Occupational Therapy In Health Care, 28(2):177–187, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.903582
OUTCOMES RESULTING FROM THE GAPS AND PATHWAYS PROJECT
Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise Amy Lane1 , Elizabeth Green1 , Anne E. Dickerson2 , Elin Schold Davis3 , Beth Rolland1 , & Janet T. Stohler1 1
The Association for Driver Rehabilitation Specialists, Hickory, North Carolina, USA, 2 Occupational Therapy Department, East Carolina University, Greenville, North Carolina, USA, 3 American Occupational Therapy Association, Bethesda, Maryland, USA
ABSTRACT. This paper highlights the critical need for a diverse span of services targeted at older drivers that is clear and understandable to health care professionals, service providers, and consumers. The paper describes how a panel of expert driver rehabilitation specialists and researchers on older drivers affirmed consensus statements addressing the need for clarification of terms and services. It also presents a new document that describes a spectrum of driver services from education to specific driver rehabilitation services. The document will provide consumers, referral sources, payers, and stakeholders invested in older drivers’ services, with the information to refer the right people to the right service at the right time. KEYWORDS.
Driver rehabilitation, driving, older adults, terminology
BACKGROUND Driver rehabilitation programs across North America and worldwide provide a range of services related to driving and community mobility needs for individuals with disabilities or persons whose critical driving skills are significantly affected by medical or age-related changes. Typically, these programs offer driving skills assessment, education, and training in the use of adaptive driving equipment, and experience in using adaptive motor vehicles. The services can differ based on the program’s history, setting, staffing of personnel, as well as the skills and expertise of the providers of services. Differentiating the services offered within program models all broadly referred to as Driver Rehabilitation Programs may be challenging for the consumers, referral sources, researchers, and other stakeholders (e.g., licensing authorities and health care providers), especially when attempting to establish effective and efficient referral pathways. Address correspondence to: Anne E. Dickerson, Occupational Therapy, East Carolina University, Greenville, NC, USA. (E-mail: [email protected]). (Received 17 February 2014; accepted 9 March 2014)
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For those practitioners directly working in the field of driver rehabilitation, there is a mutual understanding of terms used to describe basic to complex programs and the expertise required to offer such a range of services. As programs have grown to address older driver safety, the terminology used to describe and differentiate has lagged behind. As an example, driving education, driving schools, and driver rehabilitation programs may all use similar terms to describe distinctly different services. For many consumers, the current use of terminology related to driver rehabilitation programs can seem ambiguous and confusing particularly when comparing costs or making decisions to travel for specialized services. Furthermore, for stakeholders studying or describing driver rehabilitation (e.g., physicians, licensing agencies, transportation researchers), the same words may have distinctly different meanings (see Dickerson, Schold Davis, & Staplin in this issue). For example, because driving evaluation is the title, a family practice physician may be led to believe an online driver screening tool holds about the same value as an evaluation by a driving instructor at a driving school or a comprehensive driving evaluation by a driver rehabilitation specialist (DRS). Likewise a health care professional, or a person with a spinal cord injury, investigating returning to driving may not realize the value of the services of a DRS who has the skills and knowledge to evaluate and train a person in the use of hand controls over a driving instructor who is trained in traffic safety education. Thus, it is not surprising that with the diversity of programs available, consumers and stakeholders have difficulty determining which driver rehabilitation or driver safety programs is the one most appropriate to meet an individual’s needs. Lack of clear program terminology can lead to inconsistent translation of services and may lead individuals to ineffective or inefficient services that may not meet their needs. In recognition of these gaps and in preparation for the expert panel meeting, the need was identified to clarify and define driver rehabilitation programs, identify types of services, and categorize levels of provider knowledge and credentials. Initial Surveys of Program Models The “gap” in terminology was first identified as the authors of the American Occupational Therapy Association’s (AOTA) Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (Maguire & Schold Davis, 2012) found it impossible to create an inclusive list of distinct program models complete with descriptions of the services consumers could expect and the training required for the personnel offering those services. It was clear that single terms were used to describe a range of distinctly different services. In November of 2011, the authors asked a select group of DRSs to generate possible names to describe different models of driving programs. Working in collaboration with the leadership of The Association for Driver Rehabilitation Specialists (ADED) and using these initial findings, an electronic survey (specifically, QualtricsTM through East Carolina University) was sent via email to a small sample of 27 driver rehabilitation professionals and occupational therapists. They were invited to review descriptions of different levels of programs and generate potential titles of programs using this electronic survey program. Based on this initial pilot work, a comprehensive survey was created to gather membership wide input and build consensus about terminology used to differentiate programs. In February 2012, this Qualtrics electronic survey was sent to all active members of ADED,
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which was comprised of a mix of disciplines including occupational therapy, health care practitioners, and traffic safety educators practicing in diverse settings. Six short descriptions of different types of driver evaluation and driver rehabilitation programs were presented in the survey and the participants were instructed to read each description and indicate which title would best describe each program. Respondents were also offered an open-ended comment option to suggest an alternative title (see Figure 1 for a timeline of the development). Results About a third, 32% (n = 145) of the approximately 450 ADED members responded. The majority of the respondents (n = 83) were certified DRSs with allied health backgrounds. Results from the survey clearly supported the need to define program models, as there was no clear consistency or consensus in responses. The range of responses generated in the open-ended comment section reinforced the complexity and diversity of programs and services that might be considered a “driver rehabilitation program.” Although short program titles were preferred (e.g., Driver Rehabilitation Program), they did not accurately differentiate services for public understanding. On the other hand, the lengthy definitions, while describing program providers and services, tended to be overly cumbersome (e.g., Collaborative Occupational Therapy/Driving School Evaluation and Rehabilitation Program). Additional issues that emerged from the survey included questions about what type of practitioner could provide various services, and at what level of training, experience, and expertise. For example, not all health care providers are adept at training a person in the use of highly technical adaptive driving equipment, nor are all traffic safety educators aware of the implications of evaluating and training a person with a medical condition such as stroke or dementia. Additionally, respondents also questioned what level of training or expertise was required to use the term DRS as a credential. Reviewing and discussing these survey results with the expert panel lead to the formation of consensus statements to guide future driver rehabilitation practice. These consensus statements are listed in Table 1.
TABLE 1. Affirmed Consensus Statements in Relation to the Terms and Definitions of Driver Rehabilitation Programs and Services • Language/terminology is an issue and we want to strive to be consistent so that the community and other professionals understand and this is a priority for future work. • There is a need to differentiate programs based on their levels of service and compliance with ADED1 Best Practices. • If program models are clearly defined, then there is a need for improved and understandable descriptors/definitions for the public and other stakeholders. • There is a need to identify a level of education, training, or experience to use DRS2 as a credential. • There is a clear need for clear definition of DRS and who can use this title as compare to those who use the CDRS3 title. • There is a need to explore the training and expertise required of a provider offering a driver rehabilitation program. 1. The Association for Driver Rehabilitation Specialists 2. Driver rehabilitation specialist. 3. Certified Driver Rehabilitation Specialist. Note: These consensus statements were confirmed by a group of researchers in driving and expert driver rehabilitation specialists, March 2012.
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FIGURE 1. Timeline Describing the Developmental Process to Develop the Spectrum of Driver Services Table. Note: DR = Driver Rehabilitation; DRS = Driver Rehabilitation Specialists; ADED is The Association for Driver Rehabilitation Specialists; AOTA is the American Occupational Therapy Association; TRB is the Transportation Research Board of the National Academies.
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Typical services provided
Required Provider’s knowledge
Typical providers and credentials
Program type
Driving school
Driver screen
Enhance driving Classroom or computer-based performance Acquire driver refresher for licensed drivers: permit or license
(1) Evaluate and interpret risks associated (1) Counsel on risks with changes in vision, cognition, and associated with specific sensory-motor functions due to acute conditions (e.g., or chronic conditions. medications, fractures, and postsurgery).
Occupational Therapy Practitioner (Generalist or Driver Rehabilitation Specialist# ) Other health professional degree with expertise in Instrumental Activities of Daily Living (IADL). Knowledge of medical conditions and the implication for community mobility including driving. Assess the cognitive, visual, perceptual, behavioral, and physical limitations that may impact driving performance. Knowledge of available services. Understands the limits and value of assessment tools, including simulation, as a measurement of fitness to drive.
Clinical IADL evaluation
Medically Based Assessment, Education, and Referral
Health care professional Program-specific Licensed Driving (e.g., physician, social credentials (e.g., Instructor (LDI) worker, and certified by state AARP and AAA neuropsychologist) licensing agency Driver or Dept. of Improvement Education Program) Program-specific Instructs novice or Knowledge of relevant relocated drivers, knowledge. medical conditions, Trained in course excluding assessment, referral, content and medical or aging and/or intervention delivery. conditions that processes. might interfere Understand the limits and with driving, for value of assessment purposes of tools, including teaching/training/ simulation, as a refreshing/ measurement of fitness updating driving to drive. skills.
Driver safety programs
Community-Based Education
(Continued on next page)
Applies knowledge of medical conditions with implications to driving. Assesses the cognitive, visual, perceptual, behavioral, and physical limitations that may impact driving performance. Integrates the clinical findings with assessment of on-road performance. Synthesizes client and caregiver needs, assist in decisions about equipment, and vehicle modification options available. Coordinates multidisciplinary providers and resources, including driver education, health care team, vehicle choice and modifications, community services, funding/payers, driver licensing agencies, training and education, and caregiver support. Programs are distinguished by complexity of evaluations, types of equipment, vehicles, and expertise of provider.
Driver Rehabilitation Specialist# , Certified Driver Rehabilitation Specialist∗ , Occupational Therapist with Specialty Certification in Driving and Community Mobility+ .
Specialized Evaluation and Training Driver rehabilitation programs (includes driver evaluation)
TABLE 2. Spectrum of Driver Services: Right Services for the Right People at the Right Time A description consumers and health care providers can use to distinguish the type of services needed for an older adult.
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Program type
Driving school
Driver screen
Clinical IADL evaluation
Medically Based Assessment, Education, and Referral
review of rules Counsel with family (2) Investigate driving risk (2) Facilitate remediation of deficits to advance client readiness for driver associated with members for of the road, rehabilitation services. changes in vision, student driver driving (3) Develop an individualized transportation cognition, and skill development techniques, plan considering client diagnosis and sensory-motor function. Recommend driving risks, family, caregiver, environmental, (3) Determine actions for continued strategies, state and community options and limitations: the at-risk driver: training and/or laws, etc. Refer to IADL evaluation, Discuss resources for vehicle adaptations undergoing Enhanced (e.g., scooter lift). driver rehabilitation licensing test. self-awareness, Facilitate client training on community program, and/or other Remedial Programs choices, and transportation options (e.g., mobility services. (e.g., license capability to managers and dementia-friendly Discuss driving cessation; reinstatement self-limit. transportation). provide access to course for Discuss driving cessation. For clients with counseling and teens/adults and poor self-awareness, collaborate with education for alternative license point caregivers on cessation strategies. transportation options. reduction (4) Follow reporting/referral Refer to driver rehabilitation program. courses) structure for licensing (4) Document driver safety risk and recommended intervention plan to recommendations. guide further action. (5) Follow professional ethics on referrals to the driver licensing authority.
Driver safety programs
Community-Based Education
Navigate driver license compliance and basic eligibility through intake of driving and medical history. Evaluate and interpret risks associated with changes in vision, cognition, and sensory-motor functions in the driving context by the medically trained provider. Perform a comprehensive driving evaluation (clinical and on-road). Advises client and caregivers about evaluation results, and provides resources, counseling, education, and/or intervention plan. Intervention may include training with compensatory strategies, skills, and vehicle adaptations or modifications for drivers and passengers. Advocates for clients in access to funding resources and/or reimbursement. Provide documentation about fitness to drive to the physician and/or driver-licensing agency in compliance with regulations. Prescribe equipment in compliance with state regulations and collaborate with Mobility Equipment Dealerˆ for fitting and training.
Specialized Evaluation and Training Driver rehabilitation programs (includes driver evaluation)
TABLE 2. Spectrum of Driver Services: Right Services for the Right People at the Right Time A description consumers and health care providers can use to distinguish the type of services needed for an older adult. (Continued)
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Provides education and awareness
Enhances skills for Indicates risk or need for follow-up for medically at-risk drivers healthy drivers.
Determines fitness to drive and provides rehabilitative services.
#DRS – Health professional degree with specialty training in driver evaluation and rehabilitation, ∗ CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation Specialists) +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ˆQuality Approved Provider by NMEDA (National Mobility Equipment Dealers Association). Table 2 is used with permission by AOTA/NHSTA/ADED.
Outcome
Present resources and options for continued community mobility if recommending driving cessation or transition from driving. Recommendations may include (but not restricted to): (1) drive unrestricted; (2) drive with restrictions; (3) cessation of driving pending rehabilitation or training; (4) planned reevaluation for progressive disorders; (5) driving cessation; and (6) referral to another program.
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BASIC HIGH TECH LOW TECH Provider is a driver rehabilitation Driver Rehabilitation Specialist# , Certified Driver Driver Rehabilitation Specialist# , Certified Driver specialist (DRS)# with professional Rehabilitation Specialist∗ , Occupational Therapist Rehabilitation Specialist∗ , Occupational Therapist with background in occupational with Specialty Certification in Driving and Specialty Certification in Driving and Community therapy, other allied health field, Community Mobility+ , or in combination with LDI. Mobility+ . driver education, or a professional Certification in Driver Rehabilitation is recommended Certification in Driver Rehabilitation is recommended as team of CDRS or SCDCM with as the provider for comprehensive driving evaluation the provider for comprehensive driving evaluation and LDI∗∗ . and training. training with advanced skills and expertise to complete complex client and vehicle evaluation and training. Offers comprehensive driving evaluation, training, and Offers a wide variety of adaptive equipment and vehicle Offers comprehensive driving education, with or without adaptive driving aids that options for comprehensive driving evaluation, training evaluation, training, and and education, including all services available in a affect the operation of primary or secondary education. controls, vehicle ingress/egress, and mobility device “LOW TECH” and Basic programs. At this level, May include use of adaptive driving providers have the ability to alter positioning of primary storage/securement. May include use of adaptive aids that do not affect operation and secondary controls based on client’s need or driving aids such as seat cushions or additional of primary or secondary controls ability level. mirrors. (e.g., seat cushions or additional At the low tech level, adaptive equipment for primary High tech adaptive equipment for primary and secondary mirrors). controls includes devices that meet the following control is typically mechanical. Secondary controls May include transportation planning conditions: may include wireless or remote access. (transition and options), cessation (1) capable of controlling vehicle functions or driving planning, and recommendations May include transportation planning (transition and options), cessation planning, and recommendations controls, and for clients as passengers. (2) consists of a programmable computerized system that for clients as passengers. interfaces/integrates with an electronic system in the vehicle. Requires independent transfer into Addresses transfers, seating, and position into OEMˆ Access to the vehicle typically requires ramp or lift and may require adaptation to OEM driver’s seat. Access to OEMˆ driver’s seat in vehicle. driver’s seat. May make recommendations for driver position may be dependent on use of a transfer assistive devices to access driver’s seat, improved positioning, wheelchair securement systems, and/or seat base, or clients may drive from their wheelchair. Provider evaluates and recommends vehicle structural mechanical wheelchair loading devices. modifications to accommodate products such as ramps, lifts, wheelchair and scooter hoists, transfer seat bases, wheelchairs suitable to utilize as a driver seat, and/or wheelchair securement systems.
Levels of program and typical provider credentials
Access to driver’s position
Program service
Driver rehabilitation programs Administers comprehensive driving evaluation to determine fitness to drive and/or provides rehabilitative services.
Program type
TABLE 3. Spectrum of Driver Rehabilitation Program Services A description consumers and health care providers can use to distinguish the services provided by driver rehabilitation programs which best fits a client’s need.
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Secondary driving control examples: (A) remote horn button; (B) turn signal modification (remote and crossover lever); (C) remote wiper controls; (D) gear selector modification; (E) key/ignition adaptions.
Uses OEMˆ controls.
Typical vehicle modification: secondary controls
Primary driving control examples (in addition to low tech options): (A) powered gas/brake systems; (B) power park brake integrated with a powered gas/brake system; (C) variable effort steering systems; (D) Reduced diameter steering wheel, horizontal steering, steering wheel extension, and joystick controls; (E) reduced effort brake systems. Electronic systems to access secondary and accessory controls. Secondary driving control examples (in addition to low tech options): (A) remote panels, touch pads, or switch arrays that interface with OEM∗ electronics; (B) wiring extension for OEMˆ electronics; (C) powered transmission shifter.
# DRS – Health professional degree with specialty training in driver evaluation and rehabilitation, ∗ CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation Specialists) +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ˆOEM-Original Equipment installed by Manufacturer. Reference: NMEDA Guidelines http://www.nmeda.com. ∗∗ LDI – licensed driving instructor.
Primary driving control examples: (A) mechanical gas/brake hand control; (B) left foot accelerator pedal; (C) pedal extensions; (D) park brake lever or electronic park brake; (E) steering device (spinner knob, tri-pin, and C-cuff).
Uses OEMˆ controls.
Typical vehicle modification: primary controls: gas, brake, and steering
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Development of Spectrum of Driver Services Based on the consensus statements affirmed by the expert panel and the identified “gap” that terminology was unclear, a project was designed to bring together members of ADED and the AOTA to develop a document to describe and differentiate older driver rehabilitation services and programs. Over the next 18 months, regularly scheduled conference calls led to a draft table that distinguished programs based on their levels of service, as well as who provided those service. With the support of the Gaps and Pathways Project, representatives from the National Highway Traffic Safety Administration (NHSTA), AOTA, and ADED met in September 2013 to synthesize input gathered from stakeholder groups (e.g., ADED membership, AOTA membership, Transportation Research Board) and finalize the document. Taking the document one step further, the members from ADED worked to further clarify differences between levels of Driver Rehabilitation Programs differentiating services, vehicle modifications, and the complexity of technology used in driver rehabilitation. The Spectrum of Driver Services Table is the result of this endeavor (see Tables 2 and 3). It is the intention of the authors that this first version will generate discussion and feedback from the various programs and providers whose services it reflects; reflecting this 2014 version as a “living document” with anticipated revisions. The purpose of this document is to provide physicians and other health care professionals; consumers, family members, and caregivers; DRSs; providers of aging services; governing bodies such as licensing agencies; and stakeholder groups invested in providing older driver information (e.g., AARP, AAA, and Hartford Insurance) with the information needed to advise the most appropriate level of service for older drivers.
SUMMARY Quality services at the appropriate level are critical to meet the needs of older adults who want to continue to drive to maintain their independence, health, and life satisfaction. Not all older adults need driver rehabilitation services; however, those with medical conditions affecting driving abilities should seek the professional DRS who can best evaluate and assist in determining the need for training, rehabilitation, and/or adaptive equipment. The Expert Panel affirmed six consensus statements documenting the need for clarification of terms and services. One of the identified gaps was designated as a project bringing together an AOTA and ADED collaborative work group to develop the Spectrum of Driver Services Table described in this paper. It is hoped the document will be a useful tool to guide consumers, referral sources, and payers in referring the right people to the right service at the right time. Future practitioners can use the Spectrum of Driver Services Table to guide career development in the field of driver rehabilitation while researchers may refer to this document as a framework to identify the different settings in which driving rehabilitation programs operate. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.
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ABOUT THE AUTHORS Amy Lane, OTR/L, CDRS, is President of ADED, Hickory, North Carolina. E-mail: [email protected]. Elizabeth Green, OTR/L, CDRS is Executive Director of ADED, E-mail: [email protected]. Anne E. Dickerson is Professor, Department of Occupational Therapy, East Carolina University, Greenville, NC. E-mail: [email protected]. Elin Schold Davis, OTR/L, CDRS, is Coordinator of the Older Driver Initiative, AOTA, Bethesda, MD, E-mail: [email protected]. Beth Rolland, OTR/L, CDRS and Janet T. Stohler, OTR/L, CDRS, CDI are both on the Executive Board of ADED. REFERENCE Maguire MJ & Schold Davis E. (2012). Driving and community mobility: Occupational therapy strategies across the lifespan. Bethesda, MD: AOTA Publishing.
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OUTCOMES RESULTING FROM THE GAPS AND PATHWAYS PROJECT
Driver Rehabilitation Programs: Defining Program Models, Services, and Expertise Amy Lane1 , Elizabeth Green1 , Anne E. Dickerson2 , Elin Schold Davis3 , Beth Rolland1 , & Janet T. Stohler1 1
The Association for Driver Rehabilitation Specialists, Hickory, North Carolina, USA, 2 Occupational Therapy Department, East Carolina University, Greenville, North Carolina, USA, 3 American Occupational Therapy Association, Bethesda, Maryland, USA
ABSTRACT. This paper highlights the critical need for a diverse span of services targeted at older drivers that is clear and understandable to health care professionals, service providers, and consumers. The paper describes how a panel of expert driver rehabilitation specialists and researchers on older drivers affirmed consensus statements addressing the need for clarification of terms and services. It also presents a new document that describes a spectrum of driver services from education to specific driver rehabilitation services. The document will provide consumers, referral sources, payers, and stakeholders invested in older drivers’ services, with the information to refer the right people to the right service at the right time. KEYWORDS.
Driver rehabilitation, driving, older adults, terminology
BACKGROUND Driver rehabilitation programs across North America and worldwide provide a range of services related to driving and community mobility needs for individuals with disabilities or persons whose critical driving skills are significantly affected by medical or age-related changes. Typically, these programs offer driving skills assessment, education, and training in the use of adaptive driving equipment, and experience in using adaptive motor vehicles. The services can differ based on the program’s history, setting, staffing of personnel, as well as the skills and expertise of the providers of services. Differentiating the services offered within program models all broadly referred to as Driver Rehabilitation Programs may be challenging for the consumers, referral sources, researchers, and other stakeholders (e.g., licensing authorities and health care providers), especially when attempting to establish effective and efficient referral pathways. Address correspondence to: Anne E. Dickerson, Occupational Therapy, East Carolina University, Greenville, NC, USA. (E-mail: [email protected]). (Received 17 February 2014; accepted 9 March 2014)
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For those practitioners directly working in the field of driver rehabilitation, there is a mutual understanding of terms used to describe basic to complex programs and the expertise required to offer such a range of services. As programs have grown to address older driver safety, the terminology used to describe and differentiate has lagged behind. As an example, driving education, driving schools, and driver rehabilitation programs may all use similar terms to describe distinctly different services. For many consumers, the current use of terminology related to driver rehabilitation programs can seem ambiguous and confusing particularly when comparing costs or making decisions to travel for specialized services. Furthermore, for stakeholders studying or describing driver rehabilitation (e.g., physicians, licensing agencies, transportation researchers), the same words may have distinctly different meanings (see Dickerson, Schold Davis, & Staplin in this issue). For example, because driving evaluation is the title, a family practice physician may be led to believe an online driver screening tool holds about the same value as an evaluation by a driving instructor at a driving school or a comprehensive driving evaluation by a driver rehabilitation specialist (DRS). Likewise a health care professional, or a person with a spinal cord injury, investigating returning to driving may not realize the value of the services of a DRS who has the skills and knowledge to evaluate and train a person in the use of hand controls over a driving instructor who is trained in traffic safety education. Thus, it is not surprising that with the diversity of programs available, consumers and stakeholders have difficulty determining which driver rehabilitation or driver safety programs is the one most appropriate to meet an individual’s needs. Lack of clear program terminology can lead to inconsistent translation of services and may lead individuals to ineffective or inefficient services that may not meet their needs. In recognition of these gaps and in preparation for the expert panel meeting, the need was identified to clarify and define driver rehabilitation programs, identify types of services, and categorize levels of provider knowledge and credentials. Initial Surveys of Program Models The “gap” in terminology was first identified as the authors of the American Occupational Therapy Association’s (AOTA) Driving and Community Mobility: Occupational Therapy Strategies Across the Lifespan (Maguire & Schold Davis, 2012) found it impossible to create an inclusive list of distinct program models complete with descriptions of the services consumers could expect and the training required for the personnel offering those services. It was clear that single terms were used to describe a range of distinctly different services. In November of 2011, the authors asked a select group of DRSs to generate possible names to describe different models of driving programs. Working in collaboration with the leadership of The Association for Driver Rehabilitation Specialists (ADED) and using these initial findings, an electronic survey (specifically, QualtricsTM through East Carolina University) was sent via email to a small sample of 27 driver rehabilitation professionals and occupational therapists. They were invited to review descriptions of different levels of programs and generate potential titles of programs using this electronic survey program. Based on this initial pilot work, a comprehensive survey was created to gather membership wide input and build consensus about terminology used to differentiate programs. In February 2012, this Qualtrics electronic survey was sent to all active members of ADED,
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which was comprised of a mix of disciplines including occupational therapy, health care practitioners, and traffic safety educators practicing in diverse settings. Six short descriptions of different types of driver evaluation and driver rehabilitation programs were presented in the survey and the participants were instructed to read each description and indicate which title would best describe each program. Respondents were also offered an open-ended comment option to suggest an alternative title (see Figure 1 for a timeline of the development). Results About a third, 32% (n = 145) of the approximately 450 ADED members responded. The majority of the respondents (n = 83) were certified DRSs with allied health backgrounds. Results from the survey clearly supported the need to define program models, as there was no clear consistency or consensus in responses. The range of responses generated in the open-ended comment section reinforced the complexity and diversity of programs and services that might be considered a “driver rehabilitation program.” Although short program titles were preferred (e.g., Driver Rehabilitation Program), they did not accurately differentiate services for public understanding. On the other hand, the lengthy definitions, while describing program providers and services, tended to be overly cumbersome (e.g., Collaborative Occupational Therapy/Driving School Evaluation and Rehabilitation Program). Additional issues that emerged from the survey included questions about what type of practitioner could provide various services, and at what level of training, experience, and expertise. For example, not all health care providers are adept at training a person in the use of highly technical adaptive driving equipment, nor are all traffic safety educators aware of the implications of evaluating and training a person with a medical condition such as stroke or dementia. Additionally, respondents also questioned what level of training or expertise was required to use the term DRS as a credential. Reviewing and discussing these survey results with the expert panel lead to the formation of consensus statements to guide future driver rehabilitation practice. These consensus statements are listed in Table 1.
TABLE 1. Affirmed Consensus Statements in Relation to the Terms and Definitions of Driver Rehabilitation Programs and Services • Language/terminology is an issue and we want to strive to be consistent so that the community and other professionals understand and this is a priority for future work. • There is a need to differentiate programs based on their levels of service and compliance with ADED1 Best Practices. • If program models are clearly defined, then there is a need for improved and understandable descriptors/definitions for the public and other stakeholders. • There is a need to identify a level of education, training, or experience to use DRS2 as a credential. • There is a clear need for clear definition of DRS and who can use this title as compare to those who use the CDRS3 title. • There is a need to explore the training and expertise required of a provider offering a driver rehabilitation program. 1. The Association for Driver Rehabilitation Specialists 2. Driver rehabilitation specialist. 3. Certified Driver Rehabilitation Specialist. Note: These consensus statements were confirmed by a group of researchers in driving and expert driver rehabilitation specialists, March 2012.
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FIGURE 1. Timeline Describing the Developmental Process to Develop the Spectrum of Driver Services Table. Note: DR = Driver Rehabilitation; DRS = Driver Rehabilitation Specialists; ADED is The Association for Driver Rehabilitation Specialists; AOTA is the American Occupational Therapy Association; TRB is the Transportation Research Board of the National Academies.
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Typical services provided
Required Provider’s knowledge
Typical providers and credentials
Program type
Driving school
Driver screen
Enhance driving Classroom or computer-based performance Acquire driver refresher for licensed drivers: permit or license
(1) Evaluate and interpret risks associated (1) Counsel on risks with changes in vision, cognition, and associated with specific sensory-motor functions due to acute conditions (e.g., or chronic conditions. medications, fractures, and postsurgery).
Occupational Therapy Practitioner (Generalist or Driver Rehabilitation Specialist# ) Other health professional degree with expertise in Instrumental Activities of Daily Living (IADL). Knowledge of medical conditions and the implication for community mobility including driving. Assess the cognitive, visual, perceptual, behavioral, and physical limitations that may impact driving performance. Knowledge of available services. Understands the limits and value of assessment tools, including simulation, as a measurement of fitness to drive.
Clinical IADL evaluation
Medically Based Assessment, Education, and Referral
Health care professional Program-specific Licensed Driving (e.g., physician, social credentials (e.g., Instructor (LDI) worker, and certified by state AARP and AAA neuropsychologist) licensing agency Driver or Dept. of Improvement Education Program) Program-specific Instructs novice or Knowledge of relevant relocated drivers, knowledge. medical conditions, Trained in course excluding assessment, referral, content and medical or aging and/or intervention delivery. conditions that processes. might interfere Understand the limits and with driving, for value of assessment purposes of tools, including teaching/training/ simulation, as a refreshing/ measurement of fitness updating driving to drive. skills.
Driver safety programs
Community-Based Education
(Continued on next page)
Applies knowledge of medical conditions with implications to driving. Assesses the cognitive, visual, perceptual, behavioral, and physical limitations that may impact driving performance. Integrates the clinical findings with assessment of on-road performance. Synthesizes client and caregiver needs, assist in decisions about equipment, and vehicle modification options available. Coordinates multidisciplinary providers and resources, including driver education, health care team, vehicle choice and modifications, community services, funding/payers, driver licensing agencies, training and education, and caregiver support. Programs are distinguished by complexity of evaluations, types of equipment, vehicles, and expertise of provider.
Driver Rehabilitation Specialist# , Certified Driver Rehabilitation Specialist∗ , Occupational Therapist with Specialty Certification in Driving and Community Mobility+ .
Specialized Evaluation and Training Driver rehabilitation programs (includes driver evaluation)
TABLE 2. Spectrum of Driver Services: Right Services for the Right People at the Right Time A description consumers and health care providers can use to distinguish the type of services needed for an older adult.
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Program type
Driving school
Driver screen
Clinical IADL evaluation
Medically Based Assessment, Education, and Referral
review of rules Counsel with family (2) Investigate driving risk (2) Facilitate remediation of deficits to advance client readiness for driver associated with members for of the road, rehabilitation services. changes in vision, student driver driving (3) Develop an individualized transportation cognition, and skill development techniques, plan considering client diagnosis and sensory-motor function. Recommend driving risks, family, caregiver, environmental, (3) Determine actions for continued strategies, state and community options and limitations: the at-risk driver: training and/or laws, etc. Refer to IADL evaluation, Discuss resources for vehicle adaptations undergoing Enhanced (e.g., scooter lift). driver rehabilitation licensing test. self-awareness, Facilitate client training on community program, and/or other Remedial Programs choices, and transportation options (e.g., mobility services. (e.g., license capability to managers and dementia-friendly Discuss driving cessation; reinstatement self-limit. transportation). provide access to course for Discuss driving cessation. For clients with counseling and teens/adults and poor self-awareness, collaborate with education for alternative license point caregivers on cessation strategies. transportation options. reduction (4) Follow reporting/referral Refer to driver rehabilitation program. courses) structure for licensing (4) Document driver safety risk and recommended intervention plan to recommendations. guide further action. (5) Follow professional ethics on referrals to the driver licensing authority.
Driver safety programs
Community-Based Education
Navigate driver license compliance and basic eligibility through intake of driving and medical history. Evaluate and interpret risks associated with changes in vision, cognition, and sensory-motor functions in the driving context by the medically trained provider. Perform a comprehensive driving evaluation (clinical and on-road). Advises client and caregivers about evaluation results, and provides resources, counseling, education, and/or intervention plan. Intervention may include training with compensatory strategies, skills, and vehicle adaptations or modifications for drivers and passengers. Advocates for clients in access to funding resources and/or reimbursement. Provide documentation about fitness to drive to the physician and/or driver-licensing agency in compliance with regulations. Prescribe equipment in compliance with state regulations and collaborate with Mobility Equipment Dealerˆ for fitting and training.
Specialized Evaluation and Training Driver rehabilitation programs (includes driver evaluation)
TABLE 2. Spectrum of Driver Services: Right Services for the Right People at the Right Time A description consumers and health care providers can use to distinguish the type of services needed for an older adult. (Continued)
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Provides education and awareness
Enhances skills for Indicates risk or need for follow-up for medically at-risk drivers healthy drivers.
Determines fitness to drive and provides rehabilitative services.
#DRS – Health professional degree with specialty training in driver evaluation and rehabilitation, ∗ CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation Specialists) +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ˆQuality Approved Provider by NMEDA (National Mobility Equipment Dealers Association). Table 2 is used with permission by AOTA/NHSTA/ADED.
Outcome
Present resources and options for continued community mobility if recommending driving cessation or transition from driving. Recommendations may include (but not restricted to): (1) drive unrestricted; (2) drive with restrictions; (3) cessation of driving pending rehabilitation or training; (4) planned reevaluation for progressive disorders; (5) driving cessation; and (6) referral to another program.
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BASIC HIGH TECH LOW TECH Provider is a driver rehabilitation Driver Rehabilitation Specialist# , Certified Driver Driver Rehabilitation Specialist# , Certified Driver specialist (DRS)# with professional Rehabilitation Specialist∗ , Occupational Therapist Rehabilitation Specialist∗ , Occupational Therapist with background in occupational with Specialty Certification in Driving and Specialty Certification in Driving and Community therapy, other allied health field, Community Mobility+ , or in combination with LDI. Mobility+ . driver education, or a professional Certification in Driver Rehabilitation is recommended Certification in Driver Rehabilitation is recommended as team of CDRS or SCDCM with as the provider for comprehensive driving evaluation the provider for comprehensive driving evaluation and LDI∗∗ . and training. training with advanced skills and expertise to complete complex client and vehicle evaluation and training. Offers comprehensive driving evaluation, training, and Offers a wide variety of adaptive equipment and vehicle Offers comprehensive driving education, with or without adaptive driving aids that options for comprehensive driving evaluation, training evaluation, training, and and education, including all services available in a affect the operation of primary or secondary education. controls, vehicle ingress/egress, and mobility device “LOW TECH” and Basic programs. At this level, May include use of adaptive driving providers have the ability to alter positioning of primary storage/securement. May include use of adaptive aids that do not affect operation and secondary controls based on client’s need or driving aids such as seat cushions or additional of primary or secondary controls ability level. mirrors. (e.g., seat cushions or additional At the low tech level, adaptive equipment for primary High tech adaptive equipment for primary and secondary mirrors). controls includes devices that meet the following control is typically mechanical. Secondary controls May include transportation planning conditions: may include wireless or remote access. (transition and options), cessation (1) capable of controlling vehicle functions or driving planning, and recommendations May include transportation planning (transition and options), cessation planning, and recommendations controls, and for clients as passengers. (2) consists of a programmable computerized system that for clients as passengers. interfaces/integrates with an electronic system in the vehicle. Requires independent transfer into Addresses transfers, seating, and position into OEMˆ Access to the vehicle typically requires ramp or lift and may require adaptation to OEM driver’s seat. Access to OEMˆ driver’s seat in vehicle. driver’s seat. May make recommendations for driver position may be dependent on use of a transfer assistive devices to access driver’s seat, improved positioning, wheelchair securement systems, and/or seat base, or clients may drive from their wheelchair. Provider evaluates and recommends vehicle structural mechanical wheelchair loading devices. modifications to accommodate products such as ramps, lifts, wheelchair and scooter hoists, transfer seat bases, wheelchairs suitable to utilize as a driver seat, and/or wheelchair securement systems.
Levels of program and typical provider credentials
Access to driver’s position
Program service
Driver rehabilitation programs Administers comprehensive driving evaluation to determine fitness to drive and/or provides rehabilitative services.
Program type
TABLE 3. Spectrum of Driver Rehabilitation Program Services A description consumers and health care providers can use to distinguish the services provided by driver rehabilitation programs which best fits a client’s need.
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Secondary driving control examples: (A) remote horn button; (B) turn signal modification (remote and crossover lever); (C) remote wiper controls; (D) gear selector modification; (E) key/ignition adaptions.
Uses OEMˆ controls.
Typical vehicle modification: secondary controls
Primary driving control examples (in addition to low tech options): (A) powered gas/brake systems; (B) power park brake integrated with a powered gas/brake system; (C) variable effort steering systems; (D) Reduced diameter steering wheel, horizontal steering, steering wheel extension, and joystick controls; (E) reduced effort brake systems. Electronic systems to access secondary and accessory controls. Secondary driving control examples (in addition to low tech options): (A) remote panels, touch pads, or switch arrays that interface with OEM∗ electronics; (B) wiring extension for OEMˆ electronics; (C) powered transmission shifter.
# DRS – Health professional degree with specialty training in driver evaluation and rehabilitation, ∗ CDRS – Certified Driver Rehabilitation Specialist-Credentialed by ADED (Association for Driver Rehabilitation Specialists) +SCDCM – Specialty Certified in Driving and Community Mobility by AOTA (American Occupational Therapy Association) ˆOEM-Original Equipment installed by Manufacturer. Reference: NMEDA Guidelines http://www.nmeda.com. ∗∗ LDI – licensed driving instructor.
Primary driving control examples: (A) mechanical gas/brake hand control; (B) left foot accelerator pedal; (C) pedal extensions; (D) park brake lever or electronic park brake; (E) steering device (spinner knob, tri-pin, and C-cuff).
Uses OEMˆ controls.
Typical vehicle modification: primary controls: gas, brake, and steering
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Lane et al.
Development of Spectrum of Driver Services Based on the consensus statements affirmed by the expert panel and the identified “gap” that terminology was unclear, a project was designed to bring together members of ADED and the AOTA to develop a document to describe and differentiate older driver rehabilitation services and programs. Over the next 18 months, regularly scheduled conference calls led to a draft table that distinguished programs based on their levels of service, as well as who provided those service. With the support of the Gaps and Pathways Project, representatives from the National Highway Traffic Safety Administration (NHSTA), AOTA, and ADED met in September 2013 to synthesize input gathered from stakeholder groups (e.g., ADED membership, AOTA membership, Transportation Research Board) and finalize the document. Taking the document one step further, the members from ADED worked to further clarify differences between levels of Driver Rehabilitation Programs differentiating services, vehicle modifications, and the complexity of technology used in driver rehabilitation. The Spectrum of Driver Services Table is the result of this endeavor (see Tables 2 and 3). It is the intention of the authors that this first version will generate discussion and feedback from the various programs and providers whose services it reflects; reflecting this 2014 version as a “living document” with anticipated revisions. The purpose of this document is to provide physicians and other health care professionals; consumers, family members, and caregivers; DRSs; providers of aging services; governing bodies such as licensing agencies; and stakeholder groups invested in providing older driver information (e.g., AARP, AAA, and Hartford Insurance) with the information needed to advise the most appropriate level of service for older drivers.
SUMMARY Quality services at the appropriate level are critical to meet the needs of older adults who want to continue to drive to maintain their independence, health, and life satisfaction. Not all older adults need driver rehabilitation services; however, those with medical conditions affecting driving abilities should seek the professional DRS who can best evaluate and assist in determining the need for training, rehabilitation, and/or adaptive equipment. The Expert Panel affirmed six consensus statements documenting the need for clarification of terms and services. One of the identified gaps was designated as a project bringing together an AOTA and ADED collaborative work group to develop the Spectrum of Driver Services Table described in this paper. It is hoped the document will be a useful tool to guide consumers, referral sources, and payers in referring the right people to the right service at the right time. Future practitioners can use the Spectrum of Driver Services Table to guide career development in the field of driver rehabilitation while researchers may refer to this document as a framework to identify the different settings in which driving rehabilitation programs operate. Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this paper.
Spectrum of Driver Services
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ABOUT THE AUTHORS Amy Lane, OTR/L, CDRS, is President of ADED, Hickory, North Carolina. E-mail: [email protected]. Elizabeth Green, OTR/L, CDRS is Executive Director of ADED, E-mail: [email protected]. Anne E. Dickerson is Professor, Department of Occupational Therapy, East Carolina University, Greenville, NC. E-mail: [email protected]. Elin Schold Davis, OTR/L, CDRS, is Coordinator of the Older Driver Initiative, AOTA, Bethesda, MD, E-mail: [email protected]. Beth Rolland, OTR/L, CDRS and Janet T. Stohler, OTR/L, CDRS, CDI are both on the Executive Board of ADED. REFERENCE Maguire MJ & Schold Davis E. (2012). Driving and community mobility: Occupational therapy strategies across the lifespan. Bethesda, MD: AOTA Publishing.
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