Q: I read AOTA's take on health care reform, and how it could affect all of us. No one knows. I am scared about a lot of things, and losing my job is only one. Death and taxes are the only things I can be sure of, right?

A: Yes, that's about it. you can bet on death and taxes. You can begin advocating by empowering your own staff and by contacting your state OT association. They will know how to contact your state's legislating bodies.

This fear extends far beyond OT; it's prevalent for anyone dealing with goods and services to older people. This is especially true if you depend upon Medicare or Medicaid for reimbursement. Profitability is almost the number one word in the therapy world today, not necessarily proficiency or quality of services or care provided.

I've come up with a list of "top five fears" of occupational therapists working in geriatrics today (subject to debate and criticism).

Fear of losing your position
Many therapists fear losing their current positions or becoming victims of cuts in Medicare. But recently I saw this online while reviewing OT job opportunities: "Wanted: OTs for SNF, Master's degree preferred. COTAs needed, entry level preferred."

Are companies heading toward hiring only master's-degree OTs now? Does this mean that seasoned bachelor's-level OTs will have fewer options to job hop? Are those who hire and pay OTs looking to get the "most for their money" by signifying master's level? And why would you want only entry-level COTAs? Is it because you can pay them less?

I think we have little assurance in a country that has 46 million people without health insurance.

My advice: Look out for you and your family. Save now, shop less. If you are not saving a percentage of your income, you could be in real trouble if something happens to your job.

Fear of your job being cut back
I received an e-mail from a therapist talking about how her hours were cut back recently; the transition changed every dynamic within her family. She still has to pay for the mortgage, car, health and liability insurance, food, gas and utilities.

If you are self-employed, be competitive because the lowest bidder may get the contract. In facilities, there will be cases where OTAs will be hired instead of OTs and vice versa, depending on reimbursement, region, state and company.

My advice: Spend less, budget more and possibly start looking for a side gig if survival and savings depend upon it.

Fear of lower wages
You may be faced with a situation where you are asked to keep your current position but take a cut in pay. Should you fight it, or suck it up? Should you ask your boss to show you why, or keep quiet?

My advice: Be quiet, but ask for accountability. People in general are more apt to go along if leadership is honest. Don't make enemies or talk too much.

Fear of lackadaisical peers
There is strength in unity. In every department, there are always one or two lazy and negative people. As an occupational therapist, you are not a lone

ranger. You work with a team. There is power in sticking together to make things work for all. OTs who are not proficient, productive, progressive or positive will find themselves filing for unemployment. You have to make yourself great at what you do. Show initiative-for example, develop a program and strut your stuff. Home health agencies need OTs leading the safety and equipment program, and comprehensive ADL programs that yield greater functional outcomes for reimbursement. SNFs need documentation experts and those who take the lead in restorative/follow-up with nursing tools.

My advice: Make your work worthy of high respect.

Fear of Leaving the Profession
In many cases, I think people are now wondering what they would do if they could no longer work in OT? Many of us are getting up there in years. Are we ready for retirement? Do we have enough money after the stock-market meltdown? Can we physically go on, with our knees popping and our backs cramping?

If we should leave the OT profession and not be ready for retirement, what will we do?

My advice: For those who have the faith, endure. Take life one day at a time, and take stock of your basic skills. Look ahead, not back. Opportunities will come.

The comments above are meant to encourage you to take action now-for you, your family and your profession.

Like you, I am hoping for the best. But if you do nothing, you will get nothing. While you have your health and strength, give all you can, love all you can, and work harder than anyone. Make it difficult for your boss to consider laying you off.

And be grateful for what you have, because there is always someone worse off than you.

Clarissa Fells Smith, PhD, OTR/L, has a doctorate in health services administration with a specialty in gerontology/geriatrics. She has worked as a manager and clinical education specialist and is currently an independent contractor, trainer, consultant and workshop leader in geriatric rehabilitation. Readers may contact her at clarissafsmith@aol.com.