10-06-03
Ready To Go? Helping Older Adults Address Community Mobility

OT Practice onlineAndrea Brachtesende

Summary Community mobility means more than driving. Occupational therapy practitioners can expand older adults' opportunities for independence and help them to age in place when they can no longer drive.

Even if they didn't know her, they knew of her. Often they saw her in the town, the heavy, stooped old lady with a shock of white curls and glittering blue eyes pressing into the driver's seat of a red Volkswagen beetle, revving the engine, and pulling away from the curb. She would drive all over, visiting her daughter a few blocks away, her sons in the country, another daughter in a larger town. She would stop at the general store on Route 160 for a Coke and conversations with the other old-timers about the weather, health, family, and the sorry state of the world. Then she would zoom off again-to the market for a loaf of bread; to the post office, where she didn't even have a mailbox; to the community center for a hot meal and a round of bingo. "There goes Bessie," people would say.

Bessie, my grandmother, was 83 when she stopped driving. She didn't do it voluntarily, despite the cataracts growing in her eyes or despite aching joints that slowed her reflexes. She was involved in a car accident that left her with a broken wrist. The car was totaled. At the time, she lived alone in the house she had shared with her husband and eight children. She remained there for several months while her children drove her to doctor's appointments or to the store, but it wasn't the same. She couldn't get out on her own to make her rounds. Her town, population 246, wasn't big enough to host a public transportation system. Even if it could, she might not have been able to hoist her 180-pound, 4-foot-9-inch frame up the bus steps. She had enough trouble walking two blocks with her cane. The family convinced her to go into a nursing home. "It's not all bad," she said once. "I like the people, but I sure do miss being able to go."

More than 35 million Americans are aged 65 or older. As the baby boomer generation continues to age, the number of Americans more than 65 years of age is expected to reach 70 million by 2030,1 posing enormous challenges to the health care system, communities, policymakers, and older adults and their caregivers. By helping older clients and their families address community mobility along a continuum, occupational therapists and occupational therapy assistants can help older adults live as independently as possible and help meet the needs of an aging nation. In fact, they already have the skills to do it.

What Is Community Mobility?

Many occupational therapy practitioners seem to associate community mobility solely with driving, or rather, with getting behind the wheel with an older person and judging whether he or she is capable of driving. To some, it means having to be the bad guy and tell people they can no longer drive. Driving, however, is only one element of a larger instrumental activity of daily living (IADL), community mobility. Community mobility involves moving one's self in the community and using public or private transportation, such as driving, or accessing buses, taxis, or other public transportation.2 And as Audrey Straight, senior policy advisor with AARP's Public Policy Institute pointed out, mobility is a crucial component of successful aging: "It's critical for keeping people connected and for helping them feel they're in charge of their lives."

Anne Long Morris, EdD, BCG, OTR/L, FAOTA, a geriatric consultant with Elder Care Management in Springfield, Virginia, agrees. "Mobility is one of the most critical aspects of a client's life. Moving around the household is a smaller area of mobility, but [mobility] also has a broader connotation for occupational therapists and clients. Addressing mobility within the community gives clients the capacity to hope that they'll be able to resume interacting with friends and family," she said. Indeed, many occupational therapy practitioners and others outside the profession see mobility as a cornerstone of overall health and independent living.

"We know that decreased mobility leads to decreased participation in community, which leads to increased depression and increased loss of functionality," said Bryna Helfer, a transportation policy analyst with the Federal Transit Administration who also has worked extensively with persons with brain injury. Wendy Stav, PhD, OTR/L, CDRS, called mobility, especially driving, "the occupation-enabler." "Driving is everything to an older person. It's their independence. It allows them to engage in so many other occupations. It allows access to shopping, friends, leisure activities, and so much more," said Stav, assistant professor of occupational therapy at Cleveland State University in Ohio. "There's a tremendous sense of loss when you can't drive anymore. You're losing the ability to do for yourself, and that's devastating."

Where Driving Fits In

When an 86-year-old man plowed through a crowded farmer's market in Santa Monica, California, in July 2003, the media, policymakers, and public were quick to scrutinize the nation's handling of older drivers. Unfortunately, as often happens, it takes a high-profile tragedy to effect changes in legislation, social attitudes, and behaviors and to address the interplay of conditions and circumstances that lead to such devastating events. With the increase in number and size of the suburbs, Americans have grown increasingly dependent on automobiles to navigate their communities. In fact, private automobile is the primary mode of transportation for most Americans, and persons over age 65 make more than 90% of their trips by car, either as drivers or passengers.3 In 2001, there were 191 million licensed drivers in the United States,4 with 19 million over age 70.5 Within the next 20 years, the proportion of drivers over age 70 will increase to 14%.6 More drivers on the road means more potential for accidents. Although older people are not responsible for a disproportionate number of car crashes, they are less likely than younger people to survive accidents.5 In addition, advances in science and medicine have increased life expectancy, which means older adults are likely to retire later and lead active lives longer. Occupational therapy practitioners, then, have an opportunity to contribute their expertise to help the current population of elderly Americans maintain quality of life and live independently. What's more, they also have a unique opportunity to help the coming generations of drivers and caregivers face these issues by promoting public awareness of driving safety and arming the public with the information to make appropriate mobility choices.

Addressing driving does not mean that occupational therapy practitioners must specialize in driver rehabilitation or become a certified driver rehabilitation specialist (CDRS), although many areas desperately need such services. Occupational therapy expertise of several different levels is needed to help older adults to successfully engage in meaningful occupations that driving facilitates. In "Defining OT Roles in Driving," (OT Practice, January 13, 2003, pp.15-18), Elin Schold Davis, OTR/L, CDRS, identified three driving roles for occupational therapists: the occupational therapy generalist, the occupational therapist with advanced training, and the occupational therapist with specialized training.7 (Note: The article did not explicitly address the role of the occupational therapy assistant in driving. The assistant's role would be in compliance with the standards of practice, as in any occupational therapy program.) Generalists draw on their general knowledge and understanding of how performance and process skills (e.g., range of motion, vision, attention, cognition) relate to driving but do not evaluate driving competence.7 They can evaluate the subskills used for driving, consider the implications of the evaluation, and refer to others as appropriate.7 Therapists with advanced training exercise the same skills as generalists but have additional training in the area of driving, such as continuing education, that expands their role to include determining whether skills are optimized for driving and counseling and advising clients about driving concerns and mobility alternatives.7 Lastly, occupational therapists with specialized training have advanced expertise that includes targeted clinical assessment, on-road assessment, and driver retraining.7 They are qualified to evaluate driving competence and may also be able to prescribe, install, and train clients in the use of appropriate adaptive equipment.7 Examples of therapists with specialized training include certified driver rehabilitation specialists or those who have been trained in driver's education.7

Regardless of the role they play, occupational therapists at all levels and in all practice areas are qualified to address the subskills required for driving and should be knowledgeable of driving resources within their communities.7 They should also be aware of the needs of caregivers. Bessie's children, for example, believed that she needed to limit her driving before the accident but they had difficulty communicating their concerns to her and did not know where to find help. After the accident, they had to help Bessie cope with the loss of her car keys, which was a sad and stressful event for all involved. Occupational therapy practitioners can assist caregivers by providing driving resources and coping strategies and by staying abreast of intervention techniques.

Addressing Community Mobility in the Clinic

Perhaps the first step for occupational therapy practitioners to take in addressing the community mobility issues of older adults is to understand how and why they are prepared to help. "To me, occupational therapists are uniquely suited to address community mobility because they're trained in all the areas necessary for navigating the community: physical function-for instance, does a person have the strength to cross the street; sensory problems that interfere with navigation-is the person's vision good enough to cross the street or drive; and cognition-how well can the person process what's going on around them?" said Dennis McCarthy, MEd, OTR/L, codirector of the National Older Driver Research Center (NODRC) at the University of Florida. "OTs also have a philosophical foundation that makes them well-suited to address mobility. They are looking to maximize clients' ability to participate in their communities."

Stav agrees. "I don't think OTs feel they know about driving, but they already do," she said. "They know about judgment, about the aging process, and about independence. Driving is an IADL, and we as OTs need to look at it as an IADL, not a specialized area of practice." By asking older clients where they need to go, how much they need to get around, and whether they want to drive, occupational therapists are addressing driving and mobility concerns. "Probing is half the battle," Stav said. "If you make a referral for a comprehensive driving evaluation, you have just addressed driving."

Decreased range of motion, strength, endurance, vision, hearing, and memory processing are all markers of the normal aging process, which can affect performance skills needed for mobility regardless of whether it takes the form of driving, crossing the street, or riding a bus. They also are areas that occupational therapy practitioners are accustomed to addressing in the clinic. In addition, older adults' mobility difficulties may be compounded by chronic conditions such as hypertension or diseases such as diabetes. Not only do such conditions exacerbate the normal problems of aging, but side effects from medications used to treat them also can affect performance skills. Occupational therapists can evaluate clients' motor and process skills and determine appropriate interventions to be carried out by the occupational therapist or occupational therapy assistant. Or, they can make referrals to other health professionals (e.g., to another occupational therapist, an ophthalmologist, an ambulatory specialist, etc.) when appropriate. As Carol Wheatley, OTR/L, CDRS, with the Workforce and Technology Center in Baltimore, Maryland, pointed out, addressing mobility concerns involves striking a balance between independence and safety. "Occupational therapists' role is to enable an individual to continue driving as long as they are safe," she said. To that end, occupational therapy practitioners may help older adults self-limit their driving or provide persons with good judgment with the information and resources to make decisions for themselves. "Occupational therapists in all practice areas should include the issue of driving in their assessment-to determine the role of driving in the person's life, to do a basic evaluation of the person's capacities and limitations, and to make a referral to driver rehabilitation services in their local area," Wheatley added.

According to Straight, ongoing work and involvement by occupational therapy practitioners in mobility issues are crucial: "OTs are equipped to do the really hard part, which is identifying cognitive problems that affect driving. We need OTs who are already thinking about cognitive functioning in other areas to think in terms of driving. We need professionals who are able to say to an older person, 'You can drive but you need these adaptations or modifications to improve,' or 'You can't drive but it's not the end of your life. Here's what you can do.'"

One of the most important things a clinician can do, according to Susan Cooper, OTR, is to let clients know what mobility options are available to them. "Don't underestimate what you can do in the clinic," advised Cooper, who works in outpatient therapy and considers herself an occupational therapy generalist. "My goal as an OT generalist is to prepare my clients for driving as thoroughly as I can without getting into a car, before referring them for the driver's evaluation." Sometimes, however, she knows that a client will not be able to safely resume driving and does not refer them on for the evaluation, which can be expensive. "It's not always necessary to send someone for an evaluation. If you know their attention skills or mental flexibility are such that they can't drive safely, you can have a physician tell them not to drive or to limit their driving," she said. In situations where clients' driving skills cannot be improved so that they can drive safely, Cooper helps them determine their options. That means not simply knowing what alternative transportation is available but also asking clients questions, such as "How do you feel about using this option?" and "What are the barriers to you using this option?" It also means helping them overcome the barriers. "Community mobility means more than driving. I often train clients to use the city bus system, assist them with obtaining discount cards, or help them apply for and learn to use the paratransit system," said Cooper.

Making the transition from driving oneself to using public or private transit systems is not always easy, especially for elderly persons. Relying on others, whether relatives or mass transit, restricts an older person's spontaneity. "If you wake up Monday and decide you're going to bake a cake, then find out you don't have enough eggs, you can't just get in your car and go to the store," said Wheatley. "You have to wait until your daughter can pick you up or until the next bus arrives. You have to plan ahead." In addition, most elderly persons do not like depending on others for transportation or do not want to be a burden on their families. (In a recent survey by AARP, two thirds of respondents said they did not anticipate relying on family or friends to help them with tasks that would allow them to remain in their homes.8) Older adults also may find the mode itself stressful. As Wheatley said, "Most people have built their lives without public transportation and have no idea about the dramatic shift involved. They may have to travel some distance to a bus stop, have personal safety concerns, or worry about getting on the right bus." Other obstacles that create anxiety for an older person include asking for a ride, trying to get information about transit cost or schedules, counting fares, or just knowing how to ask the right questions. In addition, lack of bathrooms on buses, negotiating transfers, lack of shelter from the weather at bus stops, and length of rides may limit clients' usage of mass transit. Occupational therapy practitioners can use their clinical skills to help clients address the potential barriers and adapt to using public and private transportation so they can be as independent as possible.

Addressing Community Mobility Outside the Clinic

Occupational therapy practitioners' expertise also is needed outside the clinic. Many opportunities-as advisers, consultants, educators, and volunteers-exist for practitioners who would like to become more involved with older adult mobility issues.

Collaborating With Federal Agencies

"It's an exciting time [in the area of older driver rehabilitation]. Government transportation agencies have been looking at the older driver problem for a while and have recognized the skills of the occupational therapist as a good match for assessment and training of older drivers," Wheatley said. Agencies such as the National Highway Traffic and Safety Administration (NHTSA) have sought input from the American Occupational Therapy Association (AOTA) and occupational therapy practitioners on addressing driving and mobility of older adults. In December 2002, AOTA held an Older Driver Consensus Conference, funded by a NHTSA grant, that brought together government agency representatives, occupational therapy practitioners, physicians, and others involved in aging issues to examine and develop strategies for enabling older adults to drive safely for as long as possible. In 2003, AOTA and the University of Florida gained Congressional approval for $1.6 million in funding to establish the university's new NODRC, headed by McCarthy and William Mann, PhD, OTR. The funds, which flow through the Centers for Disease Control and Prevention and the Federal Highway Administration, will support many NODRC activities, including establishing a system for identifying elderly drivers who are at risk for unsafe driving, providing referrals to appropriate professionals (e.g., ophthalmologists) who address skills associated with driving, providing training and assistive devices that may enable safe driving, and conducting and promoting research on older driver issues. AOTA will subcontract with the university to serve as a chief disseminator of knowledge and as a training resource to advance the ability of members of the profession to address societal concerns about older driver safety.

Collaborating With National, State, and Local Groups

In addition to sharing their expertise with government transportation agencies, practitioners may consider getting involved with national organizations that educate health care professionals, the public, and policymakers about aging issues or transportation. For instance, Stav contributed a chapter to the American Medical Association's Physician's Guide to Assessing and Counseling Older Drivers (available at www.ama-assn.org), a guide for clinicians that contains scientific evidence and clinical consensus from multidisciplinary researchers in the area of older drivers, client advocacy groups, and government agencies.

At the national level, AOTA and the American Society on Aging have collaborated to produce online continuing education courses in older driver issues, as well as to promote wellness and independent living for older adults. In addition, Morris and Linda Hunt, MS, PhD, OTR, of Flathead Valley Community College in Whitefish, Montana, worked with the American Society on Aging to develop online seminars on the challenges affecting older drivers. The seminars, on medical conditions that affect driving and on assessing driving capacity, respectively, are part of a series sponsored by NHTSA. The series, Promoting Safety and Independence Through Older Driver Wellness, also includes a presentation by gerontologist Vicki Schmall on helping families cope with driving issues. It is available through December 30, 2003, at www.asaging.org/ webseminars.

Occupational therapy practitioners can reach out to organizations at the state and local levels as well. Area Agencies on Aging, state motor vehicle departments, senior center networks, state and local health departments, transit authorities, planning and zoning commissions, and law enforcement are just some of the groups that can benefit from practitioners' knowledge of aging processes and environmental modifications that enhance accessibility, mobility, and safety for older adults. For example, practitioners who attend local planning meetings can educate city planners about how new development projects might affect elderly persons in the community or recommend ways to improve the existing infrastructure (e.g., contrast curbs, street signs with large lettering, longer crossing lights at intersections) that improve older adults' ability to navigate their communities without driving. Practitioners also may volunteer to provide educational presentations or seminars to organizations or community groups (e.g., presenting safe driving tips to senior groups). Or, they may advise transit authorities or taxi companies on strategies to enhance mobility for elderly customers, such as having bus drivers loudly call out stops, providing large-print signs on buses that display upcoming stops, or telling taxi customers the fare up front.

Advising Businesses

"Cars today aren't designed for older adults," said Stav. "The airbag was designed for a 6-foot, 200-pound man. The force of an airbag can actually injure older people because their bones are frail. There also is some fear [among older adults] of the technology that has been designed to keep them safe. They didn't grow up with airbags and antilock brakes. [The technology] is an unknown for older adults, and they often don't use it properly." Other safety equipment such as telescoping brakes and extended rearview mirrors, which can come standard on today's automobiles, also was not around when older adults were growing up. Fortunately, many occupational therapy practitioners are familiar with assistive devices and modifications for automobiles and have the ability to determine what devices clients will use and to provide them with the appropriate training. Coupled with their understanding of the physical, social, and emotional aspects of driving, this knowledge provides occupational therapy practitioners with unique expertise that can be valuable to auto manufacturers and others involved in research and development of automobiles, assistive technologies, or special programs for older drivers. Practitioners might consider offering their insights and services to automobile designers, manufacturers, and research companies as advisers or consultants.

In addition, occupational therapy practitioners may find opportunities in consulting with local businesses on how to make their buildings and services more accessible to elderly persons. For example, practitioners might suggest physical modifications such as lowering door thresholds, using large-print signage, or adding railings. They also might advise businesses to make their services more elderly friendly (e.g., suggesting that pharmacies or grocery stores offer delivery service or that the local library provide mobile checkout service by taking vanloads of books to different locations around the community).

Pioneering New Community Programs

"There will be an increasing need for community resource centers, where all mobility information-options, alternatives, resources-is available under one roof in a centralized location," Wheatley said. She believes that occupational therapy practitioners are well suited to advise and make recommendations to communities on the development of such centers. In addition, Wheatley and Helfer both see a need for travel training centers that not only help older adults understand their mobility options but also provide training in using those options, including boarding buses, getting wheelchairs into the subway system, or determining a feasible walking distance to transportation.

Occupational therapy practitioners may also consider starting or getting involved in volunteer driving programs that complement existing transportation options for older adults within their communities. "Volunteer driving is going to be huge, especially for the most fragile elders, age 85 and up," said Straight. Community-based, or supplemental, transportation programs can offer more flexibility and responsiveness to individual needs than public and paratransit services, which many older adults are not comfortable using.9 Programs such as the Regional Transportation Program (www.rtprides.org/home.html) in Portland, Maine, and PasRide (www.seniordrivers.org/STPs/PasRide.cfm) in Pasadena, California, use a mix of paid and volunteer drivers to provide seniors with rides not just to physicians' offices and grocery stores for basic needs, but also to senior centers, churches, and shopping malls for social activities. In addition, the drivers escort passengers into buildings when necessary to provide physical and social support. The two programs, funded with the help of the American Automobile Association (AAA) Foundation for Traffic Safety and The Beverly Foundation, offer same-day service, although advance notice is required for some trips. Volunteer drivers who use their personal vehicles are reimbursed for mileage. According to a AAA nationwide survey of 236 supplemental programs, 69% charge no fees for rides (although rider donations are often accepted) whereas others have flat fees, sliding fees, or rates based on mileage.9 More information on volunteer driving programs is available from the AAA Foundation for Traffic Safety at www.aaafoundation.org/pdf/STP.pdf or The Beverly Foundation at www.beverlyfoundation.org.

Conclusion

Community mobility means more than just driving. "Mobility isn't just about whether the client can continue to be a safe driver. It's also about helping the client figure out what to do when they can no longer drive. These issues are central to quality of life for older people, and it's important to get a dialogue started about them now," Morris said. Using the unique skills and knowledge that are already within their scope of practice, occupational therapy practitioners are poised to make significant contributions to addressing the mobility issues of older adults and their caregivers. "A person's life encompasses more than just the four walls of an apartment. As occupational therapists, we have an understanding of occupational engagement and an understanding of all the things people do to fill their lives. We also understand the context of the community the client lives in as well as the cultural context [of mobility]," said Stav. "The occupational implications of keeping your license and being able to get around in the community are tremendous, and I don't think other disciplines address that." Whether by helping older adults improve driving safety, helping them find and use other transportation options within their communities, or educating businesses, communities, or policymakers about the community mobility needs of older adults, occupational therapy practitioners can help older adults continue to "go," as Bessie would say. That is, they can enable older adults to successfully engage in the occupations they find meaningful.

References

1. U.S. Census Bureau. (2000). Projections of the total resident population by 5-year age groups, race, and hispanic origin with special age categories: Middle series, 2025 to 2045. Washington, DC: Author. Retrieved July 2, 2003, from http://www.census.gov/population/projections/nation/summary/np-t4-f.txt

2. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.

3. AARP. (1999). Older drivers. Washington, DC: Author. Retrieved June 30, 2003, from http://research.aarp.org/consume/fs51r_older_drivers.html

4. National Highway Traffic Safety Administration, U.S. Department of Transportation. (2001). Traffic safety facts 2001: A compilation of motor vehicle crash data from the fatality analysis reporting system and the general estimates system. Washington, DC: Author. Retrieved July 7, 2003, from http://www-nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSFAnn/TSF2001.pdf

5. National Highway Traffic Safety Administration, U.S. Department of Transportation. (2000). Traffic safety facts 2001. Washington, DC: Author. Retrieved June 16, 2003, from http://www.nrd.nhtsa.dot.gov/pdf/nrd-30/NCSA/TSF2001/2001olderpop.pdf

6. Eberhard, J. (1998). Driving is transportation for most older adults. Geriatrics, 53(Suppl. 1), S53-S55.

7. Davis, E. S. (2002). Defining OT roles in driving. OT Practice, 8(1), 15-18.

8. AARP. (2003). These four walls...Americans 45+ talk about home and community. Washington, DC: Author. Retrieved July 1, 2003, from http://research.aarp.org/il/four_walls.html

9. AAA Foundation for Traffic Safety. (June 2001). Supplemental transportation programs for seniors. Retrieved July 7, 2003, from http://www.aaafoundation.org/pdf/STP.pdf

Andrea Brachtesende is the associate editor of OT Practice.
Keys to Starting a Driver Rehabilitation Program
Liz Green

As the population ages, driver evaluation and rehabilitation services are in greater demand throughout the country. By providing driver evaluation and rehabilitation services, occupational therapy practitioners are expanding their community-service involvement. The goal of a driver rehabilitation program is not only to help drivers decide when and how to retire from driving but also to provide necessary skills and equipment to safely lengthen the client's driving career.

With a unique background in activity analysis and occupational performance systems, mental health, medical illness, and disease, occupational therapy practitioners are well-positioned to provide driver rehabilitation services. Practitioners are encouraged to explore developing or expanding driver rehabilitation services in their area by obtaining additional training in driver rehabilitation and taking advantage of the availability of advanced certification.

What are the steps in developing a driver rehabilitation program?

I. Research and decide if a career in driver rehabilitation is right for you. A driver rehabilitation specialist requires a certain skill set and talents that may not be available to every clinician. Occupational therapy practitioners in the field should have a working knowledge of disease and disability, creative activity analysis skills, the ability to teach, knowledge of vehicle equipment and vehicle performance, and the ability to remain calm in a crisis.

II. Perform a market survey.

  1. Where will the clients come from? Referral sources may include physicians, rehabilitation professionals, family members, vocational rehabilitation, and state driver licensing agencies.
  2. What services are currently being offered in your area and who provides them? How far do your clients have to travel to obtain a driver evaluation? If there is an established program nearby, is there room in your community for another?
  3. What is the level of demand for driver rehabilitation services for your area? Are physicians asking for assistance in determining fitness to drive? Does your state Department of Motor Vehicles (DMV) ask for assistance in determining driving privilege? Is there an active retirement community whose members would like to increase their driving career and improve driving safety in their later years?

III. Understand the established recommended practices. According to the Association for Driver Rehabilitation Specialists (ADED), a driver rehabilitation program must have a qualified driver rehabilitation specialist and the appropriate vehicle(s) and equipment to provide comprehensive services in the following areas:

  1. Clinical evaluation
  2. Driving evaluation
  3. Vehicle modification or prescription
  4. Driver education
  5. Final fitting

IV. Determine the cost to equip and run a program. Typical expenses include:

  1. Staff (full-time equivalent salary-consider clinical and office staff)
  2. Clinical evaluation tools
  3. Vehicle(s)
  4. Vehicle equipment
  5. Training
  6. License or certification fees
  7. Office equipment

V. Determine the level of support for the program.

  1. Administrative: Driver rehabilitation programs are best staffed by a full-time occupational therapy practitioner devoted to the marketing and development of the program in addition to providing direct client services and care. Only one client can be served at a time. Evaluations can be time-consuming and complex. There is greater likelihood of nonbillable patient interactions (e.g., telephone calls, letters of reference, detailed written reports, counseling family members) than in traditional therapy settings.
  2. Physician: Physicians must be willing to support referrals to the program as well as support findings and recommendations, especially when a client has been found unsafe to drive and a report must be sent to the DMV.
What resources are available for education and training?

As with any specialty service within occupational therapy, clinicians will require additional training before they are competent to offer driver rehabilitation services. Certification as a driver rehabilitation specialist is available through ADED, which permits both occupational therapists and occupational therapy assistants to become certified. (To practice as a Certified Driver Rehabilitation Specialist [CDRS], occupational therapy assistants must move out from under the occupational therapy umbrella and not represent themselves as occupational therapy practitioners. If occupational therapy assistants are going to practice or bill occupational therapy, however, then they must practice under the supervision of an occupational therapist regardless of other credentials.) Check the ADED Web site (www.driver-ed.org) for eligibility requirements. Maintaining the certification requires ongoing continuing education in the area of driver rehabilitation.

I. Continuing education

  1. ADED is devoted primarily to supporting professionals in the field of driver education and modifying transportation equipment for persons with disabilities. ADED offers an annual conference with educational workshops and networking opportunities.
  2. AOTA offers an online continuing education course called Older Driver Screening and Evaluation: The Forgotten IADL, as well as workshops and institutes on older driver rehabilitation during the AOTA Annual Conference.
  3. Workshops, seminars, and conferences with emphasis on driver rehabilitation are also available from government agencies such as state DMVs and associations such as the American Society on Aging, as well as some private businesses.

II. Research

  1. Understand your state's requirements for a driving program, such as commercial driving school registration or other state-required program standards through vocational rehabilitation.
  2. Research adaptive driving equipment and visit local driving equipment vendors.

III. Learning

  1. Locate experienced driver evaluators and ask questions.
  2. Plan a 1-day visit with to a large comprehensive driving program, preferably in a facility similar to your own.
What legal and ethical issues or challenges should be considered?

Understanding legal and ethical issues before starting a program will ensure quality service to your clients, efficient communication between the clinician and state authorities, and increased involvement with physicians. Consider the following:

I. State DMV reporting requirements

  1. What are the requirements for obtaining and maintaining a driver's license in your state?
  2. What are the guidelines and laws with respect for reporting unsafe drivers?
  3. Does your state DMV have a medical review section?

II. AOTA ethical guidelines.
Acceptance of membership in the AOTA commits members to adherence to the Code of Ethics (2000)1 and its enforcement procedures. AOTA's principles of ethical behavior place an obligation on the driver rehabilitation specialist to report unsafe drivers and explore options by

  1. demonstrating a concern for the well-being of the recipients of the services;
  2. respecting the rights of the service recipients;
  3. achieving and continually maintaining high standards of competence;
  4. complying with laws and Association policies guiding the profession of occupational therapy;
  5. providing accurate information about occupational therapy services; and
  6. treating colleagues and other professionals with fairness, discretion and integrity.

III. American Medical Association (AMA) ethical guidelines and the AMA Code of Medical Ethics.2 AMA recommendations on impaired drivers (December 1999)3 place an ethical responsibility on the physician to report unsafe drivers and to explore options to improve driving safety by

  1. assessing physical or mental impairments that might adversely affect driving ability, evaluating each case individually;
  2. suggesting further treatment, including substance abuse treatment and occupational therapy;
  3. using their best judgment in determining when to report impairments that could limit the person's ability to drive safely;
  4. disclosing and explaining to their patients this responsibility to report;
  5. protecting patient confidentiality by ensuring that only the minimal amount of information is reported; and
  6. working with their state medical societies to create statutes that uphold the best interests of patients and the community, with provisions that safeguard physicians from liability when reporting in good faith.

Driver rehabilitation can be an exciting and rewarding specialization within occupational therapy. With the right training, advanced certification, and mentorship, occupational therapy practitioners can offer support to the aging driving population and be a positive influence in their communities.

References

1. American Occupational Therapy Association. (2000). Code of ethics (2000). American Journal of Occupational Therapy, 54, 614-616.

2. American Medical Association. (2002). Code of Medical Ethics. Chicago: Author.

3. American Medical Association. (December 1999). Council on Ethical and Judicial Affairs Report 1-1-99. Chicago: Author. Retrieved on July 11, 2003, from http://www.ama-assn.org/ama/upload/mm/369/report102.pdf

Liz Green, OTR/L, CDRS, is a 1993 graduate of Loma Linda University in California. She has been working in driver rehabilitation since obtaining her Certification in Driver Rehabilitation Services from ADED in 1999. She currently works at Frye Regional Medical Center in Hickory, North Carolina, as the director of occupational therapy and is the driver assessment program coordinator there. You may contact her at driver_rehab@yahoo.com.

For More Information

AARP
601 E Street, NW
Washington, DC 20049
800-424-3410
www.aarp.org (search for Older Drivers)

American Association of Motor Vehicle Administrators (AAMVA)
4301 Wilson Blvd., Suite 400
Arlington, VA 22203
703-522-4200
www.aamva.org

AAMVA's Grand Driver Program
888-GRAND03
www.granddriver.info

American Automobile Association (AAA) Foundation for Traffic Safety
1440 New York Ave., NW, Suite 201
Washington, DC 20005
202-638-5944
www.seniordrivers.org

American Medical Association
515 N. State Street
Chicago, IL 60610
312-464-5000
www.ama-assn.org (search for Older Drivers)

The Association for Driver Rehabilitation Specialists
711 S. Vienna Street
Ruston, LA 71270
800-290-2344
www.driver-ed.org

The Beverly Foundation
566 El Dorado Street, Suite 100
Pasadena, CA 91101
626-792-2292
www.beverlyfoundation.org

Community Transportation Association of America
1341 G Street NW, Tenth Floor
Washington, DC 20005
202-628-1480
www.ctaa.org

Easter Seals Project ACTION
700 13th Street, NW, Suite 200
Washington, DC 20005
202-347-3066
202-347-7385 (TDD)
www.projectaction.org

Federal Highway Administration
Older Driver Programs
400 7th Street, SW
Washington, DC 20590
202-366-6614
safety.fhwa.dot.gov/programs/olderdriver.htm

Federal Transit Administration
400 7th Street, SW
Washington, DC 20590
202-366-4043
www.fta.dot.gov

National Association of Area Agencies on Aging
927 15th Street, NW, Sixth Floor
Washington, DC 20005
202-296-8130
www.n4a.org

National Association of State Units on Aging
1225 Eye Street, NW, Suite 725
Washington, DC 20005
202-898-2578

National Institute on Aging Information Center
PO Box 8057
Gaithersburg, MD 20898-8057
800-222-2225
800-222-4225 (TTY)
www.nih.gov/nia/

National Highway Traffic Safety Administration
400 7th Street, SW
Washington, DC 20590
888-DASH-2-DOT (888-327-4236)
www.nhtsa.dot.gov

Older Driver Screening and Evaluation: The Forgotten IADL (AOTA Online Course)
By L. A. Hunt. Bethesda, MD: American Occupational Therapy Association. (Earn up to .5 AOTA CEUs or 5 contact hours. $112 for members, $160 for nonmembers. To register, visit www.aota.org and Click on Continuing Ed, then Online Courses.)

Prescriptive Seating for Wheeled Mobility (Vol. 1-Theory, Application, and Terminology)
By D. Ward, 1994. Kansas City, MO: Healthwealth International. ($30 for members, $42 for nonmembers. To order, call toll free 877-404-AOTA or shop online at www.aota.org. Order #1367-MI)

U.S. Administration on Aging
U.S. Department of Health and Human Services
200 Independence Ave., SW
Washington, DC 20201
202-619-0724
Elder Care Locator: 800-677-1116
www.aoa.gov

Last Updated: 11/16/2009
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