EBPs. This leads to difficulties in determining the effectiveness of adaptations, replicating resultant modifications, and anticipating the impact of future adaptations based on new contexts, populations, and resources (Mejia et al., 2017). Clearly specifying and evaluating adaptations enhances an intervention’s external validity across contexts and facilitates its potential for routine implementation (Baumann et al., 2017).

To address these issues, the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) offers a structured, comprehensive approach to systematically documenting modifications to EBPs (Stirman et al., 2019). Unfortunately, systematic reporting of intervention adaptations is scarce in the occupational therapy (OT) literature. Only one OT team to-date has used FRAME to report adaptations to an evidence-based OT intervention (Piller et al., 2021). Piller’s group posits that this gap in reporting stems from the client-centred, individualized nature of OT interventions, which rarely follow scripted, step-by-step processes, thereby hindering documentation of concrete adaptations.

Lifestyle Redesign Occupational Therapy

LR-OT, an empirically supported approach to OT intervention, presents an opportune case to explore adaptations of client-centred OT EBPs. LR-OT has been continuously adapted to meet the evolving needs of diverse target populations and contexts (Pyatak et al., 2022). Originally developed at the University of Southern California through the Well Elderly (WE) studies, LR-OT was initially designed as a preventive intervention for well older adults¹ (Clark et al., 1997). The effectiveness and cost-effectiveness of LR-OT in improving the health and well-being of older people was established in two large-scale randomized controlled trials (Clark et al., 1997; Clark et al., 2011). The programmatic structure of WE LR-OT has been described elsewhere (Clark et al., 2015; Jackson et al., 1998), but is summarized in Table 1 and expanded upon in Supplemental Table 1.

Table 1.

Comparison of Adapted Lifestyle Redesign^® Programs to the Original Well Elderly Program Structure.

Category	Well Elderly Lifestyle Redesign*	Diabetic Foot Ulcer Self-management	Primary Care Chronic Condition Management	Remodeler sa Vie (Reshape your Life)	Lifestyle Redesign® for Weight Management
Key References	Clark et al., 1997 Clark et al., 2012 Clark et al., 2015 Jackson et al., 1998	Chapman et al., forthcoming Styer et al., forthcoming A pilot study is underway as of May 2025, thus primary work is not yet published.	Pyatak et al., 2019	Levasseur et al., 2019 Levasseur et al., 2022 Lévesque et al., 2020 Clark et al., 2021	USC Chan Division of Occupational Science and Occupational Therapy, n.d.
Program Objective	To support older adults in creating a meaningful and healthy lifestyle that seamlessly integrates into one’s daily routines and remains sustainable over time.	To support individuals with diabetes in self-management of DFUs, thereby leading to improved health outcomes and quality of life.	To empower individuals with diabetes and/or hypertension to adopt sustainable, healthy lifestyle changes that improve disease management, prevent complications, and enhance overall well-being.	To enhance the health, wellness, and independence of French-Canadian older adults in Francophone communities by supporting the development of healthy and meaningful routines that foster overall well-being.	To support individuals in achieving and maintaining a healthy weight through personalized, sustainable lifestyle changes and daily routines, in order to promote long-term health and well-being.
Target Population	Community-living older adults (≥60 years) At risk for age-related decline Normal cognition Often with low income	Adults with a DFU necessitating offloading English or Spanish speaking Often with low income	Adults with uncontrolled diabetes (most recent HbA1c ≥9.0%) and/or uncontrolled hypertension (most recent blood pressure reading ≥140 systolic and/or ≥90 diastolic) Currently empaneled to the primary care safety-net clinic where LR-OT services are provided	Older adults (≥65 years) with varying degrees of independence (either no/mild or moderate/severe loss of independence) Community-dwelling (reside in a conventional home or residential home for semi-independent older adults) Normal cognition French speaking Ongoing research and implementation exploring older adult caregivers	Adults (≥18 years) with interest in weight management Employees of organizations who have contracts with the University of Southern California OT Faculty Practice
Delivery Format (Overall method of delivering the program; how the intervention was delivered; frequency etc.)	6- to 9-month in-person program Small group (6–10 participants) + individual sessions with an OT Weekly 2-hour group sessions (primary focus) Monthly 1-hour individual sessions: 9 sessions (WE 1), up to 10 sessions (WE 2) Monthly group outings with an OT ≥5 individual sessions recommended for max benefit	Up to 8 individual sessions with an LR-OT (session cap due to study constraints) 1-hour sessions held approximately weekly Telehealth-only format is currently being piloted with in-person option on very limited basis upon patient request Discharge at discretion of OT	In-person and telephone, individual sessions with LR-OT at least 1x/month Brief (~10–20 minutes) telephone “boosters” between visits Discharge at discretion of OT 6-month monitoring period post-discharge with tapered telephone “check-ins” Services restart if clinical status worsens	6-month in-person program (27 sessions), with ongoing research exploring a condensed 16-week hybrid telehealth format Small group (8–10 participants) + individual sessions with an OT Weekly 2-hour group sessions (primary focus) Monthly 1-hour individual sessions for 5–11 sessions 4–5 monthly group outings with an OT	Originally a 16-week, weekly in-person program Now tailored in duration and frequency based on referral to treatment and client’s needs/goals Limited telehealth use until 2020; major shift post-COVID-19 Originally offered individual or group sessions with an OT; now only individual sessions
Session Structure (Organisation and flow of sessions; phases, components, activities that happen within/across sessions)	Combo of didactic education, peer exchange, direct experience, and personal exploration First session defines “occupation,” linking it to health, and introduces occupational self-analysis Early group sessions build group cohesion and establish roles Sessions involve “doing therapy” (e.g., doing at home, doing in the community), goal-setting, reflection, and discussion	Combo of didactic patient education, personal exploration, and direct experience First session defines occupation and LR-OT Topics addressed vary based on identified patient needs and goals but tie to DFU self-management Common initial session focuses on foot self-care Sessions involve “doing therapy” (e.g., doing at home, doing in one’s imagination), goal-setting, reflection, and discussion	Combo of didactic patient education, personal exploration, and direct experience First session defines occupation and LR-OT Topics addressed vary based on identified patient needs and goals Sessions involve “doing therapy” (e.g., doing at home, doing in one’s imagination), goal-setting, reflection, and discussion	Combo of didactic education, direct experience, peer exchange, and personal exploration First session defines “occupation,” explicates the link between occupation and health, and introduces occupational self-analysis Early group sessions involve building group cohesion, safety, and rapport through rituals and roles establishment Sessions involve “doing therapy” (e.g., doing at home, doing in the community), goal-setting, reflection, and discussion	Combo of client education, occupational self-analysis, narrative reasoning, activity analysis, and problem solving First session defines “occupation,” LR-OT, and OT’s role in weight management Clients set personally meaningful health-related goals Clients receive reading materials (e.g., healthy eating principles) and food journal to track eating routines Sessions include optional weigh-ins, goal-setting and review, education, and strategies to integrate healthy habits into daily routine
Facilitator Requirements	Licensed and registered OT ≥10 hours of intervention-specific training	Licensed and registered OT LR certification 3 hours of study and intervention-specific training plus ~7 hours of self-study	Licensed and registered OT Didactic training in LR (4-unit university course) Didactic education in clinical diabetes management Education and training in motivational interviewing (via 2- or 4-unit university course, or 12 contact hours of continuing education)	Member of Québec Board of OT Completion of USC-AOTA sponsored LR online training of the original WE LR-OT intervention (6 hours) Weekly 1-hour mentoring	Licensed and registered OT LR certification Didactic training in LR (e.g., university courses, onsite trainings) ≥16 contact hours of education and training in motivational interviewing ≥250 hours of mentored practice
Curriculum & Content (What is taught, key themes, learning objectives)	Focus on building healthy and meaningful routines Topics range from transportation and joint protection to energy conservation and nutrition OT selects modular content based on group needs Individual sessions address occupation-related health impacts and personal goals Home modifications and adaptive equipment practice offered for in-home sessions	Focus on diabetic foot self-care, offloading compliance and management, safe integration of physical activity, stress management, and assertive communication and health self-advocacy OT covers content based on patient’s needs and goals	Focus on meal planning and prep, meeting dietary goals, physical activity, blood glucose and blood pressure monitoring, healthy coping, and assertive communication OT covers content based on patient’s needs and goals	Focus on building healthy and meaningful routines Topics range from safety in the community and navigating the healthcare system to productive activities and stress management OT selects modular content based on group needs Individual sessions address occupation-related health impacts and personal goals	Focus on healthy eating routines, meal planning and prep, grocery shopping, reading nutrition labels, physical activity, social and emotional eating, lifestyle balance, nutrition, stress management, relaxation, and long-term planning Originally OT and participants collaborate to select order of pre-established 16-week modular content; now OT covers content based on patient’s needs and goals
Instructional Materials (Physical or digital materials to support learning/engagement)	Handouts/worksheets from an OT intervener resource manual Materials are adaptable (e.g., font size, language translation, replacing written materials with demonstration) Supplies available on site (e.g., markers, paper)	Shared drive repository for OT of materials adapted to DFU population (English and Spanish) Shared drive repository for OT of preexisting LR-OT materials related to general lifestyle factors Silicone foot models for wound and foot self-care education and demonstration	Shared drive repository for OT of preexisting LR-OT materials related to general lifestyle factors (English and Spanish) Therapist-created materials to address specific patient needs Models and demonstration kits (e.g., glucose wands, portion size demonstration) Paper-pencil worksheets and activities	Handouts/worksheets from an OT intervener resource manual Materials are adaptable (e.g., font size, summarizing English videos in French) Supplies available on site (e.g., markers, paper)	Shared drive repository for OT of weight management module materials and resources Paper-pencil and digital worksheets and activities
Language & Literacy Considerations	Primarily in English Language translation based on local context and participant needs (Mandarin, Spanish)	Primarily in English Spanish language translation based on local context and patient needs	Primarily in Spanish Multi-language translation services offered by clinic based on patient needs	Primarily in French Language translation for some resources not available in French based on participant needs	Primarily in English Spanish translation in later years with sessions led by Spanish-speaking OTs
Implementation Setting	Group sessions in community spaces (e.g., senior centres) Individual sessions in participants’ homes or community location	Individual telehealth sessions delivered remotely in a private setting	Individual sessions within primary care clinic Booster sessions via telephone	Group sessions in community spaces (e.g., senior residence) or at research centre Individual sessions primarily at participants’ homes, occasionally at research centre	Original group and individual sessions in clinic; now individual sessions in clinic Limited telehealth until 2020 (major shift post- COVID-19 pandemic), delivered remotely in a private setting
Required Resources	Grant-funded OT salary support Physical space for group and individual sessions Instructional and activity-based materials Adaptive equipment Transportation for outings and home visits Time commitment from participants and OT	Grant-funded salary support for OT Private space for individual sessions HIPAA-secure video-conference software Computer and telephone for telehealth sessions Patient scheduling coordinator Clinic translation services Instructional and activity-based materials Time commitment from patients and OT	University department provided salary and benefits for OT Physical treatment room for individual sessions Clinic-provided computer for online activities Clinic-provided telephone for booster sessions Instructional and activity-based materials Time commitment from patients and OT	Grant-funded OT salary support Physical space for group and individual sessions Instructional and activity-based materials Transportation for outings and home visits Adaptive equipment Volunteers to assist with outings as needed Time commitment from participants and OT	Clinic-funded OT salary support Physical space for group and/or individual sessions Instructional and activity-based materials Body Composition Analyzer Scale Time commitment from clients and OT
Evaluation Methods	Pre-/post-intervention self-report assessments of health, physical and mental functioning, occupational engagement, and life satisfaction	Pre/post intervention self-report assessments of healthcare satisfaction, diabetes distress, and offloading knowledge and attitudes Occupational performance and satisfaction assessed at baseline, midway (optional), and discharge DFU wound status reviewed in medical charts at baseline, 3 months, and 6 months post-enrollment	Pre/post intervention self-report assessments of occupational performance and satisfaction and overall health status Routine assessments of HbA1c (3 months) and blood pressure (every clinic visit)	Pre-/post-intervention self-report assessments of health, physical and mental functioning, occupational engagement, life satisfaction, social participation, leisure interest, mobility, life balance, and self-compassion and gratitude	Pre-/post-intervention self-report assessments of occupational performance and satisfaction and physical and mental health-related quality of life Pre-/post-intervention body composition assessment (i.e., total weight, muscle mass, fat mass, total body water)

Notes:

^*Refer to Supplemental Table 1 for expanded details on the Well Elderly program structure. Abbreviations: DFU(s)=diabetic foot ulcer(s); LR=Lifestyle Redesign; OT=occupational therapy/ist; WE=Well Elderly

The foundation of LR-OT lies in its core elements, illustrated in Figure 1, which provide a framework for fidelity while supporting flexible adaptation. Core characteristics (i.e., focusing on daily activity orchestration, applicability to lifestyle challenges, collaborative therapist-client process with individualization, health-relevant outcomes, and delivery by trained OT practitioners) distinguish LR-OT from other approaches (Pyatak et al., 2022). These characteristics are operationalized through core domains (i.e., meaningful occupations, habits, and routines; chronic condition management; psychological well-being; environment and context; and advocacy and healthcare access) that guide intervention content. Practitioners employ core techniques (i.e., patient education, occupational self-analysis, narrative reasoning, problem solving, and autonomy-enhancing communication) that shape therapeutic processes. Together, these characteristics, domains, and techniques form an integrated fidelity framework that both grounds adaptation and supports individualized implementation.

Figure 1.

Core Elements of the Lifestyle Redesign^® Occupational Therapy Intervention Framework.

Study Purpose

The purpose of this paper is to apply FRAME to characterize adaptations made to four distinct case examples of adapted LR-OT programs. These four cases were selected because they reflect diverse adaptations across populations, settings, and delivery models, offering a unique opportunity to systematically document adaptation processes. Together, they illustrate how LR-OT has been translated in research and practice and highlight the balance between adaptation and fidelity across varied contexts. Secondarily, we examine the fidelity-consistency of these interventions by mapping their components to the structure of the original WE EBP and core elements of the overarching LR-OT framework. By analyzing these cases, we offer insights into how evidence-based OT interventions can be responsibly adapted while maintaining fidelity, thereby expanding representation of OT EBPs in the implementation science literature.

Method

Adapted LR-OT Case Examples: Program Descriptions

This paper examines four adapted LR-OT implementation efforts, representing different populations, settings, and stages of implementation. Two of these efforts have been fully implemented and two are currently in a pilot phase. General descriptions of each program, along with the adaptation processes employed, are included below and are referred to by their abbreviated names throughout this paper: Diabetic Foot Ulcer Self-management (DFU-SM) Program, Remodeler Sa Vie (RV), Primary Care Chronic Condition Management (PC-CCM) Program, and Lifestyle Redesign^® for Weight Management (WM). Program/study details are summarized in Table 1, allowing for direct comparison to the original structure of the LR-OT WE Program (Supplemental Table 1). Terminology referring to participants varies intentionally by program context: participants in clinical settings (PC-CCM and DFU-SM) are referred to as “patients,” participants in the private practice intervention (WM) as “clients,” and participants in the community-based program (RV) as “older adults” or “individuals.” This distinction reflects the relationship of the participants to the intervention.

Diabetic Foot Ulcer Self-management (DFU-SM) Program.

In an ongoing pilot study, an LR-OT outpatient program is being developed for patients with diabetes who are managing diabetic foot ulcers (DFUs) and prescribed offloading treatment (i.e., physician-prescribed devices or techniques to relieve pressure on the ulcer and promote healing; Chapman et al., forthcoming). The program supports lifestyle changes that will improve wound healing and overall quality of life. The program’s primary long-term goal is to promote limb preservation in patients at high risk for lower-extremity amputation.

Primary Care Chronic Condition Management (PC-CCM) Program.

This program delivers LR-OT to under-resourced patients with diabetes and/or hypertension receiving primary care at a single clinic within a safety-net medical centre (Pyatak et al., 2019). The overall goal of PC-CCM is to improve occupational performance, clinical outcomes, and healthcare utilization. The current model is implemented by newly licensed OT practitioners as part of their OT residency training at the clinic.

Remodeler sa Vie (Reshape your Life; RV).

Modeled closely after the WE program, RV has been culturally adapted for French-Canadian older adults, focusing on late-life well-being and health self-management in a Canadian (Québec) context (Levasseur et al., 2022). Delivered by a trained OT in a community setting, this six-month program empowers participants to develop healthy routines and engage in meaningful activities. The intervention follows 12 French-translated and culturally adapted modules developed from the English WE manual (Clark et al., 2015) to guide goal-setting in areas such as physical, social, and spiritual health.

Lifestyle Redesign^® for Weight Management (WM).

This LR-OT program is delivered in a private practice setting to help clients achieve and maintain a healthy weight through personalized, sustainable lifestyle changes (USC Chan Division of Occupational Science and Occupational Therapy, n.d.-b). The objective is to promote long-term health and well-being by addressing clients’ unique needs and goals. Services are offered individually in-person or via telehealth, with flexible content and duration.

Program Adaptation Documentation and Analysis

Individuals with in-depth knowledge of each adapted program, invited as co-authors, received a structured form to document program modifications. The form included: (1) for reference, a summary of the original WE LR-OT program structure (Supplemental Table 1) along with descriptions of the LR-OT core characteristics, domains, and techniques; (2) a section to outline steps taken to modify the program into its current form; (3) a table informed by the template for intervention description and replication (TIDieR; Hoffmann et al., 2014) to document the program’s structure (Table 1); (4) a mapping table of questions, definitions, and predefined responses from the FRAME Coding Manual (Stirman, 2023; see Table 2), and space for detailed responses to ensure accuracy and alignment with FRAME definitions; and (5) a mapping template to link adaptations to LR-OT’s core characteristics (Table 3) and domains (Table 4), which served as a fidelity check.

Table 2.

Mapping Adapted Lifestyle Redesign^® Occupational Therapy Programs to the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME).

FRAME question	Diabetic Foot Ulcer Self-management	Primary Care Chronic Condition Management	Remodeler sa Vie (Reshape your Life)	Lifestyle Redesign® for Weight Management
WHEN did modifications occur?	Pre-implementation/planning/pilot	Pre-implementation/planning/pilot Implementation Maintenance/sustainment	Pre-implementation/planning/pilot	Pre-implementation/planning/pilot Implementation Maintenance/sustainment
Were modifications planned?	Planned/proactive	Planned/proactive Reactive	Planned/proactive Reactive	Planned/proactive Reactive
WHO participated in the decision to modify?	Informed Decision-making Research team Treatment/intervention team Individual practitioner/facilitator Community members Team Recipients Final Decider(s) Research team	Informed Decision-making Administration Program developer/purveyor Individual practitioner/facilitator who delivers intervention Team Recipients Coalition of stakeholders Final Decider(s) Administration Program developer/purveyor Team	Informed Decision-making Program developer/purveyor Research team Community members Team Recipients Final Decider(s) Research team	Informed Decision-making Program developer/purveyor Treatment/intervention team Individual practitioner/facilitator Administration Final Decider(s) Administration Program developer/purveyor
WHAT was modified?	Content Contextual Training and evaluation	Content Contextual Training and evaluation Implementation and scale-up activities	Content Contextual Training and evaluation	Content Contextual Training and evaluation Implementation and scale-up activities
At what LEVEL OF DELIVERY (for whom/what are the modifications made)?	Target intervention group Cohort/individuals that share a characteristic Individual recipient	Target intervention group Cohort/individuals that share a particular characteristic Individual recipient Clinic/unit level	Target intervention group Cohort/individuals that share a characteristic Individual recipient	Target intervention group Individual recipient Clinic/unit level
What is the NATURE of content modifications?	Tailoring/tweaking/refining Shortening/condensing (pacing/timing) Adding elements Removing/skipping elements	Tailoring/tweaking/refining Integrating into another intervention framework Adding elements Removing/skipping elements	Tailoring/tweaking/refining Removing/skipping elements	Tailoring/tweaking/refining Shortening/condensing (pacing/timing) Adding elements Removing/skipping elements
What contextual modifications were made?	Format Setting Population	Format Setting Personnel Population	Format Setting Population	Format Setting Population
Relationship to FIDELITY/core elements?	Fidelity consistent/core elements and functions preserved (see Table 3 and 4)	Fidelity consistent/core elements and functions preserved (see Table 3 and 4)	Fidelity consistent/core elements and functions preserved (see Table 3 and 4)	Fidelity consistent/core elements and functions preserved (see Table 3 and 4)
What were the REASONS for modifications, including intent/goal?	Reasons: Organization/setting Service structure Time constraints Location/accessibility Identified disparities, inequities Provider Previous training and skills Clinical judgement Recipient Access to resources Literacy and education level First/spoken languages Comorbidity/multimorbidity Goal/Intent: Improve feasibility Improve fit with recipients Improve effectiveness/outcomes Increase satisfaction	Reasons Organization/setting Available resources Service structure Mandates Billing constraints Provider Previous training and skills Clinical judgement Recipient Access to resources Literacy and educational level First/spoken languages Comorbidity/multimorbidity Motivation and readiness Goal/Intent Improve feasibility Improve fit with recipients Improve effectiveness/outcomes Increase satisfaction Promote equity/reduce disparities	Reasons Sociopolitical/outer context Societal/cultural norms Organization/setting Social context Cultural or religious norms Provider Previous training and skills First/spoken languages Recipient Disability status First/spoken languages Access to resources Goal/Intent Improve fit with recipients Address cultural factors	Reasons Organization/setting Available resources Service structure Location/accessibility Billing constraints Provider Previous training and skills Recipient Comorbidity/multimorbidity Motivation and readiness Goal/Intent Improve fit with recipients Improve effectiveness/outcomes

Table 3.

Examples of how the Well Elderly Program and Adapted Programs Align with Lifestyle Redesign^® Core Characteristics.

LR Core Characteristic	Examples of Fidelity-consistency with Core Characteristics
	Well Elderly Lifestyle Redesign	Diabetic Foot Ulcer Self-management	Primary Care Chronic Condition Management	Remodeler sa Vie (Reshape your Life)	Lifestyle Redesign® for Weight Management
Therapeutic focus on orchestration of daily activities	Guiding participants in analyzing daily and seasonal patterns of occupations, exploring how time use and routines can shift across the day and year to optimize engagement in meaningful activities	Facilitating occupational storytelling and story-making to help a patient envision an ideal offloading routine that supports health and well-being Guiding the restructuring of daily routines to accommodate diabetic foot ulcer-related health demands (e.g., balancing offloading, wound care, and mobility restrictions with meaningful activity)	Evaluating occupational performance and satisfaction pre-post treatment to ensure treatment is rooted in occupational self-analysis Reinforcing the therapeutic focus on daily activities in the plan of care by routinely documenting collaboratively established short- and long-term goals related to diabetes and/or hypertension, developed using motivational interviewing	Facilitating structured self-reflection about occupations in daily life, and aiding exploration and experimentation with current, new, and previously abandoned meaningful activities and healthy routines	Encouraging occupational storytelling and story-making to help one envision ideal weight management routines Guiding the restructuring of routines to include occupations supportive of weight management Supporting continuation of health promoting occupations and discontinuation of occupations that deter from a healthy lifestyle
Applicability to lifestyle related challenges	Addressing real-world occupational challenges older adults may face with aging such as driving retirement, effectively managing energy, and adapting routines to maintain independence	Exploring the long-term occupational disruptions associated with diabetic foot ulcers, such as work instability and reduced physical activity, and supporting patients in developing strategies to maintain engagement despite setbacks Addressing barriers to social participation related to mobility and offloading restrictions, using problem-solving strategies to identify alternative means of engagement that will foster social well-being	Educating patients on why their primary care doctors have made certain health-related restrictions Using techniques like narrative reasoning and problem-solving to create action plans that involve visual/auditory reminders to support behaviour change (e.g., checking blood sugar at an agreed upon frequency) Identifying realistic changes to a diet that fit into one’s lifestyle and culture (e.g., low carb alternatives to favorite foods) Integrating telehealth options, specifically during COVID-19 allowing for not only chronic condition management but also COVID-19 prevention practices relevant to disease prevention	Exploring real-world occupational challenges older adults may face with aging such as disabilities and comorbidity, care partnering responsibilities, and social isolation from downsized social networks	Exploring individual challenges clients face in implementing health promoting habits and routines to successfully manage weight (e.g., healthy eating, physical activity) Exploring topics that influence healthy habit engagement, such as time management and stress management Exploring barriers to successful weight management, such as access to resources and demands from other roles, as well as supports to engaging in healthy habits and routines
Techniques that facilitate therapist-client collaboration and individualization	Guiding occupational self-analysis and goal setting so that participants can identify meaningful lifestyle changes, co-develop strategies, and integrate personally relevant adaptations into daily life Establishing a personal engagement plan with each participant, co-constructed with guidance from the OT, to enhance daily routines and participation in meaningful activities	Providing tailored patient education on offloading self-management strategies, ensuring information is personalized to each patient’s needs and lifestyle Employing motivational interviewing to encourage self-reflection on personal attitudes toward offloading adherence and collaboratively developing strategies to enhance compliance Integrating occupational storytelling to draw on a patient’s lived experiences with managing diabetic foot ulcers and offloading prescriptions, and co-creating a future-oriented narrative that supports adherence and well-being	Integrating LR-OT documentation (e.g., goal progress, occupational performance) into team-based care medical records to reinforce individualization and systematic care coordination Focusing evaluation and team-based care documentation on occupational self-analysis, providing structure for the OT to routinely guide patients to inspect how daily activities and their choices impact condition management Tailoring education for Spanish-speaking, low-literacy, low-tech, low-resourced, and multimorbid populations to ensure relevance, advancing individualized treatment and engagement	Practicing active listening to understand and respond to group and individual needs Facilitating occupational self-analysis and goal setting to support meaningful lifestyle changes, collaboratively developing strategies, and incorporating personalized adaptations into daily routines Offering direct support, collaborating with a participant to obtain necessary resources for meaningful engagement Facilitating reflection on accomplishments and providing positive reinforcement Following up to support participant actions (e.g., having follow-up communications with case managers or health navigators)	Guiding occupational self-analysis and goal setting so that clients identify meaningful lifestyle changes, co-develop strategies, and integrate personally relevant adaptations into daily life Providing tailored client education on healthy habits and routines to support weight management Viewing the client as the expert Facilitating occupational self-analysis and narrative reasoning to explore past lived experiences, current habits and routines, and desired lifestyle
Concerned with range of health-relevant outcomes	Assessing outcomes via participant self-report across multiple domains including overall health, physical and mental functioning, occupational engagement, and life satisfaction, demonstrating the intervention’s impact on daily life and function	Assessing outcomes including proximal (e.g., diabetes management self-efficacy, pain) and long-term measures (e.g., amputation status), incorporating patient-reported (e.g., diabetes distress) and clinical data (e.g., wound status) across general (e.g., occupational performance) and diagnosis-specific (e.g., diabetic foot ulcer recurrence) domains	Connecting broad and specific relevant health outcomes by evaluating clinical (e.g., HbA1c, blood pressure) and behavioural outcomes (e.g., medical treatment adherence) in addition to occupational performance, self-efficacy, and perceived health status	Assessing outcomes via participant self-report across multiple domains ranging from overall health, social participation, and attitudes toward leisure, to life balance, self-compassion, and engagement in meaningful activities	Assessing condition-specific outcomes such as weight loss or maintenance (as desired by the client) and broad outcomes including physical and mental health-related quality of life and occupational performance and satisfaction
Administration by an OTP with advanced training	Delivering the intervention by a licensed and registered OT who has received ≥10 hours of intervention-specific training	Delivering the intervention by a licensed and registered OT with LR certification Prioritising OT practitioners with experience in diabetes management and/or specialized diabetes training (e.g., Certified Diabetes Care and Education Specialist credentials)	Delivering the intervention by a licensed and registered OT with specific LR-OT training Including didactic education in LR-OT (4-unit university course), didactic education in clinical aspects of diabetes management, and training in motivational interviewing (2- to 4-unit university course or 12 contact hours of continuing education)	Delivering the intervention by an OT who is registered to practice (member of Québec’s OT board) and has received ≥10 hours of intervention-specific training	Delivering the intervention by a licensed and registered OT with LR certification Including additional training in weight management, motivational interviewing (≥16 contact hours), and ≥250 mentored practice hours

Note: The descriptions in each cell provide illustrative examples of how each adapted program aligned with the core characteristic. These examples are not exhaustive; each program may have met the characteristic in additional ways. Abbreviations: LR=Lifestyle Redesign; OT=occupational therapy/ist.

Table 4.

Examples of Content from the Original Well Elderly Program and Tailored Topics from Each Adapted Program that Align with Lifestyle Redesign^® Core Domains.

LR Core Domain	Examples of Tailored Intervention Components that Represent LR-OT Core Domains
	Well Elderly Lifestyle Redesign	Diabetic Foot Ulcer Self-management	Primary Care Chronic Condition Management	Remodeler sa Vie (Reshape your Life)	Lifestyle Redesign® for Weight Management
Meaningful occupations, habits, routines	Analyzing the value placed on security and stability of routine versus spontaneity, stimulation, and engagement Exploring the balance of occupations (work/productive activity, rest/sleep, leisure/play, self-care) across days, weeks, and months	Orchestrating safe and meaningful physical activity routines that comply with offloading prescription while promoting overall well-being Establishing or enhancing a structured foot self-care routine that includes consistent foot self-checks and wound monitoring Organizing diabetic foot ulcer-related healthcare appointments to minimize disruption to valued roles and occupations	Structuring habits and routines to support engagement in diabetes and/or hypertension self-management tasks (e.g., blood glucose and blood pressure tracking, following medication regimens) within the context of the patient’s roles and responsibilities Supporting patients in reframing their perspective on self-care and health management (e.g., controlling blood pressure as essential to continue working) to increase participation in health management tasks	Involving participants in a citizens action activity to promote social solidarity and community engagement Educating and engaging participants in occupational self-analysis of risk as linked to occupation (e.g., medication adherence, recognizing symptoms of chronic conditions, social withdrawal, overexertion)	Orchestrating habits and routines to include occupations supportive of successful weight management (e.g., healthy eating, physical activity) Educating about the value of occupations intended to promote successful weight management and well-being Exploring strategies to identify and engage in meaningful daily activities that support health and well-being, and prevent the onset of chronic conditions linked to overweight and obesity
Occupations relevant to wellness and chronic condition management	Demonstrating and practising with adaptive equipment for everyday life (e.g., jar openers to accommodate reduced grip strength from arthritis, magnifying glasses to read small-print newspapers) Practising deciphering food labels to abide by dietary restrictions (e.g., low-sodium diet)	Enhancing awareness of signs, symptoms, and risk factors of diabetic foot ulcers and preparing a plan for timely response Implementing offloading techniques into daily routines to optimize wound healing and prevent complications Introducing adaptive equipment to enhance daily function and self-care while adhering to offloading treatment Structuring daily occupations and infusing strategies to manage diabetic foot ulcer symptoms (e.g., pacing, energy conservation)	Enhancing understanding of the connection between daily habits and routines and overall health to support awareness of diabetic symptoms and risk factors of secondary complications Training in assertive communication to advocate for health-related needs with healthcare providers and in the workplace Collaborating to identify tools and strategies to optimize self-management that is financially feasible, physically accessible, and culturally applicable (e.g., resources within walking distance, involving family in health management routines)	Introducing structured strategies for time management in daily life to promote health self-management (e.g., planning self-care, prioritizing medical appointments, using energy conservation techniques) Modifying outings and activities to accommodate participants with wide-ranging disability statuses (e.g., soliciting help from volunteers during group outings, centering discussions on public transportation and paratransit versus driving for those who are unable to drive)	Using education and problem solving to support clients’ abilities to engage in occupations supportive of weight management and a healthy lifestyle (e.g., physical activity, sleep hygiene, eating routines) Educating on chronic conditions that have strong evidence for co-occurrence with higher weight in order to support prevention
Psychosocial well-being and mental health	Exploring adaptations that are or could be made in daily life to cope with the aging process Discussing ageism including societal views and personal perspectives Compiling “words of wisdom” about the meaning of health and wellness in later life Exploring occupations that can support coping with loss of a loved one and managing grief	Identifying and leveraging social support networks to facilitate diabetic foot ulcer management and emotional well-being Fostering adaptive coping strategies for managing the emotional and psychological aspects of diabetic foot ulcer care Enhancing self-efficacy and problem-solving skills for self-managing diabetic foot ulcers and offloading regimens	Practising and implementing self-regulation strategies to mitigate stress related to condition/health status and engaging with the medical system (e.g., white coat syndrome, barriers to accessing prescriptions) Developing reactive coping plans in response to symptom exacerbation, unexpected challenges with acquiring diabetes supplies, and developing secondary complications Co-creating social prescriptions that optimize social supports and promote self-regulation	Promoting emotional well-being through engagement in a gratitude card-based activity that fosters positive reflection, emotional resilience and self-kindness—values that align with cultural traditions of mutual aid community solidarity, and social connectedness in French-Canadian culture Adding outcome measurements of gratitude, self-compassion, and attitudes toward leisure to better capture psychosocial and emotional well-being	Building self-efficacy in weight management skills and experiencing the benefits of behaviour change that can contribute to improved mental health Educating on the sympathetic and parasympathetic nervous systems, the stress response, and relaxation response Identifying healthy pleasures and non-food rewards Guiding direct experiences in healthy coping mechanisms (e.g., deep breathing exercises)
Environment and context	Compiling and analyzing a list as a group of the positive aspects and areas for growth relevant to the current senior residence facility Creating a safe environment in the home following a home safety evaluation	Developing fall prevention strategies that ensure safe life-space mobility while adhering to offloading treatment Fostering understanding of diabetic foot ulcer self-management within the context of the healthcare system Exploring community and life-space mobility while adhering to offloading restrictions	Adapting self-management routines for situations outside the home (e.g., when traveling, while at work, when caregiving) and problem-solving strategies to support optimal self-management in various contexts Addressing physical and social spaces that impact engagement in self-management routines, especially around dining and blood glucose monitoring Analyzing a patient’s environment to customize diabetes-specific toolkits to prepare for emergencies (e.g., low/high blood sugar)	Acknowledging and considering important public holidays (e.g., Quebec’s National Holiday, Christmas, Easter) and seasonal events in French-Canadian culture Modifying an activity dedicated to the impact of key historical events on participants’ life stories by aligning details with Canada’s history Incorporating intergenerational activities to promote connectedness among different age groups (e.g., hosting a healthy pleasures fair with kiosks where participants share life experiences with university students)	Identifying barriers and supports to engagement in health promoting activities such as access to food, resources, physical activity facilities, and the built environment Engaging in environmental modifications to support success in healthy living and weight management Problem solving and strategizing about transferring weight management skills to various contexts and situations
Advocacy and Healthcare Access	Exploring accessible options for transportation and creating a resource book for public transit Assessing health literacy and reviewing medical terminology frequently used by providers at healthcare visits	Enacting time management strategies to effectively coordinate diabetic foot ulcer care within daily life Developing strategies to prepare for and actively engage in diabetic foot ulcer care appointments to optimize treatment outcomes Building communication skills to self-advocate for needs and preferences during diabetic foot ulcer care appointments Enhancing communication strategies used with family and friends to maximize social support for offloading management	Building assertive communication skills to support healthcare navigation, access to prescriptions, and receiving specialty referrals Supporting patients in communicating with healthcare providers to optimize patients’ role as active members of their own healthcare Using visual aids to support preparing for appointments and prioritizing concerns Enhancing resource-seeking skills for autonomous chronic condition self-management Optimizing care partner relationships and roles while centering patient-led decision-making	Providing culturally sensitive education aligned with groups’ local/provincial/national resources such as legal rights and ethical decision-making around end-oflife planning within the context of Québec’s legal framework for medical assistance in dying	Identifying self-advocacy strategies to discuss weight-related health concerns and request referrals (e.g., to a dietitian or endocrinologist) Educating participants on how to access insurance-covered weight management services or food assistance programs

Completion of the structured documentation was guided by multiple sources of data, including: (a) program records (e.g., study protocols, manuals, IRB applications); (b) publications, including those that reported implementation context, feasibility, and other process indicators; and (c) the experiential knowledge of team members directly involved in program design, delivery, or evaluation. This triangulated approach ensured that adaptation documentation reflected both written materials and lived experience with the program’s implementation. Upon submission, two LR-OT-certified authors (SSN, EAP), both with in-depth knowledge of the WE program and LR-OT framework, reviewed each form for accuracy and completeness. Discrepancies or unclear classifications were discussed and resolved with the broader authoring team. The compiled materials were then analyzed to identify frequency and patterns of adaptations across teams.

The research activities described in this paper involve a review and analysis of program adaptations and do not involve human participants or identifiable private information. As such, these activities were determined to be Not Human Subjects Research (NHSR) in accordance with the University of Southern California IRB guidelines and did not require IRB oversight.

Results

Adaptation Processes Across Programs

Overview.

This section overviews the adaptation processes used across the four programs, illustrating how each team approached LR-OT modification. The DFU-SM study team followed the ADAPT-ITT model (Wingood & DiClemente, 2008) to adapt LR-OT by including the following steps. Assessment: DFU patients’ needs were identified via literature reviews and the team’s prior needs assessment research (Crocker et al., 2021). Decision: adaptation was chosen over adoption. Administration: theater testing of diabetes-focused LR-OT was conducted to gather tailoring recommendations from key informants (e.g., DFU patients, podiatrists). Production: DFU-specific materials and intervention processes were drafted. Topical experts: modifications were made to initial materials/processes with guidance from DFU experts (e.g., wound care nurse, orthotist). Training: a certified LR-OT intervener and research staff were trained in intervention- and study-specific details. Testing: a pilot clinical trial (goal N=20) is ongoing to assess program feasibility and potential for improving patient outcomes.

The PC-CCM team began the adaptation process (see Pyatak et al., 2019) by meeting with primary care clinic leadership at a safety-net medical centre to discuss clinic needs and integration of LR-OT services. The target patient population was selected—patients with uncontrolled diabetes—and the REAL Diabetes treatment manual (another LR-OT adapted program) was trialed in a one-year hybrid effectiveness-implementation study (N=73; Pyatak et al., 2019). Following the pilot study, the team met with clinic leadership to explore sustaining LR-OT services within the clinic’s interdisciplinary team, and expanding services to include hypertension management. Upon securing support, the team developed processes to onboard a resident, including training the resident in clinic-specific procedures and in delivering modified LR-OT services that address both diabetes and hypertension management in the primary care setting.

The RV study team undertook a transcultural adaptation process involving rigorous translation of WE LR-OT materials into French and collaboration with end users, older adult organizations, and OT associations to ensure cultural appropriateness. The RV program retained many structural features of the original WE intervention but modified content to reflect the healthcare system, social norms, and values of Francophone older adults. A mixed-methods feasibility and pilot study was conducted with older adults (N=17), OTs, and decision-makers to ensure program relevance, acceptability, and preliminary efficacy in the Québec context (Levasseur et al., 2022).

The WM program emerged organically from knowledge gleaned from the WE studies, expert consultations (e.g., nutritionist, economist), and review of relevant evidence. Designed for immediate clinical implementation without pilot testing, it incorporated pre-planned adaptations based on anticipated needs of clients pursuing weight management and to improve its appeal to private health insurers and self-insured employers. As the healthcare landscape evolved and new funding opportunities emerged—such as obesity becoming a billable diagnosis—clinic leadership engaged in iterative adaptations to align with changing reimbursement models, including integration into broader healthcare systems and insurance networks. These adaptations were guided by assessments of logistical feasibility, financial sustainability, and client engagement. Throughout, adaptation decisions reflected a dynamic process shaped by contextual demands, resource availability, and client input.

Patterns of Adaptations.

Despite varying adaptation strategies, common patterns and distinctions emerged across the four programs. The DFU-SM team adhered to a formalized, stepwise process using the ADAPT-ITT framework. The other teams followed more flexible adaptation processes but still featured key steps commonly included in systematic adaptation frameworks (Escoffrey et al., 2018). For example, the PC-CCM team adapted based on stakeholder input and prior research, while RV employed a rigorous translation and cultural tailoring process. The WM program, in contrast, implemented a fluid adaptation process informed by client feedback, clinical context, and evolving payer requirements. Pilot testing was conducted by all except the WM team. Although pilot testing can be an effective method that reduces the need for extensive reactive adjustments, it can also be resource-intensive and delay scale-up (Beets et al., 2021). Teams weighed these trade-offs in light of their goals and resources.

As mapped to FRAME, all program adaptations began at the pre-implementation/planning/piloting stage (Table 2). Adaptations during pre-implementation and planning phases were proactive (e.g., the DFU-SM and RV teams conducted linguistic translation before pilot testing), whereas those occurring during pilot testing or implementation were reactive (e.g., the WM team pivoted screening practices to accommodate reimbursement changes). Unlike the PC-CCM and WM teams which had to rapidly transition to telehealth due to the pandemic, the DFU-SM team preemptively incorporated a telehealth model, enabling careful planning to optimize intervention quality. The PC-CCM and WM teams also enacted proactive modifications during the maintenance/sustainment phase. The PC-CCM group explored the residency model to sustain the piloted program after the conclusion of the grant-funded preliminary study, while the WM program focused on maintaining financial viability by seeking Preferred Provider Organization coverage following conclusion of initial contracted services.

Engagement of key players was essential across all programs (Table 2). Decision-making was collaborative, and input ranged from expert perspectives on condition management (e.g., consulting nutritionists in adapting the WM program) to administrative considerations (e.g., budgeting for staff training and ensuring alignment with patient privacy laws in the PC-CCM program). Among all programs, PC-CCM was the only one that explicitly identified a coalition of affected stakeholders (e.g., the IT department responsible for building electronic medical record forms). The PC-CCM and WM programs, having progressed to full implementation, involved a broader group of decision makers including individuals responsible for integrating programs into routine care, such as clinical leadership. Because the DFU-SM (pilot ongoing) and RV programs had not yet reached the implementation stage, their research teams served as the sole final deciders.

Each team aimed to adapt their program primarily to improve fit with recipients. All programs except RV sought to improve outcomes, a distinction likely due to RV’s close alignment with the original WE program and prioritization of replicating WE’s excellent outcomes that were relevant to the French-Canadian population. The PC-CCM team uniquely emphasized reducing disparities as a driver for adaptation, particularly within the under-resourced, safety-net patient population, highlighting its focus on social determinants of health.

Reasons for adaptation aligned with FRAME’s four categories. Organizational/setting factors played a role across all programs, with the clinically focused teams adapting to fit within service structures and address practical constraints like resource availability and billing. Recipient factors were also universally considered, with teams adapting most commonly for resource access, comorbidity, and language needs. For the latter recipient factor, the DFU-SM and PC-CCM teams proactively modified materials for Spanish-speaking communities and the RV team rigorously adapted resources and content for the Francophone community.

All teams identified provider-level previous training and skills as a reason for adaptation, with the DFU-SM and PC-CCM teams also noting clinical judgment. Training adaptations incorporated condition-specific requirements in the DFU-SM, PC-CCM, and WM programs, while the RV group capitalized on newly created training resources for the OT community made available at the conclusion of the WE studies. Finally, sociopolitical factors were relevant for the RV program, which placed strong emphasis on selecting societal and cultural norms applicable to the social context of French-Canadian older adults.

Characteristics of Program Structure and Delivery Model Adaptations

The above adaptations shaped key structural and delivery modifications across programs. All teams reported training and evaluation, contextual, and content modifications, and two identified implementation and scale-up activity adaptations. These modifications occurred at delivery levels, ranging from target intervention group-level (e.g., the RV team’s translation of materials into French for the Francophone community) to clinic/unit-level changes (e.g., clinic-wide workflow adjustments in the WM and PC-CCM programs).

Training and Evaluation Adaptations.

Modifications to training and evaluation were made with the intention to ensure interventionists possessed the prerequisite knowledge and skills to treat the target population and that program outcomes were suitably captured. For instance, the DFU-SM team implemented a combined guided and self-study approach to orienting the OT to DFU self-management to complement the LR-OT’s assumed baseline knowledge of general diabetes care. (Although program teams reported that orientation and training approaches were modified to support interventionists’ preparedness, this study did not directly measure knowledge acquisition or competency.) Regarding evaluation, the RV team added measures of self-compassion and gratitude which aligned with the intervention’s cultural changes. The clinically focused DFU-SM, PC-CCM, and WM teams introduced objective clinical indicators to their assessment batteries (e.g., EMR-documented wound healing status, HbA1c, and body composition, respectively) to sync with expected healthcare service outcomes. In contrast, the original WE program focused exclusively on self-report measures.

Contextual Adaptations.

Contextual modifications included adaptations to the intervention’s format, target population, implementation setting, and personnel. The delivery format of the DFU-SM and PC-CCM interventions focused exclusively on one-to-one treatment sessions whereas the WM program initially offered both individual and group formats before transitioning to an individually focused model. The RV program maintained a primarily group-focused model with monthly one-to-one sessions, preserving a “peer exchange” element from WE not featured in the other programs. A fully telehealth delivery mode is being tested in the DFU-SM study, while the PC-CCM and WM programs pivoted from in-person to telehealth during the COVID-19 pandemic. Post-pandemic, the WM program now offers telehealth or in-person options. Of the four programs, only the PC-CCM team modified personnel from the WE model of practicing OTs, integrating post-professional doctoral OT residents to build workforce capacity.

Content Adaptations.

Although the WE study allowed for flexibility in delivery, all four programs made content modifications designed for specific target populations. These adaptations included tailoring/refining, adding elements, removing/skipping elements, shortening/condensing pacing or timing, and in the PC-CCM program’s case, integrating the intervention into another framework.

Tailoring was a common strategy, as the broad topics outlined in the WE study provided a foundation for customization. The PC-CCM program aligned its content with safety-net primary care patients’ needs, while the DFU-SM program tailored elements related to foot self-care and offloading management. Similarly, the RV program was culturally adapted for French-Canadian older adults, incorporating local healthcare organizations and resources. The WM program adjusted its content to include weight management topics such as the psychological and behavioural aspects of eating, refining the WE content on dining and social eating to include emotional eating and alternatives to food-based reward systems. Additionally, most programs—except for RV—removed age-specific language so that the materials were not limited to older adults but could be applied across a broader adult audience.

Language modifications were also prominent. Although the WE study permitted tailoring language for participant comprehension, the DFU-SM, PC-CCM, and RV teams proactively translated materials at the outset to meet the known linguistic needs of their target populations. Spanish translations were incorporated into the DFU-SM and PC-CCM programs, while the RV program adapted materials into French. Other refinements included modifications to worksheets and handouts. For instance, the DFU-SM team tailored coping strategies to address offloading management for foot wounds. Healthcare content was also revised to reflect the realities of different healthcare systems, such as the RV program’s focus on navigating Canada’s public health system and the PC-CCM program’s integration within a patient-centred medical home model.

Beyond tailoring, three of the programs introduced additional content to address population-specific concerns. The WM program incorporated structured materials on eating routines, meal planning/preparation, and grocery shopping; the DFU-SM program added content on foot self-care routines, adaptive equipment for offloading, and safe physical activity; and the PC-CCM team expanded content to address issues such as building emergency toolkits for high/low blood sugar and planning for common comorbid conditions such as visual impairment and peripheral neuropathic pain.

In contrast, each program removed or skipped content that was less relevant to their populations. All but the RV team eliminated the WE “group outing,” primarily to align with the transition to one-to-one sessions and fit with altered program delivery settings. For their initial groups, the RV team did not target WE content related to hormones, aging, and sexuality, as participants did not choose these topics.

Adjustments to the pacing or length of the WE program (6–9 months) were also noted. The DFU-SM team reduced its program to an eight-session, approximately weekly model to accommodate grant funding timeline constraints. Similarly, the WM program originally implemented a four-month weekly format to fit with established contracts but allowed clients to engage in additional continuation sessions if requested.

The PC-CCM team was the only group that integrated LR-OT into an alternate intervention framework: the team-based care model. This was accomplished through electronic health record messaging, structured documentation, and in-person discussions with the clinical team to ensure that patients’ daily habits, routines, and goals were incorporated into collaboratively managed health plans.

Despite making content modifications, none of the teams reported deviations from the intervention framework, such as drifting from LR-OT principles or integrating other treatments into the program. Rather, adaptations were made to preserve the relevance, feasibility, and accessibility of the intervention while maintaining fidelity to its foundational approach. Whereas Table 2 categorizes these content modifications, the next section will examine the extent to which the adapted programs remain consistent with LR-OT’s core characteristics (Table 3) and core domains (Table 4).

Implementation/Scale-up Adaptations.

The PC-CCM and WM teams also made adaptations to support implementation and scale-up efforts, as the WE studies involved research-based implementation and did not have an established method of integrating services into routine community programming. For the PC-CCM program, the team educated referring providers during staff meetings to increase awareness of LR-OT services and coordinate care with other clinical team members from the unit. The WM program involved modifications to facilitate program implementation (e.g., securing insurance coverage and extending eligibility for reimbursement).

Fidelity Consistency with LR-OT Core Elements

Given the breadth of adaptations made across multiple program components, it is essential as part of the FRAME to assess whether these modifications remained aligned with LR-OT’s core elements (Figure 1). In this section, we describe how the adapted programs preserved fidelity to LR-OT’s core characteristics (Table 3) and core domains (Table 4), based on illustrative examples provided by each team. Although teams were not asked to supply exhaustive accounts, the examples demonstrate consistency with LR-OT’s defining features and were deemed sufficient to indicate fidelity alignment.

Core Characteristics.

All four adapted programs, as characterized through program team accounts and available documentation, maintained fidelity to the core characteristics of LR-OT, reinforcing the intervention framework’s adaptability across diverse populations and contexts (Table 3). The RV program most closely mirrored the original WE program, with its primary distinction being cultural and linguistic adaptations for French Canadians. As a result, its mapping to the core characteristics largely paralleled that of the WE program. Across all programs, a key emphasis remained on optimizing daily routines, whether through assisting patients in structuring offloading regimens in the DFU-SM program or guiding adjustments to routines to support healthy weight in the WM program. Similarly, each program provided examples of lifestyle-related challenges specific to its target population, such as the PC-CCM program addressing the potential mismatch between diabetic dietary restrictions and favorite foods, and the RV program acknowledging evolving care responsibilities with aging. Health-related outcomes remained a central focus, with the clinically adapted programs expanding beyond the original WE program’s psychosocial measures to include physiological markers like blood pressure and body composition. The therapist-client dynamic was consistently shaped by core LR-OT techniques that supported collaboration and individualization, ranging from motivational interviewing to occupational self-analysis. While the specific training requirements for interventionists varied by program, all OT practitioners required advanced training in LR-OT, with some adaptations necessitating additional clinical expertise, such as diabetes management for the DFU-SM and PC-CCM programs or specialized knowledge of weight regulation in the WM program.

Core Domains.

The adapted programs remain aligned with the core domains. Table 4 illustrates how both the original WE program content and the modified content from the adapted programs mapped onto these domains while also addressing the unique needs of each target population and implementation context.

Across all adaptations, meaningful occupations and psychosocial well-being remained central, with numerous examples demonstrating how content was tailored while upholding these foundational elements. Although some programs modified session topics or introduced additional materials beyond those in the WE program, they consistently addressed essential LR-OT domains—for instance, attending to the physical environment for fall prevention, which in the DFU-SM program specifically focused on safe use of an offloading device. Certain programs emphasized particular domains more heavily to meet their population’s needs, such as the clinically based programs prioritising advocacy and healthcare access. Similarly, the DFU-SM and PC-CCM programs, relative to the original WE program content, placed greater emphasis on chronic condition management, given their focus on patients with specific diagnoses.

Discussion

This study applied the FRAME to examine four programmatic adaptations of LR-OT. Through a multiphase process, each team engaged in adaptations to align the intervention with contextual and population-specific needs while maintaining fidelity to LR-OT’s fundamental principles. Analysis was informed primarily by structured documentation completed by team members with in-depth knowledge of each program, supplemented by program records and published materials. Several key adaptation patterns emerged, highlighting strategies that upheld core characteristics and domains of the intervention while ensuring appropriate contextual fit.

By analyzing adaptation strategies and evidence of fidelity-consistency across programs, we identified critical factors that contributed to successful modifications. Specifically, teams balanced fidelity and fit, a well-documented tension in implementation science (Mejia et al., 2017). Rather than treating fidelity and adaptation as opposing forces, teams navigated this balance by implementing culturally responsive modifications, adjusting program delivery, engaging key stakeholders in decision-making, and leveraging interdisciplinary partnerships. These strategies reflect the perspectives of LR-OT program insiders and available documentation, though the actual impact on participant outcomes was not directly measured. Thus, this study builds on the work of Pyatak et al. (2022) by further clarifying the essential elements of LR-OT, situating core domains and techniques within real-world adaptations. Further, the study highlights considerations for scaling and sustaining LR-OT interventions. Modifications such as telehealth integration, alignment with clinical workflows, and condensed program structures tailored to health system constraints may enhance program scalability but require further empirical validation Additionally, ensuring sustainable financial structures, including reimbursement opportunities, appears essential for broader program dissemination.

A critical challenge involved addressing practical constraints and resource limitations inherent to different settings. For example, in medical contexts, LR-OT was adapted to align with clinic workflows and the priorities of interdisciplinary teams, such as the requirement to integrate objective health indicators. Such modifications facilitated program adoption and sustainability, reinforcing the importance of contextual fit in implementation success. The role of structured flexibility in scaling interventions warrants further investigation. Researchers argue that scalability is enhanced when interventions maintain key core elements while allowing adaptable delivery mechanisms (Aarons et al., 2017).

The LR-OT variants examined in this study benefited from longstanding access to LR-OT developers, which may have provided atypical resources for ensuring fidelity-consistent adaptations. This highlights the importance of comprehensive training and deep understanding of intervention frameworks in successful adaptation efforts. Lifestyle Redesign^® Certification (LRC; USC Chan Division of Occupational Science and Occupational Therapy, n.d.-a) may play a crucial role in supporting clinicians to achieve successful modifications while maintaining fidelity to core principles.

By systematically examining LR-OT adaptations, this study advances OT intervention research within the implementation science arena. Building on Piller and colleagues’ (2021) work using FRAME to report adaptations to a stepwise vestibular and bilateral integration OT intervention, this is the first application of FRAME to an individualized, client-centred OT intervention model. We emphasize that findings describe the adaptation processes as documented by knowledgeable program team members and do not provide empirical evidence regarding intervention effectiveness for participants. Although LR-OT is a distinctive form of client-centred OT, the process and principles for documenting and guiding adaptations—particularly with FRAME—is broadly applicable to other complex OT interventions. This study bridges a critical gap between OT practice and implementation science by demonstrating how a flexible OT intervention framework can be adapted systematically while maintaining fidelity consistency, as assessed through structured documentation and mapping to core elements.

Finally, these findings have policy implications for funding and supporting adaptable health interventions. Reimbursement models and grant funding structures should accommodate flexible intervention frameworks such as LR-OT, rather than imposing rigid protocol requirements or fixed intervention durations. Overly restrictive funding criteria risk undermining the effectiveness of client-centred EBPs. Additionally, grant funders should prioritize studies that compare different adaptation approaches to evaluate their impact on intervention outcomes, ultimately strengthening the evidence base for scalable, adaptable interventions.

Limitations and Future Directions

Several limitations warrant consideration. The retrospective, self-reported nature of the adaptation data may have introduced recall bias and compromised the accuracy of the documented modifications. The analysis reflects the subjective assessment of knowledgeable program team members and available documentation; direct evaluation of the impact of adaptations on participant knowledge, skills, or outcomes was not conducted. Although fidelity consistency was assessed descriptively rather than through independent measurement, insider perspective provides deep contextual insight into how LR-OT adaptations are enacted in practice. Further, the inclusion of only four case examples may not capture the full diversity of adapted LR-OT programs and limits the generalizability of findings. The use of FRAME also presents challenges. As an emerging tool, FRAME offers limited guidance on application across diverse types of EBPs and practice settings. Specifically, OT interventions often lack stepwise protocols, making FRAME less applicable to many OT EBPs (Piller et al., 2021). LR-OT, with its inherently flexible and client-centred design, complicates the use of FRAME further; its adaptability resists rigid classification and may obscure or hinder tracking of nuanced modifications. Furthermore, the original WE LR-OT program lacks a standardized implementation protocol, making fidelity assessment difficult across adapted versions. Consequently, this study relied heavily on the program’s identified core characteristics and domains to anchor evaluation.

Looking ahead, the defined LR-OT core characteristics, domains, and techniques offer a useful foundation for guiding future adaptations. Developing an “adaptation data platform” or similar tracking tools, as Piller and team suggested (2021), could support systematic documentation, evaluation, reproducibility, comparability of adaptations for other types of OT interventions. More broadly, there is a need within the OT field for empirical testing of adaptation strategies and rigorous assessment of their impact on implementation and client outcomes.

Conclusion

This study’s findings highlight that structured flexibility within LR-OT enables successful adaptation as documented by knowledgeable program personnel and investigators. Across programs, team accounts reflected a successful balance between fidelity and fit through culturally responsive modifications, stakeholder engagement, and integration with local healthcare structures. The results contribute to implementation research in OT by providing a model for systematically documenting intervention adaptations. By demonstrating how fidelity-consistent modifications can enhance cultural and contextual relevance, this study offers practical insights for clinicians and researchers aiming to scale LR-OT or similar EBPs. Additionally, findings emphasize the importance of well-designed training processes, interdisciplinary collaboration, and sustainable funding models to support long-term implementation. At the same time, because these findings rely on insider team accounts rather than direct measurement, they should be interpreted as descriptive evidence of how adaptations were enacted in practice. Future research should investigate the impact of adaptations on client outcomes and develop standardized mechanisms for tracking modifications. Strengthening implementation science within OT will promote identification of scalable, client-centred interventions that remain responsive to evolving healthcare and community needs.

Key Messages.

• This study demonstrates how documented structured flexibility in the Lifestyle Redesign^® occupational therapy (OT) intervention framework can support adaptations that aim to maintain fidelity while responding to diverse cultural and contextual needs.

• By applying FRAME to an individualized, client-centred OT intervention, we provide a descriptive model for systematically documenting and analyzing adaptations in OT practice, based on program team knowledge and records.