Starting Down the Road To Establishing a Driver Evaluation Program
Starting a driving evaluation program can broadly enhance the scope of services that your facility already offers.
Every state in the country is in need of additional driver evaluation programs. Because of the current high demand for this service, the anticipated growing need over the next 20 to 40 years with the highest number of older drivers ever, and a relatively low number of specialists working in this area, a driver evaluation program can flourish across a wide variety of occupational therapy facilities. Community mobility, which includes driving, is defined as an instrumental activity of daily living (IADL) in the Occupational Therapy Practice Framework: Domain and Process1 that is addressed not only in occupational therapy departments in hospital and rehabilitation settings, but also in community-based practices that specialize in other advanced specialty areas of occupational therapy such as low vision, home modifications, wheelchair and other assistive technology assessments, and aging-in-place evaluations.
Independence in the IADL of driving and community mobility can affect clients' occupational therapy outcomes. For example, if a person wishes to age in place, he or she must remain independent in community mobility, be it driving or learning to use alternative transportation. A person with low vision will have to seek out and learn to use new alternatives for transportation. A person who obtains a new wheelchair or scooter may have to learn how to load it into a vehicle or purchase a wheelchair-loading device.
Building a Foundation
When starting a driving program, a solid foundation must be established to insure that it will survive and be viable. There is no need to "re-invent the wheel," so to speak, as today we have a number of occupational therapists and occupational therapy assistants with experience in starting and running a driving program who can be an excellent resource for someone just getting involved in this specialty area.
The following steps are recommended as a guide for beginning the process of starting a driver evaluation program in an occupational therapy department or program.
Explore the need and support of the program in your community or surrounding region.
- Discuss the idea with physicians and other health professionals in your setting or who typically refer to your department, such as rehabilitation nurses, nurse case managers, insurance adjustors, or vocational rehabilitation counselors. A physician who understands the value of occupational therapy and driver rehabilitation can champion your program at professional meetings and when collaborating with other physicians.
- Quantify any expressed support by getting a potential number of referrals from the sources above.
- Make a list of the populations that would likely be referred to your program.
- Discuss potential funding from referral sources and inquire what they have paid in the past for this special service for their clients or what they would be willing to pay for the service, if it is new.
- In addition, there are possible referral sources from the following resources:
- Departments of driver licensing
- Car dealerships
- Senior centers
- Attorneys and judges
- American Automobile Association (AAA) and AARP local chapters
- Disability support groups
- Durable medical equipment dealers
- Eye care practitioners, including both optometrists and ophthalmologists
- Public and private school systems
- Independent living centers
- Public transportation companies
Explore any existing competition in your area.
- Does the program provide a comprehensive driver evaluation that includes both a clinical evaluation and an on-road assessment?
- How long has the program been in existence?
- How many people are involved in the program?
- What is the background of the persons performing the comprehensive driver evaluations? Does the program only use occupational therapists or a multidisciplinary team? Is the on-road assessment performed by a commercial driving school instructor, a driver educator, an occupational therapist, or other?
- What type of evaluation vehicles are used? What type of adaptive equipment is in the vehicles? (Some programs may have an evaluation car as well as an evaluation van to handle a variety of client needs.)
- Does the program provide driver education, driver training, or other intervention services related to driving and community mobility?
- What does the program charge for a driver evaluation? Is there a discount for private pay at the time of service if insurance does not cover it?
Draw a chart comparing any existing programs and the program that could be established at your facility. Compare the following:
- Specific diagnoses and age groups for which intervention is provided. For example, does your facility treat primarily older or younger adults?
- The level of expertise. Would your new program perform evaluations for persons who require a car or a van, or who require a car only? Would your program work with novice drivers as well as experienced drivers?
- The charges billed in each program, based on the type of service being provided. There is a wide variance of charges for a clinical evaluation and on-road assessment in the United States, depending on the location and whether the service is provided by an allied health professional or a nonprofessional, such as a commercial driving school instructor or a state-certified driver instructor. With a few exceptions, Medicare and private health insurance companies do not pay for occupational therapy driver rehabilitation services at this time, although this is expected to change in the future. Driving programs in states in which Medicare does not recognize driving as a medical necessity have the most chance of staying viable by providing older drivers with a fee-for-service option in addition to developing a consistent referral base with the funding available through state agencies of vocational rehabilitation and workers' compensation insurance companies that usually pay the billable charge for service. Clients sometimes receive funding assistance from their place of worship or via fundraising events in their communities. It is also worth exploring donations by local Boy or Girl Scout troops; service clubs such as the Shriners, the Elks, and Rotary clubs; and grant monies through nonprofit organizations, such as a Center for Independent Living.
Establish a professional development plan to become an occupational therapy driver rehabilitation specialist.
- Begin to collect and read professional journal articles, books, or other reference materials that are relevant to the driver rehabilitation or driver evaluation field. A bibliography and suggested readings can be found on AOTA's older driver microsite at www.aota.org/olderdriver/reading-room.html. See "For More Information" below for my recommendations for the top initial reading "musts."
- Attend a specialized educational workshop or course on driver rehabilitation services to increase your knowledge and skill level in this area. Check the Web sites at AOTA (www.aota.org), the Association for Driver Rehabilitation Specialists (ADED) (www.aded.net), and Adaptive Mobility Services (www.adaptivemobility.com).
- Attend a national symposium or professional conference whose focus is on driver rehabilitation services to remain current with this practice area and to network with other driver rehabilitation specialists around the country.
- Spend time with an expert in an established driver evaluation program to fine-tune your skills and techniques. You can find a listing of driver rehabilitation specialists and programs at the AOTA older driver microsite at www.aota.org/olderdriver/reading-room.html and the ADED Web site at www.aded.net.
- Develop a mentorship with an experienced occupational therapy driver rehabilitation specialist. You can find an occupational therapy driver rehabilitation specialist at AOTA's older driver microsite at www.aota.org/olderdriver/reading-room.html.
- Take a class in traffic safety or driver education to become familiar with driver education terminology and principles, road rules, and traffic safety issues. The occupational therapist must become an expert in analyzing the occupation of driving and its required performance skills and activity demands. Local resources may include your local department of motor vehicles office or state trooper organization, a high school driver education program, a traffic safety council office, a local AARP (www.aarp.org) or AAA (www.aaa.com) driver refresher course, ADED conference presentation, or educational workshops. It is also very important to learn in-vehicle skill and technique through a hands-on specialized workshop that provides in-vehicle practice.
- You do not have to be certified in driver rehabilitation to practice in this area, and the current certification programs require a minimum number of years of experience in the field. It is recommended that you prepare to enhance your professional credentials by working toward becoming certified as a driver rehabilitation specialist, either through AOTA or ADED. If your state requires it, you may have to become a certified driver instructor at the state level before performing any in-vehicle work. Check the American Association of Motor Vehicle Administrators at www.aamva.org for a list of state regulations.
Prepare Your Facility
After you have established the foundation for a driving program, you will need to ensure that your facility is prepared for this new practice area. For a new program, it is recommended that a car is purchased before a van so the occupational therapy driver rehabilitation specialist can start working with the simple mechanical adaptive equipment used in a car before the more high-technology equipment in a van. However, it should be recognized that some clients who do not require adaptive equipment have much more difficult problem areas to work on for driving in the visual and cognitive realms, and it can in fact be more difficult to work with them in the car.
It is recommended that you develop a 3-year plan for a new driving program with an initial scope being narrow and focused with plans to potentially expand to include a greater range of clients and adaptive equipment. Next, a budget for the program needs to be drawn up. Developing a budget for a driving program can be easier if the research suggested above has been completed so that your expenses will focus on the specific client needs that your program would service. A driving program that services clients who require a van has a much higher budget than other programs since a properly equipped evaluation van can cost $100,000. A driving program that will only serve clients driving a car will have a much lower budget. A very important aspect of planning for a driving program is funding for developing the knowledge and skill of the person who will be providing the service. The first-year budget should include money for specialized education and training for the occupational therapist or occupational therapy assistant in driver rehabilitation, at a minimum of $3,000 per person.
If you have done a good job in marketing, you should begin receiving referrals quickly. My final recommendation is to control the types of clients your program serves as it is getting established. Start simple and advance your practice into the more complex evaluations as you gain experience and expertise. For example, a person with minor aphasia and no motor involvement may be easier to begin with than a person who is impulsive and lacks insight. A 40-year-old person with a traumatic brain injury may be easier to work with than a 72-year-old person who has experienced a double amputation from diabetic neuropathy. By starting with a more targeted diagnostic group you can fine-tune your skills and program procedures, advance with confidence, and avoid getting in over your head.
Take inventory of the current clinical assessment tools and tests in your facility and develop a budget for additional tools, tests, and equipment that will be needed for the driver evaluation service. Evaluate their evidence-based support and standardized norms as well as administration efficiency and time. The established driving programs you visit may help you select tests to suit your client population. Most occupational therapy departments already have sufficient tools for evaluating physical and visual-perceptual performance skill areas. However, your budget will need to allow for the purchase of additional visual screening and cognitive tools and tests specific to driving for the particular ages that will be seen. It is reasonable to budget approximately $4,000 to $5,000 for additional clinical tools and tests, and approximately $20,000 to $25,000 for an appropriate evaluation car for on-road assessments (assuming that a new car will be purchased). A used car could also be used, which would decrease this cost significantly. Start-up adaptive driving and dual-control equipment needed for an evaluation car may cost as little as $2,500. If a new car is purchased, some vehicle manufacturers offer up to between $750 and $2,000 in rebates to purchase adaptive equipment for a driver education vehicle. Do some research with other programs to determine which vehicles would be best suited for the types of drivers you anticipate would enroll in your program (i.e., a bench seat allows better access for intervention and on-road evaluations). Some driving programs use an outside service to provide the on-road assessment, in which case the purchase of a vehicle would not be necessary.
Develop marketing materials, such as a brochure and business cards. Stationery and envelopes for the program will also be needed, unless this is already available at the facility. Develop program forms such as a referral form, medical approval form, client waiver form, and report forms for the clinical evaluation and on-road assessment.
Multiple means of communication are very important for a driving program, and they can make many time-consuming tasks more efficient. The minimal requirements are a private telephone for the driving office (with its own number, if possible), an answering machine, and a fax machine. A computer and access to the Internet for additional resources and for e-mail, along with quick access to a copying machine, are also very valuable. A laptop may be helpful if the occupational therapist partners with the driving instructor, who could be in the front seat with the driver, while the therapist observes and documents from the back seat.
Develop a professional liability plan to reduce liability and enhance risk management. A therapist and employer's liability is minimal if driving program staff:
- Have knowledge of the field.
- Develop skill in performing the duties of a driver rehabilitation specialist.
- Follow safe and accepted practices in the field of driver rehabilitation.
- Remain up-to-date and current with the field of occupational therapy and driver rehabilitation or evaluation.
- Prepare accurate, inclusive documentation.
- Have personal professional liability insurance.
- Develop a routine vehicle maintenance program. Vehicle insurance and liability insurance for the program can be a challenge to set up; using the AOTA driving listserv and ADED bulletin board to share information with others in the driver rehab field can be invaluable.
Collect marketing tools and develop a marketing plan to educate all referral sources, both in-house and out-of-house. A great marketing tool is a PowerPoint presentation with pictures or a video; however, be sure your PowerPoint slides complement your presentation, rather than repeating the information. The video Mobility Assessment Program, developed by Linda Hunt, PhD, OTR, follows a client with impairments participating in an occupational therapy driving assessment. It provides medical staff or referral sources with insight into a client being evaluated and may help clinicians describe the driving evaluation process to clients and their families (see For More Information). Be sure to distribute the program's brochures, business cards, and referral forms during in-services with referral sources.
If you have followed the above steps, you should be on the road to developing a comprehensive driver evaluation program. The program can service many persons in your community and state who have specific diagnoses or disabilities, who are aging with various impairments, or who are well-elderly and require assistance for driving or using transportation alternatives for as long as possible.
Helping a person to obtain his or her first driver license, maintain driving privileges, or remain living independently by using alternative transportation options is an exciting part of being an occupational therapy driver rehabilitation specialist. The rewards are so great, and the challenges are so varied. The occupational therapist must use all of his or her knowledge and skill in evaluation, intervention, analysis of occupational performance, and interview techniques and observation, along with critical thinking strategies. If you are an independent, creative, dynamic therapist with a holistic perspective and can understand the entire occupation of driving and community mobility, I challenge you to come on board and start down the path of developing a driving program. I hope to see you around the corner.
1. American Occupational Therapy Association. (2002). Occupational therapy practice framework: Domain and process. American Journal of Occupational Therapy, 56, 609-639.
Susan Pierce, OTR/L, CDRS, has more than 26 years of full-time experience in driver rehabilitation services. She developed driver rehabilitation programs in Georgia, Louisiana, and Florida before starting her own business, Adaptive Mobility Services, Inc. in 1990. In 2003 she was invited by AOTA to serve on an expert panel for advice on the Association's older driver initiatives and currently is serving on the Specialty Certification Panel.
For More Information
Assessment of Driving Capacity: Handbook of Geriatric Assessment
By L. A. Hunt & K. Weston, 1999. New York: Wiley. (An overview of how to assess elderly drivers.)
Driving Performance in Persons With Mild Senile Dementia of the Alzheimer Type
By L. A. Hunt, J. C. Morris, D. F. Edwards, & B. Wilson, 1993. Journal of the American Geriatrics Society, 41, 747-753. (This was the first research conducted by an occupational therapist that actually examined on-road performance in healthy older persons and elderly persons with dementia.)
Driver Rehabilitation: An Occupational Therapy Guide
By S. Redepenning, 2005. Bethesda, MD: American Occupational Therapy Association. ($39 for members, $55 for nonmembers. To order, call toll free 877-404-AOTA or shop online at www.aota.org. Order #1237-MI)
Driving Rehabilitation: A Guide for Assessment and Intervention
By W. Stav, 2004. San Antonio, TX: PsychCorp. ($49.95 for members, $70.95 for nonmembers. To order, call toll free 877-404-AOTA or shop online at www.aota.org. Order #1316-MI)
Environmental Cueing May Affect Performance on a Road Test for Drivers With Dementia of the Alzheimer Type
By L. A. Hunt, C. F. Murphy, D. Carr, J. M. Duchek, V. Buckles, & J. C. Morris, 1997. Alzheimer Disease and Associated Disorders, 11(Suppl. 1), 13-16. (This article shows that the road test can be deceptive and that clinical tests must also be considered in the decision-making process.)
Physician's Guide to Assessing and Counseling Older Drivers
By the American Medical Association and the National Highway Transportation Safety Board, 2003. Available free from www.ama-assn.org/go/olderdrivers or www.nhtsa.dot.gov.
Reliability of the Washington University Road Test. A Performance-Based Assessment for Drivers With Dementia of the Alzheimer Type
By L. A. Hunt, C. F. Murphy, D. Carr, J. M. Duchek, V. Buckles, & J. C. Morris, 1997. Archives of Neurology, 54, 707-712. (The road test is based on activity analysis of the critical driving behaviors that the elderly have difficulty with, and it shows that a road test can be reliable from one evaluator to the next.)
Restoring Competence in Mobility
By S. Pierce, 2001. In C. A. Trombly & M. V. Radomski (Eds.), 2001. Occupational therapy for physical dysfunction (5th ed.; chapter 31). Philadelphia: Lippincott Williams & Wilkins.
American Automobile Association (AAA)
www.aaa.com and www.aaafoundation.org or www.seniordrivers.org
American Occupational Therapy Association Driving Microsite
Association for Driver Rehabilitation Specialists (ADED)
AOTA Online Course: Driving and Community Mobility for Older Adults: Occupational Therapy Roles
S. L. Pierce & L. A. Hunt (faculty), 2005. Bethesda, MD: American Occupational Therapy Association. Earn .5 AOTA CEUs (5 PDUs/5 contact hours). $112.50 for members, $160 for nonmembers. To order, go to www.aota.org and click on Continuing Education. Order #OL25-MI. (A great start for any occupational therapist or occupational therapy assistant is this new AOTA online course, which defines in detail the role of the occupational therapist in addressing driving and community mobility. Whether you want to transition into the driver rehabilitation specialist's role or need to know how to address driving and community mobility as a generalist, this course is an excellent start to learning the what, how, and why.)
AOTA Online Course: Promoting Safety and Independence Through Older Driver Wellness
Three-part seminar. For more information go to www.aota.org and click on Continuing Ed
National Highway Traffic Safety Administration
National Institute on Aging
Adaptive Mobility Services, Inc.
Series of specialized educational workshops in driver rehabilitation. For information go to www.adaptivemobility.com/occupational_therapy_workshops.html
Mobility Assessment Program and Partners in Safety (Videos)
Developed by L. Hunt, the first follows a client with impairments participating in an occupational therapy driving assessment and may help clinicians describe the driving evaluation process to clients and their families. The second addresses how occupational therapy practitioners can work with law enforcement officials, licensing agency staff, and physicians to evaluate older drivers who are noted as impaired when driving. The videos are available as a set for $49.95 by contacting Linda Hunt at email@example.com or 406-751-6965.
Pierce, S. (2005). Starting down the road to establishing a driver evaluation program [Electronic Version]. OT Practice, 10(10), 10-15.
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