Occupational Therapy Within Integrated Community Care Systems: A Systematic Review and Narrative Synthesis of Policy and System-Level Evidence

Su-Min Cha

doi:10.3390/healthcare14193222

. 2026 Sep 30;14(19):3222. doi: 10.3390/healthcare14193222

Occupational Therapy Within Integrated Community Care Systems: A Systematic Review and Narrative Synthesis of Policy and System-Level Evidence

Su-Min Cha ¹

Editors: Daniele Giansanti¹, Rosario Caruso¹

PMCID: PMC13665334 PMID: 42881661

Abstract

Background/Objectives: Population aging and rising long-term-care demand require community-based systems that support function and participation. Occupational therapy (OT) is provided across community-care settings, yet its policy- and system-level position remains inconsistently defined. This review examined how OT is positioned, financed, accessed, coordinated, staffed, and implemented within integrated community care. Methods: PubMed, CINAHL, Scopus, ProQuest Central, and APA PsycINFO were searched for English-language peer-reviewed literature published from 1 January 2010 to 29 July 2026. Two reviewers independently conducted study selection, data extraction, and design-matched critical appraisal. GRADE-CERQual and GRADE were applied to eligible qualitative and quantitative findings, respectively. The review synthesized peer-reviewed evidence describing policy- and system-level arrangements rather than systematically reviewing primary policy documents themselves. Results: Of 15,402 records, 5131 duplicates were removed, 10,271 screened, and 38 reports assessed in full text; 21 reports representing 20 unique studies/datasets were included. Framework synthesis refined the initial deductive categories into five higher-order domains: institutional positioning; financing/coverage; referral/coordination; service-delivery roles/infrastructure; and workforce/implementation support, with accessibility, equity, and user participation as cross-cutting themes. CERQual confidence was moderate for role clarity/team understanding, organizational integration supports, and service context/workforce capacity, and low for reimbursement/billing constraints, referral-prioritization/fairness judgments, and service-redesign tensions. Waiting-time change, waiting-list association, and OT integration feasibility had very low GRADE certainty. Conclusions: OT integration reflected interrelated policy-system arrangements rather than a validated model. Downstream system effects remain insufficiently established.

Keywords: occupational therapy, integrated care, community care, health policy, financing, referral, service accessibility, workforce, implementation

1. Introduction

Population aging and the rising prevalence of chronic conditions and multimorbidity are heightening the need for health systems to address sustained, complex care needs [1]. Across OECD countries, chronic conditions become increasingly common with age, and multimorbidity is particularly prevalent among older adults [1]. The WHO framework on integrated, people-centered health services identifies fragmentation and weak coordination across services as system barriers to continuity and person-centered care [2]. The subsequent WHO report on strengthening integrated, people-centered health services further emphasizes coordinated, system-level organization rather than isolated episodes of care [3]. These developments have made integrated, person-centered care a major policy priority, with a focus on reorganizing and coordinating services rather than simply adding isolated services [2,3].

Integrated care has been conceptualized in several complementary ways [4,5,6]. Kodner and Spreeuwenberg described it as a coherent set of methods and models designed to foster connectivity, alignment, and collaboration within and across levels of care [4]. Valentijn et al. organized integration across system, organizational, professional, and clinical levels in the Rainbow Model of Integrated Care [5]. Goodwin emphasized that integrated care is context-dependent and should not be reduced to a single organizational template [6]. Evidence syntheses likewise show that outcomes depend on how integration is configured [7,8]. Baxter et al. reported heterogeneous effects across integrated-care programs and outcomes, with some improvements in service quality, patient satisfaction, and access, but no uniformly effective model [7]. In community-based multidisciplinary care involving general practitioners, Hayes et al. found long-term improvements in functional status, hospitalization, and patient satisfaction, while evidence for several other outcomes was non-significant and generally of low or very low certainty [8]. Taken together, these conceptual and empirical sources support the understanding that integrated care is the organization of roles, pathways, financing, coordination, and governance mechanisms, rather than simply the addition of community programs [4,5,6,7,8].

For this review, policy- and system-level evidence was defined in relation to health-system and integrated-care concepts rather than as a synonym for clinical effectiveness [2,5,6]. The WHO framework identifies governance, coordination, service-delivery organization, and enabling system conditions as central to integrated people-centered care [2]. Valentijn et al. distinguish system and organizational integration from professional and clinical integration [5], while Goodwin stresses that the form of integration depends on local institutional and service contexts [6]. On this basis, policy- and system-level evidence in the present review was operationalized as peer-reviewed evidence describing the rules, institutional arrangements, organizational mechanisms, and implementation conditions that shape or constrain the institutional positioning and delivery of occupational therapy within community-based care systems [2,5,6]. The scope covered macro-level policy and financing arrangements, meso-level service-system arrangements, and cross-cutting issues of accessibility, equity, and user participation, consistent with the multi-level and people-centered framing of integrated care [2,5]. Individual-level clinical outcomes or intervention effectiveness were therefore not considered policy- or system-level evidence in themselves and were included in this interpretation only when explicitly linked to such policy or system arrangements [2,5,6].

Within this policy-and-system scope, rehabilitation has attracted growing international attention as a health-system priority [9]. The WHO Rehabilitation 2030 initiative calls for strengthening rehabilitation through governance, workforce development, financing mechanisms, and integrated service delivery across levels of care [9]. Global estimates from the Global Burden of Disease Study 2019 indicate that approximately 2.41 billion people had conditions that would benefit from rehabilitation in 2019 [10]. Occupational therapy services in primary care have been described as supporting function, daily living, participation, and self-management across diverse populations [11]. Freeman et al. [12] documented wide international variation in the organization, financing, workforce supply, and training needs of occupational therapy in primary care, highlighting substantial differences in how occupational therapy is positioned and supported within primary care systems. Complementing this system-level evidence, Cumming et al. [13] reported benefits of occupational therapist-led home hazard assessment and modification for fall prevention, particularly among older adults with a history of falls. Pighills et al. [14] further examined the effectiveness of occupational therapist-led environmental assessment and modification in preventing falls, while Stark et al. [15] provided more recent evidence that occupational therapist-led home hazard removal can reduce fall rates among community-dwelling older adults. In contrast, Legg et al. [16] found no eligible comparative studies establishing the effectiveness of publicly funded home-care reablement and highlighted major definitional and evidentiary gaps. In stroke rehabilitation, Qin et al. found a short-term benefit in basic ADLs when home-based rehabilitation was added to usual care, whereas other comparisons were not clearly superior, and the evidence quality was low [17]. Chen et al. reported benefits of reablement for ADL and IADL but no significant effects on quality of life, hospitalization, or unplanned emergency-department use [18]. Collectively, these studies establish clinical and service relevance but also illustrate why policy- and system-level conditions should not be inferred from intervention-effectiveness evidence alone [13,14,15,16,17,18].

Despite this growing policy relevance, much of the occupational therapy literature has focused on clinical effectiveness, profession-specific practice, or local service implementation [11,13,14,15,16,17,18]. Such evidence is important, but it does not, by itself, establish how occupational therapy is institutionally recognized, financed or reimbursed, referred to and prioritized, embedded within multidisciplinary pathways, or supported through workforce and implementation infrastructure [11,12,16]. These organizational and policy conditions operate beyond the individual clinical encounter and can shape whether services are available, accessible, coordinated, and sustainable in practice [2,3,9]. The WHO integrated-care framework explicitly treats governance and coordinated service-delivery arrangements as system requirements for people-centered care [2]. The later WHO report reinforces the need to strengthen integrated service organization across health systems [3]. WHO rehabilitation guidance similarly identifies governance, financing, workforce, and service delivery as health-system actions required to strengthen rehabilitation [9]. A systematic review focused specifically on policy- and system-level evidence is therefore warranted to identify enabling and constraining arrangements, compare them across jurisdictions, and distinguish documented organizational structures from downstream effects that remain uncertain [2,3,9,12].

Accordingly, this review did not conduct a statute-by-statute legal analysis or a comprehensive mapping of government policy documents. Instead, it systematically synthesized peer-reviewed empirical, analytical, and structured implementation evidence that directly addressed occupational therapy at the policy or service-system level. Eligible evidence covered institutional recognition and role definition; financing, coverage, and reimbursement; referral, prioritization, and coordination; service-delivery organization and infrastructure; workforce capacity and implementation support; and policy-relevant access, equity, and user-participation issues. Evidence limited to individual clinical effectiveness without a substantive policy or system component fell outside the review scope. This boundary was applied consistently across the search, eligibility assessment, data extraction, framework synthesis, and interpretation of findings.

Recent institutional reform in the Republic of Korea on integrated community care underscores the need to clarify professional roles, referral pathways, and interagency coordination structures as linkages among health care, long-term care, and community services are strengthened [19]. In this context, occupational therapy should be considered part of the functional and institutional design of integrated community care systems rather than a stand-alone service [2,9,12,19].

This study aimed to systematically characterize and synthesize the policy and system conditions that shape the positioning and implementation of occupational therapy within community-based integrated care, and to derive an evidence-informed analytic framework to support cross-jurisdictional comparison. The review was designed not to determine whether occupational therapy is clinically effective in general, but to answer the prior system question of how function-centered occupational therapy services become recognized, financed, accessed, coordinated, staffed, and sustained within real-world community care arrangements. To this end, five research questions (RQ1–RQ5) were addressed. First, how is occupational therapy described in policy and institutional terms within community-based integrated care systems? Second, what roles and functions are attributed to occupational therapy at the policy and service-delivery levels? Third, how do financing, coverage, referral pathways, and service-delivery systems for occupational therapy vary across countries and institutional contexts? Fourth, how is the integration of occupational therapy connected to continuity of care, sustained community living, function and participation, prevention, and long-term care demand management? Fifth, what are the key conditions supporting the positioning and implementation of occupational therapy within community-based integrated care systems?

Together, these research questions informed a review-based framework for organizing comparisons of the institutional positioning and implementation of occupational therapy across community-based health and social care systems.

2. Materials and Methods

2.1. Study Design

This study was conducted as a systematic review and reported in accordance with PRISMA 2020 [20]. A systematic review design was selected rather than a scoping review because the review addressed explicitly defined research questions, applied explicit eligibility criteria, used duplicate review procedures with inter-reviewer agreement assessed using Cohen’s kappa [21], employed design-matched critical appraisal, and sought to interpret the strengths and limitations of the evidence concerning defined policy and system arrangements rather than merely mapping the extent and characteristics of the literature. Because the included evidence was heterogeneous in terms of study design, jurisdiction, service context, exposure, and outcome definition, meta-analysis was not appropriate. Therefore, a structured narrative synthesis was used to organize and compare the evidence [22].

The Open Science Framework record (https://doi.org/10.17605/OSF.IO/P7WYD; registered 29 April 2026) was created after the initial bibliographic search and is described as a retrospective methodological record rather than a prospectively registered protocol. The record was subsequently updated to document methodological revisions and the final review procedures. In accordance with PRISMA 2020 Item 24c, changes from the initial approach and the retrospectively created OSF record are explicitly reported. Subsequently, the bibliographic search strategy was redesigned and rerun; the databases searched and the publication period were revised; and eligibility was restricted to peer-reviewed evidence, resulting in the exclusion of non-peer-reviewed grey literature from the final evidence base. The screening procedure was also revised to incorporate a finalized operational eligibility codebook, independent dual screening, and consensus-based reconciliation of title and abstract screening decisions. The synthesis was further strengthened through design-matched critical appraisal, structured framework synthesis, sensitivity analyses, and GRADE-CERQual or GRADE assessments, as applicable. These changes were made to improve disciplinary coverage, reproducibility, the consistency of study selection, and alignment between the research questions and the policy- and system-level evidence base. They were implemented before the revised screening, appraisal, and synthesis reported in this manuscript were finalized. Accordingly, these methods are described as revised or finalized review procedures rather than as prospectively registered protocol elements.

The five research questions and the operational eligibility codebook used in the revised review were finalized as part of these methodological revisions, before the revised screening, final data extraction, framework synthesis, and critical appraisal were conducted. They were therefore specified prospectively in relation to the final screening and synthesis procedures but were not prospectively registered before the original search or the initiation of the review.

2.2. Eligibility Criteria for Study Inclusion

For this review, community-based integrated care systems encompassed coordinated primary care, home care, community rehabilitation, social care, home- and community-based services/long-term services and supports (HCBS/LTSS), and hospital-to-community arrangements organized to support continuity outside inpatient- or residential-only settings. Here, LTSS refers to long-term services and supports delivered in home and community settings rather than in institutional long-term residential care. For eligibility, policy- and system-level evidence was operationalized as peer-reviewed evidence concerning at least one OT-related institutional, financing, access, referral/coordination, service-organization, workforce, governance, or implementation arrangement that could influence how occupational therapy was positioned or delivered within a community-based care system. Accordingly, “policy-level evidence” in this review refers to peer-reviewed evidence that describes or analyzes policy-relevant institutional and service-system arrangements, rather than to a systematic review of primary policy documents themselves. Primary government policies, statutes, payer rules, regulatory documents, health-system guidance, and other non-peer-reviewed primary policy materials were outside the final evidence base. A report was included only when all mandatory domains were satisfied: (1) a community-based or hospital-to-community context with explicit community referral, transition, follow-up, or service integration; (2) explicit and separately analyzable OT relevance; (3) at least one substantive OT-related policy- or system-level finding that was separately analyzable and concerned institutional positioning, financing or coverage, referral or coordination, access, service organization, workforce, governance, or implementation; (4) an eligible empirical, analytical, or structured implementation/service-development design; (5) peer-reviewed journal publication; (6) English language; (7) complete full text; and (8) publication from 1 January 2010 to 29 July 2026. Structured implementation/service-development reports were eligible when an implemented OT service or program, identifiable operational data, and traceable OT-related system findings were reported. Reviews, conference abstracts, non-peer-reviewed grey literature, non-analytical professional opinion, and studies limited to individual clinical effectiveness without a policy/system component were excluded. The operational criteria are summarized in Table 1. Multiple reports from one project were retained only when they addressed substantively different questions or outcomes.

Table 1.

Eligibility Criteria.

Domain	Inclusion Criteria	Exclusion Criteria
Population/context	Community-dwelling populations; primary care, community rehabilitation, social care, home care, home health, HCBS, reablement, community LTSS; hospital-to-community transitions when separately analyzable.	Hospital, institution, or residential-only settings without community transition, referral, coordination, follow-up, or separately extractable community findings.
OT relevance	OT services, therapists, or workforce explicitly presented; at least one substantive OT-related finding separately extractable.	OT absent, incidental, listed only among professions, or not separable from generic multidisciplinary rehabilitation.
Policy/system relevance	At least one OT-related result in recognition, governance, legislation, eligibility, financing, reimbursement, coverage, commissioning, referral, coordination, access/waiting, workforce, organization, implementation, or resources.	Policy/system terms only in the background/discussion; clinical technique or patient-level effectiveness without an OT-related system finding.
Design/analysis	Original qualitative, quantitative, mixed, health services, implementation, workforce, organizational, comparative, or analytic case study; transparent policy/legal/document analysis.	Review, editorial, commentary, advocacy, opinion, position paper without an identifiable source base and transparent analysis, or descriptive clinical case.
Publication	Peer-reviewed journal article, 1 Jan 2010–29 Jul 2026, English, complete full text.	Grey literature, conference material, protocol, book/chapter, thesis, non-English, unavailable full text, outside period.
Companion reports	May retain distinct reports from one dataset when questions or outcomes differ; link to that dataset.	Exact duplicates or substantially overlapping reports without additional relevant information.

Concept Block	Purpose	Core Search-Term Families (Examples)
Occupational therapy	Explicitly identify the target profession	occupational therapy; occupational therapist ; occupational therapy practitioner
Community-based integrated-care context	Capture primary, community, home, rehabilitation, and social care contexts outside acute inpatient-only care	integrated care; primary care/primary health care; community care/community health; home care; HCBS; community rehabilitation; home-based rehabilitation; social care; LTSS; reablement; transitional care; aging/ageing in place
Policy/system-level factors	Capture institutional conditions that govern how services are positioned, financed, referred to, coordinated, and implemented	policy/policies; governance; legislation/regulation; financing/funding; reimbursement/payment; coverage/eligibility; referral; care coordination; access/accessibility; waiting list/prioritization; workforce/staffing; service delivery/organization; implementation; integration

Stage	What Was Done in This Review	Decision Criteria	Output
1. Initial analytic framework	Eight provisional categories were developed deductively from RQ1–RQ5, the policy- and system-related concepts defined for the eligibility criteria and search strategy, and the multilevel and people-centered conceptualization of integrated care.	Provisional categories were used as an initial analytic scaffold and were not treated as fixed final domains.	Eight deductively derived provisional categories
2. Study-level charting and category refinement	Included studies were charted using the extraction matrix and original reports. Overlapping categories were merged, broad categories were split or reframed, and findings spanning multiple areas were retained as cross-cutting considerations.	Recurrent concepts that were not analytically separable were merged, while substantively distinct concepts were retained. Directly documented findings were distinguished from interpretations or hypotheses.	Refined candidate domains and cross-cutting considerations
3. Cross-study and cross-jurisdictional comparison	The refined matrix was compared across studies, jurisdictions, and service contexts to examine recurrent patterns, differences, and context-specific findings.	Both recurrence and substantive policy/system distinctiveness were considered; frequency alone did not determine domain importance.	Higher-order candidate policy/system domains
4. Robustness assessment and final integration	Sensitivity analyses were used to assess robustness, and applicable CERQual/GRADE assessments were used to calibrate the strength of interpretation before final integration.	Directly documented policy/system arrangements were distinguished from causal or effect claims.	Final integrated organizing framework

Design/Evidence Type	Appraisal Tool
Qualitative studies	JBI Critical Appraisal Checklist for Qualitative Research
Analytical cross-sectional studies	JBI Critical Appraisal Tool for Analytical Cross-Sectional Studies
Quasi-experimental/ feasibility studies	JBI Critical Appraisal Checklist for Quasi-Experimental Studies
Mixed-methods studies	MMAT 2018—Mixed Methods
Quantitative descriptive surveys	MMAT 2018—Quantitative Descriptive
Diverse/non-standard designs	QuADS
Professional-position component	JBI Textual Evidence—Expert Opinion

Study	Country/ Jurisdiction	Care Context	Design and Sample/Data Source	OT-Related Focus	Key Policy/System Contribution
Freeman et al. (2025) [12]	Global/WFOT	Primary care	Cross-sectional survey; 59/100 WFOT member organizations	Global mapping of OT primary-care services, settings, populations, financing, workforce and enabling factors	Policy/institutional position; financing; workforce
Nash et al. (2025) [41]	United States	Primary care	Mixed methods; 41 PCPs, 305 OTs; interviews with 6 PCPs and 1 OT	Receptiveness to OT inclusion, delegation preferences, reimbursement, and role barriers	Institutional position; financing; workforce
Evans et al. (2023) [42]	Australia	Community health	Cross-sectional mixed-methods survey; 80 OTs	Intra-disciplinary OT practice, peer consultation, management support, funding, and organizational barriers	Service delivery; workforce
Dibsdall (2022) [43]	United Kingdom	Reablement/social care	Realist qualitative multiple-case study; 3 reablement services	OT assessment, goal setting, intervention selection, support-worker training, co-location and communication	Service delivery; implementation
Lim et al. (2022) [44]	South Korea	Home-based rehabilitation	Q methodology; 34 rehabilitation-team members	Five role-perception types emphasizing home adaptation, participation, service reliability, client needs, and professional development	Institutional position; service delivery; workforce
Rouch et al. (2022) [45]	United States	Primary care	Descriptive qualitative study; 7 OTs	Entry to primary-care teams, team navigation, patient-centered practice, reimbursement and expansion barriers	Institutional position; financing; referral; workforce
Missen et al. (2021) [46]	Australia	Rural community health	Pre/post service evaluation; 456 clients	Basic Assessment Model using OT/AHA workflow; median wait decreased from 105 to 80 days	Access/waiting; service delivery; workforce
Smith & Gallego (2021) [47]	Australia	Community child health	Mixed methods: routine service data plus parent/carer survey (n = 21)	Outreach, attendance, and transport/health-literacy barriers in a disadvantaged area	Access/equity; service delivery
Raymond et al. (2020) [48]	Canada/Quebec	Home-care OT	Qualitative component: 11 OTs, 10 older persons, 9 adults with disabilities	Stakeholder differences in referral-prioritization rationales: safety, independence and social participation	Referral/prioritisation; equity; participation
Bolt et al. (2019) [31]	Europe/COTEC	Primary/community care	Survey of 20/30 COTEC member associations embedded in a position paper	Cross-country service/funding organization plus professional recommendations for primary-care positioning	Institutional position; financing; service delivery
Dickson & Toto (2018) [49]	United States	LTSS care coordination	Single-group feasibility study; 23 referred, 16 evaluated	Feasibility of embedding OT evaluation and goal-based intervention in an aging-in-place care-coordination program	Service delivery; coordination; implementation
Friedman & VanPuymbrouck (2018) [50]	United States	Medicaid HCBS/ LTSS	Mixed quantitative/document analysis; 111 waivers from 46 states and DC	OT waiver coverage, projected utilization, expenditures, reimbursement, and service definitions	Financing/coverage; policy design
Dahl-Popolizio et al. (2017) [51]	United States	Primary care	Descriptive survey with open-ended responses; OTs and PCPs	Receptiveness to OT on primary-care teams and perceived funding/role barriers	Institutional position; service delivery; financing
Koverman et al. (2017) [52]	United States	Geriatric primary care	Structured implementation/service-development report; 8-week pilot	Operational development of OT service using logic model, EMR, scheduling, referral, and reimbursement processes	Service infrastructure; financing; implementation
Raymond et al. (2016) [53]	Canada/Quebec	Home-care OT	Cross-sectional program survey; 55 programs	Waiting-list management strategies for low-priority clients and association with wait-list length	Access/waiting; service management
Wilberforce et al. (2016) [54]	United Kingdom	Integrated health and social care	Cross-sectional time-use pilot; 151 practitioners	Distribution of OT and assistant time across direct care, indirect casework, team/service activity, and therapeutic work	Workforce; service organization
Donnelly et al. (2013) [55]	Canada/Ontario	Primary care	Multiple case studies; 4 Family Health Teams	Organizational structures supporting OT integration: communication, trust, role understanding, co-location, EMR, and team meetings	Institutional position; referral/coordination; service delivery/infrastructure; workforce/implementation
Raymond et al. (2013) [56]	Canada/Quebec	Home-care OT	Survey/content analysis; 55 programs	Referral-prioritization criteria and wide differences in wait times by priority level	Referral/prioritisation; access/equity
London-Willis et al. (2012) [57]	United Kingdom	Adult social care	Qualitative interviews; 6 OTs	Perceived effects of personalization on OT roles, identity, opportunities and threats	Institutional position; workforce; service delivery
Carrier et al. (2010) [58]	Canada/Quebec	Community OT services	Legal, ethical and clinical document analysis	Access, prioritization, waiting, resource allocation, distributive justice, and service quality	Financing/coverage; referral/coordination; accessibility/equity (cross-cutting)
Quick et al. (2010) [59]	Australia/Victoria	Community health	Descriptive postal survey; 101 returned, 72 eligible	Scope of practice, health promotion, funding/resource barriers, and workforce characteristics	Service delivery; workforce; financing

Study	Appraisal Tool	Principal Methodological Limitation	Evidence Contribution	Restriction Applied in Synthesis
Freeman et al. (2025) [12]	JBI analytical cross-sectional	Member-organization self-report; representativeness and measurement partly unclear	Cross-jurisdictional service, financing, referral, and workforce patterns	No causal or fully representative global inference
Nash et al. (2025) [41]	MMAT mixed methods	Convenience/snowball sampling; very small interview sample; limited integration	Reported receptiveness and reimbursement/role barriers	Perceptions only; no prevalence or effectiveness claim
Evans et al. (2023) [42]	MMAT mixed methods	Convenience sample; self-developed survey; geographic overrepresentation	Organizational and interdisciplinary practice experiences	Limited national generalization
Dibsdall (2022) [43]	JBI qualitative	Single researcher; limited direct service-user voice and reflexivity	Contextual mechanisms in reablement	Contextual qualitative interpretation only
Lim et al. (2022) [44]	QuADS	Purposive sample; non-loading participants; limited reflexivity	Q-method role typologies	No population prevalence
Rouch et al. (2022) [45]	JBI qualitative	Small self-selected sample; single-PI analytic influence	Primary-care barriers and facilitators	No frequency estimates
Missen et al. (2021) [46]	JBI quasi-experimental	No concurrent control; staffing changes occurred during implementation	Observed local waiting-list change	Not interpreted as causal effectiveness
Smith & Gallego (2021) [47]	MMAT mixed methods	Small selected parent sample; outreach before survey; limited integration	Access barriers and proof-of-concept service adaptation	No population prevalence or effectiveness
Raymond et al. (2020) [48]	JBI qualitative	Scenario-based judgments and transferability limits	Stakeholder perspectives on prioritization	Not actual referral behavior or frequency
Bolt et al. (2019) [31]	MMAT quantitative descriptive + JBI expert opinion	Limited survey reporting; empirical and advocacy components mixed	Member-association findings and professional recommendations	Survey findings and proposals separated
Dickson & Toto (2018) [49]	JBI quasi-experimental	Small selected single group; no control; short follow-up	Feasibility of OT integration	No effectiveness, cost, or institutionalization conclusion
Friedman & VanPuymbrouck (2018) [50]	MMAT mixed methods	Waiver projections rather than actual use; single qualitative coder	Direct coverage and financing structures	Planned and actual utilization distinguished
Dahl-Popolizio et al. (2017) [51]	MMAT quantitative descriptive	Convenience/snowball sample; unknown response denominator; unvalidated survey	Respondent receptiveness and role perceptions	No representative prevalence
Koverman et al. (2017) [52]	QuADS	Limited sampling, data collection, analytic, ethical, and audit-trail reporting	Implemented workflow, EMR, scheduling, and billing arrangements	No success, referral-effect, or effectiveness claim
Raymond et al. (2016) [53]	JBI analytical cross-sectional	Cross-sectional design; proxy waiting outcome; residual confounding	Waiting-list management patterns and associations	No causal inference
Wilberforce et al. (2016) [54]	JBI analytical cross-sectional	Self-reported time use; measurement validity unclear; one trust	Workforce deployment and role distribution	Limited transferability
Donnelly et al. (2013) [55]	JBI qualitative	Four early-stage Ontario cases; limited reflexivity; no patient outcomes	Organizational integration structures and processes	Not universally necessary or sufficient conditions
Raymond et al. (2013) [56]	JBI analytical cross-sectional	Regional transferability; constructed calibration; companion publication	Prioritization criteria and waiting patterns	Counted with 2016 report as one dataset
London-Willis et al. (2012) [57]	JBI qualitative	Six early volunteers; saturation not reported	Policy-related professional role change	No system-wide generalization
Carrier et al. (2010) [58]	QuADS	Document flow, dual review, and audit trail not reported	Legal and ethical interpretation of access/resource allocation	Not empirical service-effect evidence
Quick et al. (2010) [59]	MMAT quantitative descriptive	Sampling denominator, non-response, and measure validation unclear	Reported scope of practice and barriers	No representative or causal inference

Jurisdiction	Main Care Context	Distinctive Policy/System Pattern	Main Barrier/Enabler	Interpretive Boundary
Global/ WFOT	Primary care	Wide variation in formal recognition, financing, coverage, and service models.	Workforce supply, funding, and training repeatedly constrained implementation.	Member-organization survey; high-income settings overrepresented.
United States	Primary care; LTSS care coordination; Medicaid HCBS	Reimbursement, billing, waiver design, referral pathways, and team integration were prominent.	Role recognition, workflow, leadership, and reimbursement shaped implementation.	Mostly local/convenience samples, except for national waiver analysis.
Canada (Quebec/ Ontario)	Home/community OT; Family Health Teams	Waiting-list prioritization and access were prominent in Quebec; shared records, co-location, and team processes supported integration in Ontario.	Resource constraints, fairness, role understanding, and trust influenced delivery.	Mostly regional qualitative/program data; limited downstream outcomes.
United Kingdom	Reablement; integrated health/social care; adult social care	Role redesign and service integration occurred within commissioning and personalization contexts.	Co-location, training, workload distribution, and role identity shaped implementation.	Local/small qualitative evidence plus one single-trust time-use study.
Australia	Community health; rural/community OT	Assessment models, outreach, and intra-disciplinary support addressed local access and service-delivery constraints.	Management support, funding, rural workforce capacity, and transport/health-literacy barriers mattered.	Predominantly descriptive/local evidence; one uncontrolled pre/post evaluation.
South Korea	Home-based rehabilitation	OT roles were framed within a team-based home rehabilitation model.	Collaboration, service reliability, client needs, and professional development were emphasized.	Single small Q-methodology study.
Europe/ COTEC	Primary/community care	Country-to-country variation in organization and financing was reported.	Professional recognition and wider primary-care integration were emphasized.	Limited survey reporting; the position component was normative.

Research Question	Synthesized Answer	Interpretive Boundary
RQ1. How is OT positioned in policy and institutional terms?	OT was positioned through primary-care teams, publicly organized home/community services, Medicaid HCBS coverage, LTSS care coordination, reablement/social care, community health, and home-based rehabilitation. Formal recognition varied by jurisdiction and did not itself ensure service availability.	Evidence is primarily descriptive and jurisdiction-specific; institutional presence should not be interpreted as universal coverage or access.
RQ2. What service and system functions are attributed to OT?	Across settings, OT functions included contextualized functional/ADL-IADL assessment, environmental modification, participation-focused intervention, reablement, self-management, caregiver support, assistive technology, coordination, role consultation, and support-worker/team education.	Roles are consistently described, but comparative evidence identifying a superior role configuration is absent.
RQ3. How do financing, coverage, referral, access, and delivery arrangements vary?	Variation was documented in public financing, Medicaid waiver coverage and reimbursement, billing, referral routes, prioritization rules, waiting-list management, outreach, EMR/shared records, staffing, and local service organization.	The evidence demonstrates heterogeneity but does not establish a single optimal financing, referral, or delivery model.
RQ4. Which policy/system outcomes are documented?	Directly reported outcomes concerned waiting time, attendance/access, service activity, projected expenditure/utilisation, workforce time use, and implementation feasibility. Stakeholder studies documented concerns about fairness and access. Hospitalization, institutionalization, cost savings, and long-term care demand were not established as effects of OT integration.	Quantitative outcome evidence was sparse and mostly non-randomized; downstream system effects remain unconfirmed.
RQ5. Which conditions recur in implementation?	Five recurrent policy-system domains were supported across the evidence: institutional recognition; financing/coverage; referral/coordination; service-delivery infrastructure; and workforce/implementation support. Access, equity, and user participation cut across these domains.	These domains represent higher-order organizing categories refined from heterogeneous evidence and should be interpreted in relation to the contexts of the contributing studies.

Sensitivity Restriction	Result	Interpretive Consequence
Exclude professional/normative recommendations	All five organizing domains remained identifiable.	The framework was not dependent on advocacy statements.
Restrict synthesis to directly reported findings and remove unmeasured downstream outcomes	All five domains remained; claims about hospitalization, institutionalization, costs, and long-term care demand were removed or reframed as hypotheses.	Direct system arrangements could be described, but downstream effects could not be claimed.
Control companion publications and restrict structured implementation reports to traceable operational evidence	Core referral/access and implementation patterns remained.	Double-counting and unsupported implementation claims were reduced.
Restrict uncontrolled studies to feasibility or observed local change	Access and implementation patterns remained, but causal-effect language was removed.	Uncontrolled studies informed feasibility/local change only.

Evidence Finding/Outcome	Approach	Rating	Interpretation in This Review
Role clarity and team understanding	GRADE-CERQual	Moderate	Consistent pattern, but some limitations in data richness/context breadth.
Co-location, shared records, team meetings, and managerial support	GRADE-CERQual	Moderate	Supports organizational integration, with some contextual limitations.
Service context and workforce capacity shape OT roles	GRADE-CERQual	Moderate	Recurrent across settings, but largely in high-income systems.
Reimbursement/billing constraints impede integration	GRADE-CERQual	Low	Limited qualitative data; interpret as a plausible barrier rather than a universal conclusion.
Stakeholders differ in referral-prioritisation/fairness judgments	GRADE-CERQual	Low	Supported by a small evidence base; avoid broad generalization.
Service redesign may create tension with occupation-focused practice	GRADE-CERQual	Low	Limited direct qualitative evidence; use cautiously.
Waiting-time change; waiting-list association; OT-in-care-coordination feasibility	GRADE	Very low (all 3 outcomes)	Observed changes/associations may be reported, but causal effectiveness cannot be established.

Synthesized Domain	Pattern Identified Across the Evidence	OT-Related System Contribution	Boundary/Remaining Uncertainty
Policy recognition and institutional positioning	The way in which OT was formally positioned within teams, service specifications, coverage rules, and organizational roles varied across jurisdictions and service systems.	Linking function, occupation, participation, and person–environment fit was recurrently identified as an important OT-related contribution within community-based systems.	Descriptive and observational evidence does not establish that formal recognition itself improves access to services or outcomes.
Financing and coverage	Government funding, Medicaid waiver arrangements, reimbursement and billing mechanisms, and local financing structures were reported as conditions that could enable or constrain the availability and sustainability of OT services.	Financing and coverage arrangements that support community-based functional assessment and intervention were identified as important institutional conditions for service delivery.	Comparative evidence is insufficient to determine which financing or coverage model is most effective or equitable.
Referral and coordination	Referral pathways, triage and prioritization, shared records, team communication, and inter-service linkages were recurrently identified as operational conditions related to timeliness and service integration.	OT contributed information on functional risk, home and environmental conditions, and participation priorities to referral and coordination processes.	The effects of standardized referral and coordination pathways on equity, continuity, and longer-term outcomes remain insufficiently evaluated.
Service-delivery roles and infrastructure	OT roles were reported alongside operational infrastructure, including workflows, access to records, co-location, outreach, and service-delivery models.	Home and environmental assessment, reablement, ADL/IADL, assistive technology, self-management, and caregiver support were recurrent service functions explicitly associated with OT.	Comparative effectiveness across service models, resource requirements, and longer-term system outcomes remains poorly established.
Workforce capacity and implementation support	Workforce supply, role understanding, leadership, managerial support, peer consultation, training, and protected time for team collaboration were reported as facilitators or constraints to OT integration.	OT integration appeared to involve not only workforce availability but also role design, team processes, and organizational support for implementation.	Most evidence was local or self-reported, and transferable workforce or competency standards have not been established.
Cross-cutting considerations: accessibility, equity, and user participation	Waiting time, geographic access, transportation, health literacy, prioritization rules, and differences between professional and user priorities appeared across multiple policy-system domains.	The evidence highlighted the relevance of accessibility, fairness, and community-user priorities to service design and resource allocation.	Evidence from service users and caregivers, rural and remote populations, and diverse cultural and socioeconomic groups remains limited.

Database	Complete Search String
PubMed/MEDLINE	(“Occupational Therapy”[MeSH Terms] OR “Occupational Therapists”[MeSH Terms] OR “occupational therapy”[Title/Abstract] OR “occupational therapist”[Title/Abstract] OR “occupational therapy practitioner”[Title/Abstract]) AND (“Community Health Services”[MeSH Terms] OR “Home Care Services”[MeSH Terms] OR “Primary Health Care”[MeSH Terms] OR “Delivery of Health Care, Integrated”[MeSH Terms] OR “Patient-Centered Care”[MeSH Terms] OR “Continuity of Patient Care”[MeSH Terms] OR “Long-Term Care”[MeSH Terms] OR “integrated community care”[Title/Abstract] OR “community-based integrated care”[Title/Abstract] OR “community based integrated care”[Title/Abstract] OR “integrated health and social care”[Title/Abstract] OR “integrated care”[Title/Abstract] OR “integrated health care”[Title/Abstract] OR “integrated healthcare”[Title/Abstract] OR “care integration”[Title/Abstract] OR “integrated service delivery”[Title/Abstract] OR “community care”[Title/Abstract] OR “community-based care”[Title/Abstract] OR “community based care”[Title/Abstract] OR “home care”[Title/Abstract] OR “home health care”[Title/Abstract] OR “home-based care”[Title/Abstract] OR “home based care”[Title/Abstract] OR “home and community-based service”[Title/Abstract] OR “home and community based service”[Title/Abstract] OR HCBS[Title/Abstract] OR “primary care”[Title/Abstract] OR “primary health care”[Title/Abstract] OR “community health service”[Title/Abstract] OR “community support service”[Title/Abstract] OR “community rehabilitation”[Title/Abstract] OR “community-based rehabilitation”[Title/Abstract] OR “community based rehabilitation”[Title/Abstract] OR “home-based rehabilitation”[Title/Abstract] OR “home based rehabilitation”[Title/Abstract] OR “ambulatory rehabilitation”[Title/Abstract] OR “social care”[Title/Abstract] OR “long-term services and supports”[Title/Abstract] OR “long term services and supports”[Title/Abstract] OR LTSS[Title/Abstract] OR “long-term care”[Title/Abstract] OR “long term care”[Title/Abstract] OR reablement[Title/Abstract] OR “care transition”[Title/Abstract] OR “transitional care”[Title/Abstract] OR “continuity of care”[Title/Abstract] OR “aging in place”[Title/Abstract] OR “ageing in place”[Title/Abstract]) AND (“Health Policy”[MeSH Terms] OR “Public Policy”[MeSH Terms] OR “Policy Making”[MeSH Terms] OR “Health Services Administration”[MeSH Terms] OR “Delivery of Health Care”[MeSH Terms] OR “Health Services Accessibility”[MeSH Terms] OR “Referral and Consultation”[MeSH Terms] OR “Case Management”[MeSH Terms] OR “Patient Care Team”[MeSH Terms] OR “Interprofessional Relations”[MeSH Terms] OR “Health Workforce”[MeSH Terms] OR “Health Care Reform”[MeSH Terms] OR “Insurance Coverage”[MeSH Terms] OR “Reimbursement Mechanisms”[MeSH Terms] OR “Financing, Organized”[MeSH Terms] OR “Health Planning”[MeSH Terms] OR “Models, Organizational”[MeSH Terms] OR “Resource Allocation”[MeSH Terms] OR “health polic”[Title/Abstract] OR “public polic”[Title/Abstract] OR policy[Title/Abstract] OR policies[Title/Abstract] OR policymak[Title/Abstract] OR “policy making”[Title/Abstract] OR “policy development”[Title/Abstract] OR “healthcare policy”[Title/Abstract] OR “health care policy”[Title/Abstract] OR “health service”[Title/Abstract] OR “health services research”[Title/Abstract] OR “service deliver”[Title/Abstract] OR “service organization”[Title/Abstract] OR “service organisation”[Title/Abstract] OR “service structur”[Title/Abstract] OR “service model”[Title/Abstract] OR “care model”[Title/Abstract] OR “model of care”[Title/Abstract] OR “delivery model”[Title/Abstract] OR governance[Title/Abstract] OR legislat[Title/Abstract] OR regulat[Title/Abstract] OR financ[Title/Abstract] OR funding[Title/Abstract] OR reimburse[Title/Abstract] OR payment[Title/Abstract] OR coverage[Title/Abstract] OR “insurance coverage”[Title/Abstract] OR “service coverage”[Title/Abstract] OR eligib[Title/Abstract] OR entitlement[Title/Abstract] OR “benefit structur”[Title/Abstract] OR “benefit design”[Title/Abstract] OR “benefit package”[Title/Abstract] OR referral[Title/Abstract] OR “referral pathway”[Title/Abstract] OR “care pathway”[Title/Abstract] OR “care coordination”[Title/Abstract] OR “service coordination”[Title/Abstract] OR “case management”[Title/Abstract] OR commission[Title/Abstract] OR contract[Title/Abstract] OR procur[Title/Abstract] OR workforce[Title/Abstract] OR staffing[Title/Abstract] OR “workforce capacity”[Title/Abstract] OR “workforce deployment”[Title/Abstract] OR “workforce planning”[Title/Abstract] OR “workforce distribution”[Title/Abstract] OR “human resources for health”[Title/Abstract] OR implement[Title/Abstract] OR “implementation condition”[Title/Abstract] OR “implementation strateg”[Title/Abstract] OR “health system reform”[Title/Abstract] OR “health care reform”[Title/Abstract] OR “healthcare reform”[Title/Abstract] OR “organizational change”[Title/Abstract] OR “organisational change”[Title/Abstract] OR “service redesign”[Title/Abstract] OR “system redesign”[Title/Abstract] OR “health system redesign”[Title/Abstract] OR “service access”[Title/Abstract] OR “service accessibility”[Title/Abstract] OR accessibility[Title/Abstract] OR accessible[Title/Abstract] OR “access to care”[Title/Abstract] OR “access to services”[Title/Abstract] OR availab[Title/Abstract] OR “waiting list”[Title/Abstract] OR “wait list”[Title/Abstract] OR “waiting time”[Title/Abstract] OR “wait time”[Title/Abstract] OR “resource allocation”[Title/Abstract] OR “interprofessional care”[Title/Abstract] OR “interdisciplinary care”[Title/Abstract] OR “multidisciplinary care”[Title/Abstract] OR “team-based care”[Title/Abstract] OR “team based care”[Title/Abstract] OR “collaborative care”[Title/Abstract] OR “professional role”[Title/Abstract] OR “role delineation”[Title/Abstract] OR “role clarity”[Title/Abstract] OR “scope of practice”[Title/Abstract] OR “institutional position”[Title/Abstract] OR “institutional recognition”[Title/Abstract] OR “formal recognition”[Title/Abstract] OR “professional position”[Title/Abstract] OR “role integration”[Title/Abstract] OR “professional integration”[Title/Abstract])
CINAHL	(MH “Occupational Therapy+” OR TI (“occupational therapy” OR “occupational therapist” OR “occupational therapy practitioner”) OR AB (“occupational therapy” OR “occupational therapist” OR “occupational therapy practitioner”)) AND (MH “Community Health Services+” OR MH “Home Health Care+” OR MH “Primary Health Care” OR MH “Health Care Delivery, Integrated” OR MH “Continuity of Patient Care+” OR MH “Long Term Care+” OR TI (“integrated community care” OR “community-based integrated care” OR “community based integrated care” OR “integrated health and social care” OR “integrated care” OR “integrated health care” OR “integrated healthcare” OR “care integration” OR “integrated service delivery” OR “community care” OR “community-based care” OR “community based care” OR “home care” OR “home health care” OR “home-based care” OR “home based care” OR “home and community-based service” OR “home and community based service” OR HCBS OR “primary care” OR “primary health care” OR “community health service” OR “community support service” OR “community rehabilitation” OR “community-based rehabilitation” OR “community based rehabilitation” OR “home-based rehabilitation” OR “home based rehabilitation” OR “ambulatory rehabilitation” OR “social care” OR “long-term services and supports” OR “long term services and supports” OR LTSS OR “long-term care” OR “long term care” OR reablement OR “care transition” OR “transitional care” OR “continuity of care” OR “aging in place” OR “ageing in place”) OR AB (“integrated community care” OR “community-based integrated care” OR “community based integrated care” OR “integrated health and social care” OR “integrated care” OR “integrated health care” OR “integrated healthcare” OR “care integration” OR “integrated service delivery” OR “community care” OR “community-based care” OR “community based care” OR “home care” OR “home health care” OR “home-based care” OR “home based care” OR “home and community-based service” OR “home and community based service” OR HCBS OR “primary care” OR “primary health care” OR “community health service” OR “community support service” OR “community rehabilitation” OR “community-based rehabilitation” OR “community based rehabilitation” OR “home-based rehabilitation” OR “home based rehabilitation” OR “ambulatory rehabilitation” OR “social care” OR “long-term services and supports” OR “long term services and supports” OR LTSS OR “long-term care” OR “long term care” OR reablement OR “care transition” OR “transitional care” OR “continuity of care” OR “aging in place” OR “ageing in place”)) AND (MH “Health Policy+” OR MH “Public Policy+” OR MH “Policy Making” OR MH “Health Services Administration+” OR MH “Health Services Accessibility+” OR MH “Referral and Consultation+” OR MH “Case Management” OR MH “Multidisciplinary Care Team+” OR MH “Interprofessional Relations” OR MH “Health Care Reform” OR MH “Insurance Coverage+” OR MH “Reimbursement Mechanisms+” OR MH “Health Planning+” OR MH “Resource Allocation+” OR TI (“health polic” OR “public polic” OR policy OR policies OR policymak* OR “policy making” OR “policy development” OR “healthcare policy” OR “health care policy” OR “health service” OR “health services research” OR “service deliver” OR “service organization” OR “service organisation” OR “service structur” OR “service model” OR “care model” OR “model of care” OR “delivery model” OR governance OR legislat OR regulat* OR financ* OR funding OR reimburse* OR payment* OR coverage OR “insurance coverage” OR “service coverage” OR eligib* OR entitlement* OR “benefit structur” OR “benefit design” OR “benefit package” OR referral* OR “referral pathway” OR “care pathway” OR “care coordination” OR “service coordination” OR “case management” OR commission* OR contract* OR procur* OR workforce OR staffing OR “workforce capacity” OR “workforce deployment” OR “workforce planning” OR “workforce distribution” OR “human resources for health” OR implement* OR “implementation condition” OR “implementation strateg” OR “health system reform” OR “health care reform” OR “healthcare reform” OR “organizational change” OR “organisational change” OR “service redesign” OR “system redesign” OR “health system redesign” OR “service access” OR “service accessibility” OR accessibility OR accessible OR “access to care” OR “access to services” OR availab OR “waiting list” OR “wait list” OR “waiting time” OR “wait time” OR “resource allocation” OR “interprofessional care” OR “interdisciplinary care” OR “multidisciplinary care” OR “team-based care” OR “team based care” OR “collaborative care” OR “professional role” OR “role delineation” OR “role clarity” OR “scope of practice” OR “institutional position” OR “institutional recognition” OR “formal recognition” OR “professional position” OR “role integration” OR “professional integration”) OR AB (“health polic” OR “public polic” OR policy OR policies OR policymak OR “policy making” OR “policy development” OR “healthcare policy” OR “health care policy” OR “health service” OR “health services research” OR “service deliver” OR “service organization” OR “service organisation” OR “service structur” OR “service model” OR “care model” OR “model of care” OR “delivery model” OR governance OR legislat OR regulat* OR financ* OR funding OR reimburse* OR payment* OR coverage OR “insurance coverage” OR “service coverage” OR eligib* OR entitlement* OR “benefit structur” OR “benefit design” OR “benefit package” OR referral* OR “referral pathway” OR “care pathway” OR “care coordination” OR “service coordination” OR “case management” OR commission* OR contract* OR procur* OR workforce OR staffing OR “workforce capacity” OR “workforce deployment” OR “workforce planning” OR “workforce distribution” OR “human resources for health” OR implement* OR “implementation condition” OR “implementation strateg” OR “health system reform” OR “health care reform” OR “healthcare reform” OR “organizational change” OR “organisational change” OR “service redesign” OR “system redesign” OR “health system redesign” OR “service access” OR “service accessibility” OR accessibility OR accessible OR “access to care” OR “access to services” OR availab OR “waiting list” OR “wait list” OR “waiting time” OR “wait time” OR “resource allocation” OR “interprofessional care” OR “interdisciplinary care” OR “multidisciplinary care” OR “team-based care” OR “team based care” OR “collaborative care” OR “professional role” OR “role delineation” OR “role clarity” OR “scope of practice” OR “institutional position” OR “institutional recognition” OR “formal recognition” OR “professional position*” OR “role integration” OR “professional integration”))
Scopus	TITLE-ABS-KEY(“occupational therapy” OR “occupational therapist” OR “occupational therapy practitioner”) AND TITLE-ABS-KEY(“integrated community care” OR “community-based integrated care” OR “community based integrated care” OR “integrated health and social care” OR “integrated care” OR “integrated health care” OR “integrated healthcare” OR “care integration” OR “integrated service delivery” OR “community care” OR “community-based care” OR “community based care” OR “home care” OR “home health care” OR “home-based care” OR “home based care” OR “home and community-based service” OR “home and community based service” OR HCBS OR “primary care” OR “primary health care” OR “community health service” OR “community support service” OR “community rehabilitation” OR “community-based rehabilitation” OR “community based rehabilitation” OR “home-based rehabilitation” OR “home based rehabilitation” OR “ambulatory rehabilitation” OR “social care” OR “long-term services and supports” OR “long term services and supports” OR LTSS OR “long-term care” OR “long term care” OR reablement OR “care transition” OR “transitional care” OR “continuity of care” OR “aging in place” OR “ageing in place”) AND TITLE-ABS-KEY(“health polic” OR “public polic” OR policy OR policies OR policymak OR “policy making” OR “policy development” OR “healthcare policy” OR “health care policy” OR “health service” OR “health services research” OR “service deliver” OR “service organization” OR “service organisation” OR “service structur” OR “service model” OR “care model” OR “model of care” OR “delivery model” OR governance OR legislat OR regulat* OR financ* OR funding OR reimburse* OR payment* OR coverage OR “insurance coverage” OR “service coverage” OR eligib* OR entitlement* OR “benefit structur” OR “benefit design” OR “benefit package” OR referral* OR “referral pathway” OR “care pathway” OR “care coordination” OR “service coordination” OR “case management” OR commission* OR contract* OR procur* OR workforce OR staffing OR “workforce capacity” OR “workforce deployment” OR “workforce planning” OR “workforce distribution” OR “human resources for health” OR implement* OR “implementation condition” OR “implementation strateg” OR “health system reform” OR “health care reform” OR “healthcare reform” OR “organizational change” OR “organisational change” OR “service redesign” OR “system redesign” OR “health system redesign” OR “service access” OR “service accessibility” OR accessibility OR accessible OR “access to care” OR “access to services” OR availab OR “waiting list” OR “wait list” OR “waiting time” OR “wait time” OR “resource allocation” OR “interprofessional care” OR “interdisciplinary care” OR “multidisciplinary care” OR “team-based care” OR “team based care” OR “collaborative care” OR “professional role” OR “role delineation” OR “role clarity” OR “scope of practice” OR “institutional position” OR “institutional recognition” OR “formal recognition” OR “professional position*” OR “role integration” OR “professional integration”)
ProQuest Central	NOFT(((“occupational therapy” OR “occupational therapist” OR “occupational therapy practitioner”) AND (“integrated community care” OR “community-based integrated care” OR “community based integrated care” OR “integrated health and social care” OR “integrated care” OR “integrated health care” OR “integrated healthcare” OR “care integration” OR “integrated service delivery” OR “community care” OR “community-based care” OR “community based care” OR “home care” OR “home health care” OR “home-based care” OR “home based care” OR “home and community-based service” OR “home and community based service” OR HCBS OR “primary care” OR “primary health care” OR “community health service” OR “community support service” OR “community rehabilitation” OR “community-based rehabilitation” OR “community based rehabilitation” OR “home-based rehabilitation” OR “home based rehabilitation” OR “ambulatory rehabilitation” OR “social care” OR “long-term services and supports” OR “long term services and supports” OR LTSS OR “long-term care” OR “long term care” OR reablement OR “care transition” OR “transitional care” OR “continuity of care” OR “aging in place” OR “ageing in place” OR “home and community care” OR “community service” OR “community mental health”) AND (“health polic” OR “public polic” OR policy OR policies OR policymak* OR “policy making” OR “policy development” OR “healthcare policy” OR “health care policy” OR “health service” OR “health services research” OR “service deliver” OR “service organization” OR “service organisation” OR “service structur” OR “service model” OR “care model” OR “model of care” OR “delivery model” OR governance OR legislat OR regulat* OR financ* OR funding OR reimburse* OR payment* OR coverage OR “insurance coverage” OR “service coverage” OR eligib* OR entitlement* OR “benefit structur” OR “benefit design” OR “benefit package” OR referral* OR “referral pathway” OR “care pathway” OR “care coordination” OR “service coordination” OR “case management” OR commission* OR contract* OR procur* OR workforce OR staffing OR “workforce capacity” OR “workforce deployment” OR “workforce planning” OR “workforce distribution” OR “human resources for health” OR implement* OR “implementation condition” OR “implementation strateg” OR “health system reform” OR “health care reform” OR “healthcare reform” OR “organizational change” OR “organisational change” OR “service redesign” OR “system redesign” OR “health system redesign” OR “service access” OR “service accessibility” OR accessibility OR accessible OR “access to care” OR “access to services” OR availab OR “waiting list” OR “wait list” OR “waiting time” OR “wait time” OR “resource allocation” OR “interprofessional care” OR “interdisciplinary care” OR “multidisciplinary care” OR “team-based care” OR “team based care” OR “collaborative care” OR “professional role” OR “role delineation” OR “role clarity” OR “scope of practice” OR “institutional position” OR “institutional recognition” OR “formal recognition” OR “professional position*” OR “role integration” OR “professional integration”)))
APA PsycINFO	(“occupational therapy” OR “occupational therapist” OR “occupational therapy practitioner”) AND (“integrated community care” OR “community-based integrated care” OR “community based integrated care” OR “integrated health and social care” OR “integrated care” OR “integrated health care” OR “integrated healthcare” OR “care integration” OR “integrated service delivery” OR “community care” OR “community-based care” OR “community based care” OR “home care” OR “home health care” OR “home-based care” OR “home based care” OR “home and community-based service” OR “home and community based service” OR HCBS OR “primary care” OR “primary health care” OR “community health service” OR “community support service” OR “community rehabilitation” OR “community-based rehabilitation” OR “community based rehabilitation” OR “home-based rehabilitation” OR “home based rehabilitation” OR “ambulatory rehabilitation” OR “social care” OR “long-term services and supports” OR “long term services and supports” OR LTSS OR “long-term care” OR “long term care” OR reablement OR “care transition” OR “transitional care” OR “continuity of care” OR “aging in place” OR “ageing in place” OR “service integration” OR “integrated service” OR “rehabilitation service” OR “intermediate care”) AND (“health polic” OR “public polic” OR policy OR policies OR policymak OR “policy making” OR “policy development” OR “healthcare policy” OR “health care policy” OR “health service” OR “health services research” OR “service deliver” OR “service organization” OR “service organisation” OR “service structur” OR “service model” OR “care model” OR “model of care” OR “delivery model” OR governance OR legislat OR regulat* OR financ* OR funding OR reimburse* OR payment* OR coverage OR “insurance coverage” OR “service coverage” OR eligib* OR entitlement* OR “benefit structur” OR “benefit design” OR “benefit package” OR referral* OR “referral pathway” OR “care pathway” OR “care coordination” OR “service coordination” OR “case management” OR commission* OR contract* OR procur* OR workforce OR staffing OR “workforce capacity” OR “workforce deployment” OR “workforce planning” OR “workforce distribution” OR “human resources for health” OR implement* OR “implementation condition” OR “implementation strateg” OR “health system reform” OR “health care reform” OR “healthcare reform” OR “organizational change” OR “organisational change” OR “service redesign” OR “system redesign” OR “health system redesign” OR “service access” OR “service accessibility” OR accessibility OR accessible OR “access to care” OR “access to services” OR availab OR “waiting list” OR “wait list” OR “waiting time” OR “wait time” OR “resource allocation” OR “interprofessional care” OR “interdisciplinary care” OR “multidisciplinary care” OR “team-based care” OR “team based care” OR “collaborative care” OR “professional role” OR “role delineation” OR “role clarity” OR “scope of practice” OR “institutional position” OR “institutional recognition” OR “formal recognition” OR “professional position*” OR “role integration” OR “professional integration”)

Eligibility Domain	Decision	Operational Includes Rule	Operational Exclude Rule	Reviewer Instruction
Context/community setting	Include	Primary care, community health, home care/home health, home-based rehabilitation, reablement, social care, HCBS/LTSS, or hospital-to-community transition with an explicit community component.	Exclude hospital-, inpatient-, residential- or institution-only care without a separable community pathway.	If eligibility was unclear during independent screening, the record was retained for reconciliation. During reconciliation, exclusion required agreement between both reviewers that the available title and abstract information clearly failed to meet at least one mandatory eligibility criterion; records that remained uncertain or discrepant were advanced to full-text assessment.
Occupational therapy relevance	Include	OT service, therapist, workforce, or OT-related function is explicit, and at least one OT-related finding can be extracted.	Exclude studies where OT is absent, incidental, only listed among professions, or inseparable from generic multidisciplinary rehabilitation.	Require an OT-related extractable result, not just a background mention.
Policy/system relevance	Include	At least one substantive result on institutional position, eligibility, financing/coverage/reimbursement, referral/coordination, access/waiting, service organization, workforce, governance, or implementation.	Exclude papers in which policy/system terms occur only in the introduction/discussion or that report only individual clinical effectiveness.	The relevant result must be part of the study findings or documented service/policy analysis.
Study design/analytic basis	Include	Original qualitative, quantitative, mixed-methods, health-services, organizational, workforce, implementation, comparative, or analytical document/legal studies; structured implementation/service-development reports with implemented service, identifiable operational data, and traceable OT-related findings.	Exclude reviews, editorials, commentaries, conference abstracts, protocols, purely promotional/advocacy reports without an identifiable analytic or operational source base.	For implementation reports, verify actual implementation plus traceable operational data.
Publication type	Include	Peer-reviewed full journal article.	Exclude grey literature, association webpages/reports, dissertations, conference abstracts/proceedings, preprints, and non-peer-reviewed reports.	Peer-review status must be identifiable.
Language	Include	English.	Exclude non-English full text.	Apply after bibliographic identification.
Publication period	Include	1 January 2010 to 29 July 2026.	Exclude before 1 January 2010 or after 29 July 2026.	Use the publication date of the final journal version.
Full-text availability	Include	The complete article is available for eligibility and data extraction.	Exclude when the complete text cannot be obtained after reasonable retrieval attempts.	Exclusion for unavailable full text was applied only after reasonable efforts to retrieve the full text had been made.
Companion publications	Include as separate reports only if distinct questions/outcomes	Retain multiple reports from one project when they address substantively distinct review questions or outcomes.	Do not count companion reports as independent datasets when judging evidence breadth.	Link shared samples/datasets explicitly; companion reports derived from the same underlying dataset should be treated as a single dataset when judging evidence breadth.
Decision hierarchy	Apply one primary reason for exclusion at full-text assessment.	When several criteria fail, record the first decisive reason in this order: publication type `→` date/language/full text `→` context `→` OT relevance `→` policy/system relevance `→` design/analytic basis.	Do not assign multiple primary reasons to one full-text exclusion.	Use identical hierarchy for both reviewers.
Title/abstract reconciliation	Re-examine	Records retained by at least one reviewer were re-examined against the same eligibility codebook at the title/abstract level.	Exclude a record only when both reviewers agree, after re-examination, that at least one mandatory eligibility criterion is clearly not met.	Apply the same rules as the initial screening; this was not a full-text assessment.

Study	Initial Category Code(s)	Directly Extracted Policy/System Finding	Evidence Status Used in Synthesis	Final Domain Mapping	Cross-Cutting Consideration	Transformation/Decision Rationale
Freeman et al. (2025) [12]	Policy recognition; financing/coverage; workforce/implementation	Global mapping of OT primary-care positioning, financing, workforce and enabling factors	Direct descriptive survey	Policy recognition/institutional positioning; financing/coverage; workforce capacity/implementation support	None	Each arrangement was directly documented and retained.
Nash et al. (2025) [41]	Policy recognition; financing/coverage; workforce/implementation; governance/collaboration	Receptiveness to OT inclusion, delegation preferences, reimbursement, and role barriers	Mixed-method perceptions	Policy recognition/institutional positioning; financing/coverage; workforce capacity/implementation support	None	Governance/collaboration was absorbed into positioning and implementation because it concerned team authority and implementation conditions.
Evans et al. (2023) [42]	Service delivery; workforce/implementation; governance/collaboration	Intra-disciplinary practice, peer consultation, management support, funding, and organizational barriers	Mixed-method descriptive findings	Service-delivery roles/infrastructure; workforce capacity/implementation support	None	Management/collaboration was treated as implementation support rather than a separate governance domain.
Dibsdall (2022) [43]	Service delivery; workforce/implementation; governance/collaboration	Assessment, goal setting, intervention selection, support-worker training, co-location and communication	Qualitative/realist findings	Service-delivery roles/infrastructure; workforce capacity/implementation support	User participation	Co-location/communication mapped to infrastructure/implementation; goal setting informed participation.
Lim et al. (2022) [44]	Policy recognition; service delivery; workforce/implementation	Role-perception types related to home adaptation, participation, service reliability, client needs, and professional development	Q-methodology findings	Policy recognition/institutional positioning; service-delivery roles/infrastructure; workforce capacity/implementation support	User participation	Role-perception evidence informed positioning and role domains, not effectiveness.
Rouch et al. (2022) [45]	Policy recognition; financing/coverage; referral/coordination; workforce/implementation; governance/collaboration	Entry into primary-care teams, team navigation, reimbursement and expansion barriers	Qualitative experience findings	Policy recognition/institutional positioning; financing/coverage; referral/coordination; workforce capacity/implementation support	None	Team navigation content was distributed to referral/coordination and implementation.
Missen et al. (2021) [46]	Service delivery; workforce/implementation; access/equity; system outcomes	Basic Assessment Model workflow; median wait 105 to 80 days	Uncontrolled pre/post service data	Service-delivery roles/infrastructure; workforce capacity/implementation support	Accessibility	Waiting-time change retained as direct quantitative outcome; causal attribution excluded.
Smith & Gallego (2021) [47]	Service delivery; access/equity; system outcomes	Outreach, attendance and transport/health-literacy barriers	Mixed-method service data/caregiver survey	Service-delivery roles/infrastructure	Accessibility; equity; user participation	Access barriers were treated as cross-cutting because they affected service reach.
Raymond et al. (2020) [48]	Referral/coordination; access/equity; governance/collaboration	Stakeholder differences in referral-prioritization rationales	Qualitative stakeholder perspectives	Referral/coordination	Equity; user participation	Safety, independence, and participation priorities were retained as cross-cutting considerations.
Bolt et al. (2019) [31]	Policy recognition; financing/coverage; service delivery; governance/collaboration	Cross-country service/funding organization plus professional recommendations	Survey separated from normative position statements	Policy recognition/institutional positioning; financing/coverage; service-delivery roles/infrastructure	None	An empirical survey informed the framework; professional recommendations were restricted in the sensitivity analysis.
Dickson & Toto (2018) [49]	Referral/coordination; service delivery; workforce/implementation; system outcomes	Feasibility of embedding OT in aging-in-place care coordination	Single-group feasibility findings	Referral/coordination; service-delivery roles/infrastructure; workforce capacity/implementation support	None	Feasibility was retained as an implementation observation, not as evidence of downstream effectiveness.
Friedman & VanPuymbrouck (2018) [50]	Policy recognition; financing/coverage; service delivery	Medicaid waiver coverage, projected utilization, expenditure, reimbursement, and service definitions	Document/quantitative descriptive analysis	Policy recognition/institutional positioning; financing/coverage; service-delivery roles/infrastructure	Equity in coverage variation	Coverage/reimbursement was a direct system arrangement; projected utilization was not treated as causal outcome evidence.
Dahl-Popolizio et al. (2017) [51]	Policy recognition; financing/coverage; service delivery; workforce/implementation	Receptiveness to OT on primary-care teams and perceived funding/role barriers	Descriptive survey perceptions	Policy recognition/institutional positioning; financing/coverage; service-delivery roles/infrastructure; workforce capacity/implementation support	None	Perceived barriers informed implementation conditions, not prevalence estimates.
Koverman et al. (2017) [52]	Financing/coverage; referral/coordination; service delivery; workforce/implementation	Logic model, EMR, scheduling, referral and reimbursement processes	Structured implementation observations	Financing/coverage; referral/coordination; service-delivery roles/infrastructure; workforce capacity/implementation support	None	Only traceable operational elements were coded; effectiveness/cost-saving claims excluded.
Raymond et al. (2016) [53]	Access/equity; service delivery; system outcomes	Waiting-list management strategies and association with longest waiting time	Cross-sectional program survey	Service-delivery roles/infrastructure	Accessibility; equity	Association retained with very-low GRADE certainty; no causal management effect inferred.
Wilberforce et al. (2016) [54]	Service delivery; workforce/implementation	Distribution of practitioner time across direct care, casework and team/service activity	Cross-sectional time-use data	Service-delivery roles/infrastructure; workforce capacity/implementation support	None	Time allocation was workforce/service-organisation evidence, not an outcome measure.
Donnelly et al. (2013) [55]	Policy recognition; referral/coordination; workforce/implementation; governance/collaboration	Communication, trust, role understanding, co-location, EMR and team meetings	Multiple-case qualitative findings	Policy recognition/institutional positioning; referral/coordination; workforce capacity/implementation support; service-delivery roles/infrastructure	None	Co-location/EMR mapped to infrastructure; communication/trust/team processes to coordination/implementation.
Raymond et al. (2013) [56]	Referral/coordination; access/equity; system outcomes	Referral-prioritisation criteria and differences in waiting time by priority	Program survey/content analysis	Referral/coordination	Accessibility; equity	Priority criteria were direct referral evidence; waiting differences informed access; companion publication controlled in sensitivity analysis.
London-Willis et al. (2012) [57]	Policy recognition; service delivery; workforce/implementation; governance/collaboration	Personalisation-related changes in OT role, identity, opportunities and threats	Qualitative perceptions	Policy recognition/institutional positioning; service-delivery roles/infrastructure; workforce capacity/implementation support	User participation context	Role identity/organisational change were retained as positioning/implementation evidence, not causal service effects.
Carrier et al. (2010) [58]	Access/equity; governance/collaboration; financing/resource allocation; referral/prioritisation	Access, prioritization, waiting, resource allocation, distributive justice and service quality	Legal/ethical/clinical analysis	Financing/coverage; referral/coordination	Accessibility; equity	Normative/legal analysis interpreted access/allocation principles, not service effects.
Quick et al. (2010) [59]	Financing/coverage; service delivery; workforce/implementation	Scope of practice, health promotion, funding/resource barriers and workforce characteristics	Descriptive survey	Financing/coverage; service-delivery roles/infrastructure; workforce capacity/implementation support	None	Scope/resource constraints informed service/workforce domains; no inference of effectiveness.

Study	Appraisal Tool	Final Item-Level Judgments	Key Limitation
Freeman et al. (2025) [12]	JBI analytical cross-sectional	Selection U; setting Y; exposure/system measurement U; confounding identification U; confounding control U; outcome measurement U; statistical inference Y; transferability U	Member-organization self-report and representativeness/measurement limitations.
Nash et al. (2025) [41]	MMAT mixed methods	S1 Y; S2 Y; M1 Y; M2 CT; M3 CT; M4 CT; M5 CT	Convenience/snowball sampling, very small interview sample, and limited integration.
Evans et al. (2023) [42]	MMAT mixed methods	S1 Y; S2 Y; M1 Y; M2 Y; M3 Y; M4 CT; M5 CT	Convenience sampling and self-developed survey; geographic overrepresentation.
Dibsdall (2022) [43]	JBI qualitative	Q1 Y; Q2 Y; Q3 Y; Q4 Y; Q5 Y; Q6 U; Q7 U; Q8 Y; Q9 Y; Q10 Y	Researcher positioning/influence incompletely reported.
Lim et al. (2022) [44]	QuADS	Q1–Q13: 3,3,3,3,2,3,3,3,3,2,3,2,2 (35/39; descriptive total only)	Purposive Q-sample/P-sample, non-loading participants, and limited reflexivity.
Rouch et al. (2022) [45]	JBI qualitative	Q1 U; Q2 Y; Q3 Y; Q4 Y; Q5 Y; Q6 Y; Q7 U; Q8 Y; Q9 Y; Q10 Y	Small sample; single PI conducted interviews and primary analysis.
Missen et al. (2021) [46]	JBI quasi-experimental	Temporal Y; comparable groups U; similar care N; control N; repeated measures Y; follow-up Y; same outcome measurement Y; reliable measurement Y; analysis Y	No concurrent control and staffing changes during implementation.
Smith & Gallego (2021) [47]	MMAT mixed methods	S1 Y; S2 CT; M1 Y; M2 CT; M3 CT; M4 CT; M5 N	Small parent/carer sample and potential selection bias; limited integration.
Raymond et al. (2020) [48]	JBI qualitative	Q1 U; Q2 Y; Q3 Y; Q4 Y; Q5 Y; Q6 Y; Q7 Y; Q8 Y; Q9 Y; Q10 Y	Scenario-based data and context-specific transferability.
Bolt et al. (2019) [31]	MMAT quantitative descriptive + JBI expert opinion	Survey: sampling CT; representativeness CT; measurement CT; non-response CT; analysis Y. Position: expertise Y; focus Y; logic Y; literature Y; alternatives U; bias U	Survey reporting is limited, and professional advocacy is mixed with empirical survey results.
Dickson & Toto (2018) [49]	JBI quasi-experimental	Temporal Y; comparable groups N; similar care N; control N; repeated measures N; follow-up U; same outcome measurement Y; reliable measurement Y; analysis Y	Small selected single group without comparator; short follow-up.
Friedman & VanPuymbrouck (2018) [50]	MMAT mixed methods	S1 Y; S2 Y; M1 Y; M2 Y; M3 Y; M4 CT; M5 CT	Projected rather than observed utilisation/expenditure; qualitative coding limitations.
Dahl-Popolizio et al. (2017) [51]	MMAT quantitative descriptive	Sampling N; representativeness N; measurement CT; non-response N; analysis Y	Convenience/snowball sampling, unknown denominator, unvalidated instrument, and priming.
Koverman et al. (2017) [52]	QuADS	Q1–Q13: 3,3,3,2,1,1,1,2,1,1,1,2,1 (22/39; descriptive total only)	Sampling, systematic data collection, analysis, ethics, and audit trail were incompletely reported.
Raymond et al. (2016) [53]	JBI analytical cross-sectional	Selection Y; setting Y; exposure/system measurement Y; confounding identification U; control U; outcome measurement U; inference Y; transferability U	Cross-sectional design, proxy waiting-list outcome, and residual confounding.
Wilberforce et al. (2016) [54]	JBI analytical cross-sectional	Selection Y; setting Y; exposure/system measurement U; confounding identification U; control U; outcome measurement U; inference Y; transferability U	Self-report diary tool with incomplete measurement-property evidence; single trust.
Donnelly et al. (2013) [55]	JBI qualitative	Q1 U; Q2 Y; Q3 Y; Q4 Y; Q5 Y; Q6 U; Q7 U; Q8 Y; Q9 Y; Q10 Y	Researcher positioning and influence were incompletely reported; four cases.
Raymond et al. (2013) [56]	JBI analytical cross-sectional	Selection Y; setting Y; exposure/system measurement Y; confounding identification U; control U; outcome measurement Y; inference Y; transferability U	Regional confounding and the same underlying Quebec program dataset as Raymond (2016). [53]
London-Willis et al. (2012) [57]	JBI qualitative	Q1 Y; Q2 Y; Q3 Y; Q4 Y; Q5 Y; Q6 Y; Q7 U; Q8 Y; Q9 Y; Q10 Y	Six early volunteers and no explicit saturation report.
Carrier et al. (2010) [58]	QuADS	Q1–Q13: 3,3,2,3,2,2,2,2,1,2,3,1,2 (28/39; descriptive total only)	Document search/selection flow, dual review, and audit trail incompletely reported.
Quick et al. (2010) [59]	MMAT quantitative descriptive	Sampling CT; representativeness CT; measurement CT; non-response CT; analysis Y	Population denominator, non-response bias, and instrument validation were incompletely reported.

Sensitivity Analysis	Rule	Result	What Changed	Manuscript Interpretation
S1. Exclude expert opinion and author-proposed recommendations	Remove professional-position statements and other normative recommendations; retain empirical research findings.	Five organizing domains remain identifiable.	Professional advocacy is not necessary to sustain the core framework.	Policy recommendations should be phrased as considerations, not observed evidence.
S2. Direct findings only	Retain findings directly documented or measured in policy documents, service records, surveys, time-use data, and operational reports.	Financing, referral, access, service organization, and workforce patterns remain.	Many role-expansion and broader prevention claims weaken.	Use direct evidence for descriptive system claims; avoid broad role claims.
S3. Remove outcomes not directly measured	Exclude hospitalization, institutionalization, cost-saving, and long-term-care demand claims unless directly measured.	Core policy/system domains unchanged.	RQ4 narrows to waiting time, feasibility, access, expenditure structures, and service activity.	Describe downstream outcomes as future hypotheses only.
S4. Control companion publications	Treat Raymond (2013) [56] and (2016) [53] as two reports from a single Quebec dataset.	Referral/access theme remains, but the evidence count is reduced by one unique dataset.	Prevents double-counting of sample and context.	Report 21 reports and 20 unique studies/datasets, if no other overlaps exist.
S5. Restrict Koverman to traceable operational data	Retain EMR, scheduling, billing, and implemented pilot facts; remove broad success and referral-effect claims.	The service infrastructure and implementation theme remain.	Claims about increased referrals and provider acceptance weaken.	Use Koverman only as a structured implementation report.
S6. Restrict uncontrolled studies to feasibility/local change	For Missen and Dickson, retain only feasibility and observed local change.	Access and implementation domains remain.	No causal effect conclusions remain.	Use ‘following implementation’ and ‘feasible’, not ‘caused’ or ‘effective’.

Qualitative Review Finding	Contributing Qualitative Evidence	Methodological Limitations	Coherence	Adequacy	Relevance	Overall Confidence	Explanation
Role clarity and team understanding influence whether OT is integrated into routine team practice.	Donnelly (2013) [55]; Rouch (2022) [45]; Dibsdall (2022) [43]; London-Willis (2012) [57]	Moderate concerns	Minor concerns	Moderate concerns	Minor concerns	Moderate	Consistent pattern across primary care, reablement, and social care, but limited by small numbers of settings and incomplete reflexivity in some studies.
Co-location, shared records, team meetings, and managerial support facilitate organizational integration.	Donnelly (2013) [55]; Dibsdall (2022) [43]; Rouch (2022) [45]	Minor to moderate concerns	Minor concerns	Moderate concerns	Minor concerns	Moderate	Clear fit between data and findings across three qualitative studies, although the number of data-rich settings was limited.
Reimbursement and billing constraints impede the integration of OT into U.S. primary care.	Rouch (2022) [45]; qualitative component of Nash (2025) [41]	Moderate concerns	Minor concerns	Serious concerns	Moderate concerns	Low	The finding is coherent but supported by a few data-rich qualitative sources and is mainly relevant to the U.S. financing context.
Service context and workforce capacity shape how OTs enact their roles.	Dibsdall (2022) [43]; Donnelly (2013) [55]; Rouch (2022) [45]; London-Willis (2012) [57]	Moderate concerns	Minor concerns	Moderate concerns	Minor concerns	Moderate	Recurring across several service models, with some limitations in sampling, reflexivity, and contextual breadth.
Service users and professionals may differ in referral-priority and fairness judgments.	Raymond (2020) [48]	Minor to moderate concerns	Minor concerns	Serious concerns	Moderate concerns	Low	Rich within-study comparison, but based on one Canadian study using hypothetical scenarios.
Social-care or reablement redesign may create tension between expanded system roles and occupation-focused practice.	Dibsdall (2022) [43]; London-Willis (2012) [57]	Moderate concerns	Minor concerns	Serious concerns	Moderate concerns	Low	Coherent across two UK studies, but limited in quantity and jurisdictional relevance.

Quantitative Outcome	Study/Body of Evidence	Starting Level	Risk of Bias	Inconsistency	Indirectness	Imprecision/Publication Bias	Final Certainty and Interpretation
Waiting-list time following introduction of a rural assessment model	Missen et al. (2021) [46]; one uncontrolled before–after service evaluation	Low (observational/non-randomized)	Serious: no concurrent control and staffing changes	Not assessable: one study	Not serious for the local wait-list outcome	Serious imprecision; publication bias undetectable	Very low. The observed local reduction cannot be attributed causally to the model.
Association between waiting-list management practices and longest waiting time	Raymond et al. (2016) [53]; 55 Quebec programs	Low (observational cross-sectional)	Serious: cross-sectional design and residual confounding	Not assessable: one study	Serious: the longest waiting person is a proxy for overall access	Imprecision not fully quantifiable; publication bias undetectable	Very low. Supports an observed association only, not a causal management effect.
Feasibility of integrating OT into a care-coordination program	Dickson and Toto (2018) [49]; one small single-group feasibility study	Low (observational/non-randomized)	Serious: selected sample, no comparator, short follow-up	Not assessable: one study	Not serious for feasibility in the studied program; serious for broader effects	Serious imprecision; publication bias undetectable	Very low. Supports feasibility under study conditions only.

PERMALINK

Occupational Therapy Within Integrated Community Care Systems: A Systematic Review and Narrative Synthesis of Policy and System-Level Evidence

Su-Min Cha

Roles

Abstract

1. Introduction

2. Materials and Methods

2.1. Study Design

2.2. Eligibility Criteria for Study Inclusion

Table 1.

2.3. Search Strategy

Table 2.

2.4. Study Selection

2.5. Data Extraction and Preparation for Synthesis

2.6. Framework Synthesis

Table 3.

2.7. Critical Appraisal

Table 4.

2.8. Assessment of Confidence in Qualitative Findings and Certainty of Quantitative Outcomes

2.9. Sensitivity Analysis Procedures

3. Results

3.1. Literature Search and Selection

Figure 1.

3.2. Characteristics of Included Evidence

Table 5.

3.3. Critical Appraisal and Interpretive Restrictions

Table 6.

3.4. Cross-Jurisdictional Patterns

Table 7.

Figure 2.

3.5. Findings by Research Question

Table 8.

3.6. Sensitivity Analyses

Table 9.

3.7. Confidence in Qualitative Findings and Certainty of Quantitative Outcomes

Table 10.

3.8. Integrated Policy-System Synthesis Refined Through Framework Synthesis

Table 11.

Figure 3.

4. Discussion

4.1. Principal Findings and the Contribution of Occupational Therapy

4.2. Financing, Access, and Equity

4.3. Organizational Integration and Workforce

4.4. Potential Policy and Service-Planning Considerations

4.5. Strengths and Limitations

4.6. Future Research

5. Conclusions

Acknowledgments

Appendix A. Full Database-Specific Search Strategies

Appendix B. Operational Eligibility Codebook Used by Both Reviewers

Appendix C. Detailed Extraction Matrix for the 21 Included Reports

Appendix D. Study-Level Framework-Synthesis Audit Trail from Provisional Coding to Final Domains

Appendix E. Final Item-Level Design-Matched Critical-Appraisal Results

Appendix F. Detailed Sensitivity-Analysis Rules, Results, and Interpretation Changes

Appendix G. Full GRADE-CERQual Evidence Profile for Qualitative Synthesis Findings

Appendix H. Full GRADE Certainty Assessment for Eligible Quantitative Outcomes

Institutional Review Board Statement

Informed Consent Statement

Data Availability Statement

Conflicts of Interest

Funding Statement

Footnotes

References

Associated Data

Data Availability Statement

ACTIONS

PERMALINK

RESOURCES

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