WORK A Journal of Pre\lention,
Assessment & Rehabilitation
ELSEVIER
Work 8 (1997) 229-238
Starting a driver rehabilitation program Thomas D. Kalina* Adapted Driving Supervisor, Bryn Mawr Rehab Hospital, 414 Paoli Pike, P.o. Box 3007, Malvern, PA 19355-3300, USA
Received 16 February 1996; accepted 7 April 1996
Abstract Driver rehabilitation programs assist clients in restoring transportation independence. This paper explores the many factors that a facility must consider when contemplating the provision of driver rehabilitation services. Topics include estimating market demand, preliminary research, staff credentialing, costs, funding and program models. Program implementation issues include policy development, vehicle selection, adapted equipment installation and program evaluation. Marketing strategies and liability issues are explored to highlight the rewards and risks that come with providing this specialty service. © 1997 Elsevier Science Ireland Ltd.
Keywords: Adapted driving; Disabled driver training; Driver assessment; Driver rehabilitation; Elderly drivers; Occupational therapy
1. Introduction
2. Needs assessment
Personal mobility for most Americans is linked to the automobile. Individuals unable to drive due to a disability are profoundly limited in their ability to earn a living or obtain basic necessities. Driver rehabilitation programs have returned thousands of people to work by restoring their transportation independence. The purpose of this paper is to outline what is required to establish an effective driving program. The information is geared toward a hospital-based facility, but most of the ideas can be applied to other facility settings or private practice.
2.1. Estimating demand
* Corresponding author. Tel.: + 1 610 2515688; fax: 610 6473648.
Is there a demand for a driving program in your area? Almost anyone with a physical or mental disability could be a potential client of a driving program. Advances in technology have made driving accessible to people with significant physical limitations. Even clients that cannot drive may require assistance in determining the most effective transportation alternative. Public transit or a personalized transporter van for wheelchair bound individuals may be required. Concern about the safety of aging drivers has expanded the scope of many driving programs that were initially started to help young drivers learn how to drive with hand controls.
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Coming up with hard data on the number of potential clients can be time consuming. The hospital's marketing department should have the public health statistics that outline the incidence of various diagnostic groups in the area. Stroke, amputation, spinal cord injury, brain injury, multiple sclerosis and hand injury are common diagnostic groups that may require driving evaluations. People with congenital disabilities such as cerebral palsy, spina bifida, short stature and learning disabilities are also potential clients. As most driving programs see many elderly clients, the percentage of people over 65 years could be an important indicator of demand. It is no coincidence that Florida and Pennsylvania have many driving programs, given that the population in these states is heavily weighted toward the elderly. A driving program can expect a significant increase in referrals in the next 15-20 years, as the 'baby boomers' have now begun to turn 50. This age group is heavily dependent on the automobile and will demand the services required to help them return to driving after a stroke or amputation. Their children will be concerned about their elderly parents' safety and may depend on a driving program to measure driving ability objectively. One way to obtain a rough estimate of demand is to carefully track all the patients admitted to the hospital over a 1-2-month period and categorize each person by the likelihood that they will require services to return to safe driving. Apply this percentage to the yearly admissions to the hospital and other rehab programs in the area. A program must draw from many referral sources to be successful. The Commission for Accreditation of Rehabilitation Facilities requires a rehabilitation facility to provide driver rehabilitation services either directly or through a referral to a qualified provider in the area (Pierce, 1993). 2. 2. Referral sources Making inquires to potential referral sources is an excellent way to gauge demand and obtain information on what people would like to see in a driving program. Area hospitals, physicians, retirement communities, nursing homes, disability organizations, vocational rehabilitation agencies,
community mental health centers, Area Agencies on Aging, hand centers, workers' compensation case managers and adapted equipment vendors are the key sources of potential clients. A full-time driving program will require a wide referral base to maintain the client volumes to support the program. 2.3. Competition
Is there another driving program nearby? Large cities can probably support several driving programs, whereas rural states may be lucky to have a program in a nearby state. How far must people travel to get to the nearest driving program? If no programs are nearby, one can likely' assume there is sufficient demand depending on the population density. Rural settings may require either the instructor or the client to travel to obtain the services. If other programs exist, analyze what they do and determine if your program can meet a need (geographically or service related) that they do not currently meet. For example, the other program may serve vocational rehabilitation clients only, leaving the elderly market unserved. If the other program does not have a minivan, there may be a new market niche for the increasing number of clients that are demanding minivans. When investigating demand, it is important to keep in mind that very few people will require a van. Clients needing to drive from a wheelchair will most likely be a minority; most referrals will be for car evaluations. If the other facility has a well-established van program, it is more cost effective to concentrate on car evaluations and refer the van clients elsewhere. Mter researching potential demand, referral sources and the competition, one should have the information to help determine the need for a driver rehabilitation program. If there is a need for this specialty service, the next step is deciding if and how the proposed program could meet this demand. 3. Feasibility study 3.1. Institutional support
Providing driver rehabilitation services is a seri-
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ous responsibility, as driving is one activity of daily living that has the potential to inflict serious harm on the client and others (Pierce, 1987). Driving programs take much time and energy to develop, implement, administer and promote. Staff time and funds must be devoted to conducting the research and training required to develop competency in this high risk practice area. Institutional support via administrators and physicians is critical to the success of a program. Indeed, if support is lukewarm or lacking, it is unlikely that the program will get off the ground. Worse yet, a program could be started based on limited research and training, with potentially serious consequences if there were an accident or lawsuit. If there is support to continue, the next step is to thoroughly research the many nuances of driver rehabilitation to determine the optimal arrangement for the program. 3.2. Learning the basics 3.2.1. Resource organizations Several organizations can provide valuable resources to focus the research. The Association of Driver Educators for the Disabled (ADED) publishes a resource guide that contains a wealth of information on driver rehabilitation issues (1993). Their bibliography can aid in the search for articles on key subject areas. Other topics include articles on program development, adapted equipment, disabilities and their implications for driving, an international roster of driver rehabilitation programs and a resource list of available courses. The annual ADED conference has workshops on starting a program and an exhibit hall of the latest adapted equipment. The American Automobile Association (AAA) also publishes a book on driver rehabilitation resources and conducts special workshops for instructors. They also distribute many educational books, pamphlets and videos. The Transportation Research Board's Committee on the Safety and Mobility of Older Drivers publishes a resource guide and a newsletter on older driver topics. The National Mobility Equipment Dealers Association (NMEDA) publishes a quarterly newsletter and conducts yearly conferences for dealers that
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install adapted equipment. The resource guides published by the above organizations will list contacts with others in the state involved in driver rehabilitation. 3.2.2. Consult an expert Perhaps the quickest and most cost effective way to learn the basics is by consulting with a well established program. In a few hours or days one can learn what may have taken months or years to learn from original experience. The consultation experience is most beneficial if it is formal and planned in advance. (Most driving programs dread the phone call that starts with 'I am interested in starting a program. Do you have a few minutes to tell me how to do it?') Due to time and fiscal constraints, many programs will now charge for providing consultation services. Consultations should take place at the existing driving program so one can see first-hand how the evaluations and training are conducted. Experts are also available to conduct staff training at your facility. Several private practice consulting groups have been formed in the last several years to help hospitals interested in starting driving programs. These groups provide courses and individual consultations. 3.2.3. Learn about adapted equipment options Drivers that require adapted equipment will assume that the instructor/therapist will have the knowledge and expertise to make safe and appropriate recommendations. It is essential to learn what is available, the indications and contraindications of each device and who can install the equipment locally. Gather as much product literature as possible to add to a resource library. Try to drive with the equipment during the visit to an existing program or course. Visit the adapted equipment vendors and watch the installation of the equipment. Establishing a relationship with the vendors is a critical aspect of developing a driver rehabilitation program (McFarland, 1982). An easy way to get a list of local vendors is to contact any Ford, General Motors, or Chrysler dealer. Through their mobility programs they have a listing of adapted equipment vendors and driving programs in the state.
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3.2.4. Obtain proper credentialing Driving program staff are sometimes asked 'What makes you qualified to make decisions about someone's driving ability?' The program, staff and vehicles should meet any state mandated requirements for operating a driving school. These rules vary from state to state, so become familiar with the requirements in any state the program will conduct business. Most states have no rules differentiating a regular driving school from an adapted driving program. The state vocational rehabilitation office may also have criteria that the program must meet to evaluate and train vocational rehabilitation clients. Staff credentialing for this type of service is an evolving issue.· The person in the passenger seat with the training brake should, at a minimum, be licensed as a Certified Driving Instructor. State laws vary widely on what is required. Some states require college course work; others require only a passing grade on a test. The person conducting the pre-driver screening in the clinic should probably be an occupational therapist (OT), especially if the client has neurological involvement. Attending special courses and workshops can provide evidence of specialty training. There is now specialty certification in the driver rehabilitation field for both driving instructors and therapists. ADED developed a certification exam that was first administered in 1995. After passing this exam, the person is designated a Certified Driver Rehabilitation Specialist. A 4-year degree is required to sit for the exam. 3.2.5. Reimbursement for services Auto insurance will usually cover services if the person was injured in a motor vehicle accident. Workers' compensahon insurance will cover the injured worker. The state vocational rehabilitation agency will fund services for people with employment potential. Many health insurance programs, including Medicare, do not consider driving a medical necessity. This forces most older drivers to self-pay for the evaluation. Most clients are willing to pay for the services because driving is considered an essential life task. Scholarship funds and a payment plan should be developed to help the clients that cannot financially afford
extended lessons. When estimating the demand for the service, the payor mix of potential clients should be carefully tracked. Most state rehabilitation agencies will pay only a percentage of the charges. If most of the clients come through the vocational rehabilitation agency, the rate of reimbursement for services will be a critical factor in the program's profitability.
3.2.6. Start-up costs The cost of setting up a program will greatly depend on the type of program envisioned. Comparing the costs of the various program models described below will help determine the feasibility of the proposed program. One essential cost of starting a program is the staff time devoted to the needs assessment and background research. Funds must be committed to the educational costs of preparing the therapist and/or instructor for practice in this specialty field. The typical occupational therapist does not receive this training in OT school. Clinical equipment is usually limited to a reaction time tester and some basic clinical vision and perception assessment tools. A visual acuity testing device could be purchased, but a vision chart on a wall has the advantage of letting the examiner watch the client's eyes during the assessment. Adding a simulator will increase the clinical expenses considerably. Obtaining and equipping a vehicle will be the biggest up-front expense. Leasing has advantages and disadvantages: frequently trading in a vehicle will help the program stay current with equipment and vehicle options, but a program may not want to pay the expense of equipping a vehicle every 3 years. Vehicles are very visible in the community, so obtaining a donated vehicle is a real possibility. A car dealership may be willing to make a donation to the hospital, but be certain the vehicle meets the needs. Community groups or the hospital's volunteer association may be willing to donate funds for a vehicle. Equipment manufactures frequently donate equipment to assessment programs so the clients will be trained on their equipment. State vocational rehabilitation agencies have been a major source of start-up funding for many
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programs. Having an effective driver rehabilitation program in the area can make a significant difference in the employability of disabled clients. Grants can cover initial start-up salaries, office equipment, staff training, vehicle purchases and modifications. This assistance may be essential if the program wishes to obtain an evaluation van. 3.2. 7. Operational costs Once the program is operational, staff salaries will comprise the largest operating expense. Driving programs are typically expensive to operate due to the large amount of time devoted to nonbillable phone calls, documentation, informal consultations, vehicle modification research and program promotion. The client, physician, other therapists and family members may have many questions, both before and after the evaluation. Time is spent talking to potential clients that are never evaluated. Once the program is operational, it will become a public resource in the community and the staff will need time to answer the many phone calls. Other expenses include insurance, fuel, vehicle maintenance, marketing, support staff and typical office operation costs. The office space required will depend on whether the program needs to have a devoted space. If only one or two evaluations are conducted per week, using a private room for the clinical assessments may suffice. A full-time program will require office space, storage space and perhaps room for a simulator. Driving programs will never generate the volume of the typical therapy department due to the nature of the evaluations and lessons. The program's profitability may largely depend on the payor mix and the amount of indirect hospital costs attributed to the program. 'Selling' the driving program as a large revenue producer will likely lead to disappointments. A program should hope to meet its direct costs to avoid revenue loss for the institution. If a program is losing money, this loss should be balanced with the public relations benefits, crossover referrals generated, and the overall value of the program to the customers served - the clients, physicians, referral sources and the community.
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3.3. Program Models 3.3.1. Clinic screenings only If there is little demand or support to develop
an in-vehicle evaluation program, a screening program could provide some information to help guide clients and physicians on how to address return to driving issues. Pre-driver screenings typically consist of a medical and driving history, thorough visual assessment, physical evaluation (range of motion, strength, coordination, sensation, trunk balance, transfers, mobility status), reaction time test, perceptual screenings and cognitive assessments (memory, traffic sign recognition, simultaneous attention). The screening is usually conducted by an occupational therapist, as the OT has the training to conduct these varied assessments. A recent survey found that most of the practitioners conducting driving evaluations were occupational therapists (Sprigle et aI., 1995). Because driving requires the synthesis of all the above skills in a fast moving, high risk environment, the screening should not be used to make final judgments about driving potential. (An OT would not judge a client's ability to cook a meal based solely on a perceptual test; the person must be seen in the kitchen') Gathering this information can rule out driving for severely impaired individuals (i.e., people with field cuts or severe physical or perceptual limitations). A screening could also help a client become familiar with what types of adapted equipment may be required. To determine driving readiness the vast majority of people referred will require an invehicle evaluation, perhaps at a nearby program that conducts on-road assessments. The person conducting the screenings in a clinic-only program should try to observe as many on-road evaluations as possible during the start-up phase to learn how clinical performance relates to actual driving skills. 3.3.2. Clinic screenings and simulator
Adding a simulator will allow a program to study driving performance in a limited way without taking the risk of conducting evaluations in traffic. Some simulators are ideally suited to pre-
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sent a standard stimulus and objectively measure a variety of responses. This quality can be especially suited for research, as the traffic environment is difficult to control in the real world. Assessing responses to emergency situations and demonstrating basic adapted equipment are other advantages. Despite these benefits, the simulator still does not answer the question 'Can this person drive in traffic?' From a cost perspective, the simulator may cost more than a car and it consumes floor space. Will clients pay for several lessons on a simulator? If a program had to choose between a car and a simulator, the more cost effective solution to meet the needs of the clients is most likely a car.
3.3.3. Clinic screenings and in-vehicle evaluations Providing both these services will allow the program to make valuable recommendations about the client's driving potential. An OT will likely perform the pre-driver screening in-house. There are several options for providing the invehicle portion of the evaluation (Erisman, 1987). If the volumes will be low (or during the start-up phase) the hospital might consider contracting with a local driving school for the in-vehicle portion of the evaluation. This will reduce the start-up costs, but the operating costs may be high depending on the fee charged by the school. Selecting a driving school that has the willingness, capacity, sensitivity and experience to deal with a wide variety of disabled clients is paramount. Scheduling, logistics, quality of instructors and communication with the client can be compromised when several people are involved in the process. The hospital may also be taking on additional liability by signing off on a client's driving skills without actually seeing the person drive. Ideally the OT would observe the in-vehicle evaluation from the back seat, especially if the client has neurological involvement. Pierce (1993) recommends that the therapist be involved in at least the first and last behind-the-wheel sessions when working with a contracted driving school. If an adequate driving school cannot be found, and the potential client volume supports it, the most efficient route may be for the hospital to conduct both the clinical and behind-the-wheel
portions of the program. The instructor could be hired full or part-time or a therapist could be licensed as an instructor. The feasibility of having the therapist as instructor will depend on the state's laws concerning the certification of the instructor. If extensive course work is required, providing driving instruction initially may not be feasible for the therapist. Therapists involved with adapted driving should become thoroughly familiar with driver education concepts, traffic law and any special regulations concerning the retesting of disabled drivers (Strano, 1987). Ideally, someone with experience in adapted driving could be hired to set up the program. If recruitment methods are not successful in hiring an experienced person there must be an interested in-house person committed to developing the program. A dedicated, interested person overseeing the operation is the most critical factor in the success or failure of the program. No one should be 'assigned' to the driving program, as high turnover in this position due to high stress could force the program to close during periods of recruitment and retraining of staff. Some programs make the mistake of purchasing only a van in the start up phase. More than 95% of the clients will likely use a car. Should the program invest significant dollars toward modifying a training van for quadriplegic and other severely disabled clients? It is highly recommended that the program start with only a car, as the van presents a level of complexity and expense that could be overwhelming initially. If no van programs are nearby and demand for the service is strong, a van component could be added as the program evolves. 4. Program implementation
4.1. Developing policies and procedures Before any clients are evaluated, the program's policies and procedures should be in place. Topics will likely include referral method and requirements, evaluation and training protocols, policies for writing adapted equipment prescriptions and reporting policies for impaired clients. These policies will likely be used in court if there
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is a lawsuit, so it is important that they be developed with care. Most programs will require a physician's referral. A basic prescription pad referral is usually not adequate if little is known about the client. Develop a one-page referral form that gathers the basic medical history in an easy to complete format. Include these important items: diagnosis, onset, prognosis, past medical history, visuallimitations, seizure history, cardiac and orthopedic precautions and medications. Asking the physician to comment on his or her concerns regarding the client's driving ability can help focus the evaluation. The protocols and documentation for the assessments and lessons will be the road-map for how the program operates. After consulting with other programs and attending workshops, the therapist will have a good idea of what should be included in the clinical screening and in-vehicle evaluation. How the information is documented may depend on the amount of clerical and computer support available. With the move toward computerized documentation, the information on the evaluations could be entered into a database linked to a word processor. In this way the reports are neatly printed out and the data is available for research and program evaluation (e.g., funding sources, referral sources, outcomes, etc.). Careful and complete documentation is essential due to the high risk nature of the activity and the implications of the findings. Pierce (1993) recommends that reports should be written as if a lawyer would be scrutinizing the details. When adapted equipment training is completed the client or funding source is provided with a detailed written prescription. This equipment prescription is usually written after the client has passed the state requirements for driving with adapted equipment. Whether preprinted forms or narrative prescriptions are used may depend on the requirements of the funding source. A prescription should include everything a client may require, regardless if a funding source will pay for the modification. The client may request items that are not covered by the payor. What should be done if a client fails the program and driving is not recommended? Does the
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state require reporting of impaired clients? Should a client be reported even if the state does not require a report? Who should report, the driving program or the referring physician? These difficult issues must be addressed with the assistance of legal counsel. Antrim and Engum (1989), Jacobs (1978) and Annas (1975) discuss these issues in further detail. 4.2. Vehicle selection
Careful research is required before purchasing or leasing a training car. The program must live with this decision for several years and the car must meet the needs of many different clients. A two-door car is generally recommended for ease of transfers and wheelchair loading when needed. Limiting the choices to two-door cars will narrow the options considerably. Important factors to consider are: visibility to the front and rear (for both the driver and the instructor), large side mirrors, room to install a left foot gas pedal to the left of the brake, an easy-to-read dashboard (especially the gear indicator)' accessibility to the gas pedal for the instructor (rules out consoles), a column mounted gear shift, split bench seats, and a power driver's seat. When the choices are narrowed to one or two cars, consult a vendor to see if installing hand controls in these vehicles is feasible. Consulting with other programs that have recently purchased vehicles might help verify the decision. Conducting the original research is important. Vehicles can change from year to year and programs have been known to make mistakes. Gathering this information will also help guide the clients when they ask for advice on vehicle selection. 4.3. Adapted equipment installation
The following recommendations assume that the reader is familiar with the basic adapted equipment available after doing the research recommended above. For maximum safety and reduced client anxiety, most adapted equipment in the training vehicle should be removable and custom installed for the individual client. Most clients will probably not need adapted equipment.
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Older clients especially are confused by unfamiliar devices and may inadvertently grab the hand controls instead of the turn signal. They will likely blame 'all that extra equipment' if they do not pass. The basic training car should be equipped with a left foot gas pedal, several types of hand controls, several steering devices, a right turn signal extension, a left gear shift extension and a hand parking brake. A removable chest strap is required for clients with reduced trunk stability. Several sizes of cushions will help shorter drivers gain better visibility. An automatic roof-top wheelchair carrier, though rarely used, is a dramatic example of assistive technology and usually impresses audiences during equipment demonstrations. The instructor should have a training brake, rear view mirror and an 'eye check' mirror that allows the instructor to monitor the client's eye movements. A turn signal and brake light indicator installed in a small box in fron\ of the instructor on the dash will quickly point out a wrong turn signal or improper use of the brake. The standard left foot gas pedal can be folded down when not in use, but a quick-release left foot gas pedal will eliminate the awkward bump under the floor mat. A removable pedal shield that covers the gas pedal is highly recommended for amputees and others that may touch the gas pedal by mistake. The shield will also allow the client to rest the foot in a comfortable position safely. With the right equipment and a good measure of creativity by an experienced vendor, configuring the hand control mountings to allow for quick release installation of three different hand controls is possible (push-pull and push-right angle controls on the left and right, and the new 'Sure Grip' hand control on the left). If set up correctly, it is possible for the therapist to install the controls in less than 5 min and take them out in less than 1 min, without tools. This flexibility allows the client to tty different hand controls during one session if he or she is not pleased with the initial choice. At a minimum, the car should have at least two removable hand controls available for the left side. A right-sided hand control will rarely
be used, but having it for the occasional client that needs one is worthwhile. Carefully research the options and order the specific controls that other programs have found reliable. Specifying only 'hand controls' on the bid list may lead to disappointments. Before driving away from the shop the instructor/therapist should know how to install and adjust the controls.
4.4. Program evaluation Programs evolve over time, so program evaluation should be an ongoing activity. Tracking referral and funding sources will identify trends and help measure the success of marketing efforts. Tracking non-materialized referrals will shed light on why clients did not participate in the program. Outcome studies will monitor the effectiveness of the training sessions and yield estimates of how many lessons a particular diagnostic group may require. Surveying clients after discharge will determine if they ultimately met their driving goals and how the adapted equipment performed over time. Information gained can be passed on to future clients. Payor and referral sources could be surveyed to see if the program is meeting their needs. 5. Marketing A well conceived driver rehabilitation program will not meet its goals unless it is effectively promoted both internally and in the community. Fortunately, this specialized program is easy to promote because nearly evetyone can relate to the importance of driving. A marketing campaign will promote the hospital as a provider of comprehensive care. A driver rehabilitation program is an important market differentia tor in an increasingly competitive health care environment. The marketing plan should draw heavily from the needs assessment. The potential consumers were identified; now they must be made aware of the program. The program should only market internally during the start-up phase when the program is still developing (Kalina, 1993). An external marketing campaign, developed with the public relations department, should be launched
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when all the 'bugs' are worked out of the young program. Promotional materials will be essential for targeted mailings, inservices and public exhibits. A general brochure that explains the basics can be complemented by specialty handouts (i.e., 'Should My Parent Be Driving?', 'Can My Learning Disabled Child Learn to Drive?', 'Driving With Adapted Equipment: What's Involved?'). The many interesting stories of helping people return to driving will generate newspaper articles that can be reprinted for distribution. A marketing folder with promotional materials, referral forms and state law information can be a useful tool for physicians and other referral sources. Slide shows and videos will illustrate the evaluation process and equipment options during inservices. A video could be left behind after an inservice so future clients and health care practitioners could learn about the program. Local and/or national television exposure is possible, especially for a unique client or a pressing topic like older driver issues. The public relations aspect of the program is one of its greatest assets. To grow the program must devote time and resources to marketing.
client (physicians, therapists, instructors, vendors, funding sources) and the corresponding institutions could be cited in a suit. Whether the suit is successful will largely depend on the level of reasonable care exercised. The greatest protection from liability will come from having a qualified staff and sound procedures and practices. Recommending a return to driving based solely on a clinic examination could certainly expose a program to liability. Some programs rely on the state test for protection, assuming that if the state passes the client then the program is absolved of any liability. This argument is weak, as the state test is not geared specifically for disabled drivers and the state usually cannot be sued. A disabled client comes to the program for a professional opinion. If the program passes a client who should not be driving, passing the state test will provide little protection. Because a program must be accountable for the results, the evaluation should be complete and comparable to the general standard of practice in other programs (Pierce, 1993).
6. Liability
Starting a driver rehabilitation program will require careful research to match the community's needs with the facility's capabilities. Administrative support, staff training, sound procedures and proper equipment are all essential components of a successful program. Early practitioners had to start programs with little guidance; now there are mUltiple resources available to help people interested in this rewarding and essential service. The fear of liability should not stop a facility from starting a driving program. If liability were the primary concern, a hospital would advise all patients with a disability to stop driving. This is clearly not an acceptable solution in a society where the car is considered essential. A driver rehabilitation program will help those who can return to driving and clarify, with evidence, those who should not. Helping restore transportation independence will complete the rehabilitation process that otherwise would fall short of meeting the client's critical goals.
The prevalence of TV commercials starting with 'Have you been injured in an accident?' points to the increasing trend toward litigation. Is the driver rehabilitation specialist at fault if in the future the client is ever involved in an accident? If the equipment fails, who is at fault: the manufacturer, the vendor that installed the device, the evaluator who recommended the adapted equipment or the driver that failed to maintain the equipment properly? Should a therapist avoid recommending a custom modification out of a fear of liability? Is a rehabilitation professional liable if he or she is aware that an impaired individual is driving and does not advise the person to stop driving? Should the state be notified, even if reporting is not mandatory? Some of these ethical dilemmas are discussed by Cook and Semmler (1991) and Antrim and Engum (1989). One can likely assume that anyone who interacted with the
7. Summary
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References Annas, GJ. (1975) Confidentiality and the public: When must the physician warn others of the potential dangerollsness of his patient's condition? Orthop. Rev. 4(5), 55-57. Antrim, J.M. and Engum, E.S. (1989) The driving dilemma and the law: Patients' striving for independence vs. public safety. Cognit. Rehabi!. 7(2), 16-19. Association of Driver Educators for the Disabled (1993). ADED Membership Resource Guide. (Available from ADED, P.O. Box 49, Edgerton, WI 53534.) Cook, c.A. and Semmler, CJ. (1991) Ethical dilemmas in driver rehabilitation. Am. J. Occup. Ther. 45(6), 517-522. Erisman, c.L. (1987) Disabled drivers program: In house versus contract service. Phys. Disabi!. Special Interest Sect. News!., 10(4), 2. Jacobs, S. (1978) Reporting the handicapped driver. Arch. Phys. Med. Rehabi!. 59, 387-390.
Kalina, T.D. (1993) Expanding opportunities: Marketing your driving program. Phys. Disabi!. Special Interest Sect. News!. 16(1), 6-7. McFarland, S. (1982, June). Personal licensed vehicles for disabled persons. Paraplegia News 33-40. Pierce, S. (1987). Formula for developing a driving program for the disabled. Phys. Disabi!. Special Interest Sect. News!. 10(4),3. Pierce, S. (1993). Legal considerations for a driver rehabilitation program. Phys. Disabil. Special Interest Sect. News!. 16(1), 1-4. Sprigle, S., Morris, B.O., Nowachek, G. and Karg, P.E. (1995) Assessment of the evaluation procedures of drivers with disabilities. Occup. Ther. J. Res. 15(3), 147-164. Strano, C. (1987). Evaluation and training of physically disabled drivers: Additional comments. Phys. Disabil. Special Interest Sect. News!. 10(4), 6-7.
Assessment & Rehabilitation
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Starting a driver rehabilitation program Thomas D. Kalina* Adapted Driving Supervisor, Bryn Mawr Rehab Hospital, 414 Paoli Pike, P.o. Box 3007, Malvern, PA 19355-3300, USA
Received 16 February 1996; accepted 7 April 1996
Abstract Driver rehabilitation programs assist clients in restoring transportation independence. This paper explores the many factors that a facility must consider when contemplating the provision of driver rehabilitation services. Topics include estimating market demand, preliminary research, staff credentialing, costs, funding and program models. Program implementation issues include policy development, vehicle selection, adapted equipment installation and program evaluation. Marketing strategies and liability issues are explored to highlight the rewards and risks that come with providing this specialty service. © 1997 Elsevier Science Ireland Ltd.
Keywords: Adapted driving; Disabled driver training; Driver assessment; Driver rehabilitation; Elderly drivers; Occupational therapy
1. Introduction
2. Needs assessment
Personal mobility for most Americans is linked to the automobile. Individuals unable to drive due to a disability are profoundly limited in their ability to earn a living or obtain basic necessities. Driver rehabilitation programs have returned thousands of people to work by restoring their transportation independence. The purpose of this paper is to outline what is required to establish an effective driving program. The information is geared toward a hospital-based facility, but most of the ideas can be applied to other facility settings or private practice.
2.1. Estimating demand
* Corresponding author. Tel.: + 1 610 2515688; fax: 610 6473648.
Is there a demand for a driving program in your area? Almost anyone with a physical or mental disability could be a potential client of a driving program. Advances in technology have made driving accessible to people with significant physical limitations. Even clients that cannot drive may require assistance in determining the most effective transportation alternative. Public transit or a personalized transporter van for wheelchair bound individuals may be required. Concern about the safety of aging drivers has expanded the scope of many driving programs that were initially started to help young drivers learn how to drive with hand controls.
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Coming up with hard data on the number of potential clients can be time consuming. The hospital's marketing department should have the public health statistics that outline the incidence of various diagnostic groups in the area. Stroke, amputation, spinal cord injury, brain injury, multiple sclerosis and hand injury are common diagnostic groups that may require driving evaluations. People with congenital disabilities such as cerebral palsy, spina bifida, short stature and learning disabilities are also potential clients. As most driving programs see many elderly clients, the percentage of people over 65 years could be an important indicator of demand. It is no coincidence that Florida and Pennsylvania have many driving programs, given that the population in these states is heavily weighted toward the elderly. A driving program can expect a significant increase in referrals in the next 15-20 years, as the 'baby boomers' have now begun to turn 50. This age group is heavily dependent on the automobile and will demand the services required to help them return to driving after a stroke or amputation. Their children will be concerned about their elderly parents' safety and may depend on a driving program to measure driving ability objectively. One way to obtain a rough estimate of demand is to carefully track all the patients admitted to the hospital over a 1-2-month period and categorize each person by the likelihood that they will require services to return to safe driving. Apply this percentage to the yearly admissions to the hospital and other rehab programs in the area. A program must draw from many referral sources to be successful. The Commission for Accreditation of Rehabilitation Facilities requires a rehabilitation facility to provide driver rehabilitation services either directly or through a referral to a qualified provider in the area (Pierce, 1993). 2. 2. Referral sources Making inquires to potential referral sources is an excellent way to gauge demand and obtain information on what people would like to see in a driving program. Area hospitals, physicians, retirement communities, nursing homes, disability organizations, vocational rehabilitation agencies,
community mental health centers, Area Agencies on Aging, hand centers, workers' compensation case managers and adapted equipment vendors are the key sources of potential clients. A full-time driving program will require a wide referral base to maintain the client volumes to support the program. 2.3. Competition
Is there another driving program nearby? Large cities can probably support several driving programs, whereas rural states may be lucky to have a program in a nearby state. How far must people travel to get to the nearest driving program? If no programs are nearby, one can likely' assume there is sufficient demand depending on the population density. Rural settings may require either the instructor or the client to travel to obtain the services. If other programs exist, analyze what they do and determine if your program can meet a need (geographically or service related) that they do not currently meet. For example, the other program may serve vocational rehabilitation clients only, leaving the elderly market unserved. If the other program does not have a minivan, there may be a new market niche for the increasing number of clients that are demanding minivans. When investigating demand, it is important to keep in mind that very few people will require a van. Clients needing to drive from a wheelchair will most likely be a minority; most referrals will be for car evaluations. If the other facility has a well-established van program, it is more cost effective to concentrate on car evaluations and refer the van clients elsewhere. Mter researching potential demand, referral sources and the competition, one should have the information to help determine the need for a driver rehabilitation program. If there is a need for this specialty service, the next step is deciding if and how the proposed program could meet this demand. 3. Feasibility study 3.1. Institutional support
Providing driver rehabilitation services is a seri-
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ous responsibility, as driving is one activity of daily living that has the potential to inflict serious harm on the client and others (Pierce, 1987). Driving programs take much time and energy to develop, implement, administer and promote. Staff time and funds must be devoted to conducting the research and training required to develop competency in this high risk practice area. Institutional support via administrators and physicians is critical to the success of a program. Indeed, if support is lukewarm or lacking, it is unlikely that the program will get off the ground. Worse yet, a program could be started based on limited research and training, with potentially serious consequences if there were an accident or lawsuit. If there is support to continue, the next step is to thoroughly research the many nuances of driver rehabilitation to determine the optimal arrangement for the program. 3.2. Learning the basics 3.2.1. Resource organizations Several organizations can provide valuable resources to focus the research. The Association of Driver Educators for the Disabled (ADED) publishes a resource guide that contains a wealth of information on driver rehabilitation issues (1993). Their bibliography can aid in the search for articles on key subject areas. Other topics include articles on program development, adapted equipment, disabilities and their implications for driving, an international roster of driver rehabilitation programs and a resource list of available courses. The annual ADED conference has workshops on starting a program and an exhibit hall of the latest adapted equipment. The American Automobile Association (AAA) also publishes a book on driver rehabilitation resources and conducts special workshops for instructors. They also distribute many educational books, pamphlets and videos. The Transportation Research Board's Committee on the Safety and Mobility of Older Drivers publishes a resource guide and a newsletter on older driver topics. The National Mobility Equipment Dealers Association (NMEDA) publishes a quarterly newsletter and conducts yearly conferences for dealers that
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install adapted equipment. The resource guides published by the above organizations will list contacts with others in the state involved in driver rehabilitation. 3.2.2. Consult an expert Perhaps the quickest and most cost effective way to learn the basics is by consulting with a well established program. In a few hours or days one can learn what may have taken months or years to learn from original experience. The consultation experience is most beneficial if it is formal and planned in advance. (Most driving programs dread the phone call that starts with 'I am interested in starting a program. Do you have a few minutes to tell me how to do it?') Due to time and fiscal constraints, many programs will now charge for providing consultation services. Consultations should take place at the existing driving program so one can see first-hand how the evaluations and training are conducted. Experts are also available to conduct staff training at your facility. Several private practice consulting groups have been formed in the last several years to help hospitals interested in starting driving programs. These groups provide courses and individual consultations. 3.2.3. Learn about adapted equipment options Drivers that require adapted equipment will assume that the instructor/therapist will have the knowledge and expertise to make safe and appropriate recommendations. It is essential to learn what is available, the indications and contraindications of each device and who can install the equipment locally. Gather as much product literature as possible to add to a resource library. Try to drive with the equipment during the visit to an existing program or course. Visit the adapted equipment vendors and watch the installation of the equipment. Establishing a relationship with the vendors is a critical aspect of developing a driver rehabilitation program (McFarland, 1982). An easy way to get a list of local vendors is to contact any Ford, General Motors, or Chrysler dealer. Through their mobility programs they have a listing of adapted equipment vendors and driving programs in the state.
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3.2.4. Obtain proper credentialing Driving program staff are sometimes asked 'What makes you qualified to make decisions about someone's driving ability?' The program, staff and vehicles should meet any state mandated requirements for operating a driving school. These rules vary from state to state, so become familiar with the requirements in any state the program will conduct business. Most states have no rules differentiating a regular driving school from an adapted driving program. The state vocational rehabilitation office may also have criteria that the program must meet to evaluate and train vocational rehabilitation clients. Staff credentialing for this type of service is an evolving issue.· The person in the passenger seat with the training brake should, at a minimum, be licensed as a Certified Driving Instructor. State laws vary widely on what is required. Some states require college course work; others require only a passing grade on a test. The person conducting the pre-driver screening in the clinic should probably be an occupational therapist (OT), especially if the client has neurological involvement. Attending special courses and workshops can provide evidence of specialty training. There is now specialty certification in the driver rehabilitation field for both driving instructors and therapists. ADED developed a certification exam that was first administered in 1995. After passing this exam, the person is designated a Certified Driver Rehabilitation Specialist. A 4-year degree is required to sit for the exam. 3.2.5. Reimbursement for services Auto insurance will usually cover services if the person was injured in a motor vehicle accident. Workers' compensahon insurance will cover the injured worker. The state vocational rehabilitation agency will fund services for people with employment potential. Many health insurance programs, including Medicare, do not consider driving a medical necessity. This forces most older drivers to self-pay for the evaluation. Most clients are willing to pay for the services because driving is considered an essential life task. Scholarship funds and a payment plan should be developed to help the clients that cannot financially afford
extended lessons. When estimating the demand for the service, the payor mix of potential clients should be carefully tracked. Most state rehabilitation agencies will pay only a percentage of the charges. If most of the clients come through the vocational rehabilitation agency, the rate of reimbursement for services will be a critical factor in the program's profitability.
3.2.6. Start-up costs The cost of setting up a program will greatly depend on the type of program envisioned. Comparing the costs of the various program models described below will help determine the feasibility of the proposed program. One essential cost of starting a program is the staff time devoted to the needs assessment and background research. Funds must be committed to the educational costs of preparing the therapist and/or instructor for practice in this specialty field. The typical occupational therapist does not receive this training in OT school. Clinical equipment is usually limited to a reaction time tester and some basic clinical vision and perception assessment tools. A visual acuity testing device could be purchased, but a vision chart on a wall has the advantage of letting the examiner watch the client's eyes during the assessment. Adding a simulator will increase the clinical expenses considerably. Obtaining and equipping a vehicle will be the biggest up-front expense. Leasing has advantages and disadvantages: frequently trading in a vehicle will help the program stay current with equipment and vehicle options, but a program may not want to pay the expense of equipping a vehicle every 3 years. Vehicles are very visible in the community, so obtaining a donated vehicle is a real possibility. A car dealership may be willing to make a donation to the hospital, but be certain the vehicle meets the needs. Community groups or the hospital's volunteer association may be willing to donate funds for a vehicle. Equipment manufactures frequently donate equipment to assessment programs so the clients will be trained on their equipment. State vocational rehabilitation agencies have been a major source of start-up funding for many
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programs. Having an effective driver rehabilitation program in the area can make a significant difference in the employability of disabled clients. Grants can cover initial start-up salaries, office equipment, staff training, vehicle purchases and modifications. This assistance may be essential if the program wishes to obtain an evaluation van. 3.2. 7. Operational costs Once the program is operational, staff salaries will comprise the largest operating expense. Driving programs are typically expensive to operate due to the large amount of time devoted to nonbillable phone calls, documentation, informal consultations, vehicle modification research and program promotion. The client, physician, other therapists and family members may have many questions, both before and after the evaluation. Time is spent talking to potential clients that are never evaluated. Once the program is operational, it will become a public resource in the community and the staff will need time to answer the many phone calls. Other expenses include insurance, fuel, vehicle maintenance, marketing, support staff and typical office operation costs. The office space required will depend on whether the program needs to have a devoted space. If only one or two evaluations are conducted per week, using a private room for the clinical assessments may suffice. A full-time program will require office space, storage space and perhaps room for a simulator. Driving programs will never generate the volume of the typical therapy department due to the nature of the evaluations and lessons. The program's profitability may largely depend on the payor mix and the amount of indirect hospital costs attributed to the program. 'Selling' the driving program as a large revenue producer will likely lead to disappointments. A program should hope to meet its direct costs to avoid revenue loss for the institution. If a program is losing money, this loss should be balanced with the public relations benefits, crossover referrals generated, and the overall value of the program to the customers served - the clients, physicians, referral sources and the community.
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3.3. Program Models 3.3.1. Clinic screenings only If there is little demand or support to develop
an in-vehicle evaluation program, a screening program could provide some information to help guide clients and physicians on how to address return to driving issues. Pre-driver screenings typically consist of a medical and driving history, thorough visual assessment, physical evaluation (range of motion, strength, coordination, sensation, trunk balance, transfers, mobility status), reaction time test, perceptual screenings and cognitive assessments (memory, traffic sign recognition, simultaneous attention). The screening is usually conducted by an occupational therapist, as the OT has the training to conduct these varied assessments. A recent survey found that most of the practitioners conducting driving evaluations were occupational therapists (Sprigle et aI., 1995). Because driving requires the synthesis of all the above skills in a fast moving, high risk environment, the screening should not be used to make final judgments about driving potential. (An OT would not judge a client's ability to cook a meal based solely on a perceptual test; the person must be seen in the kitchen') Gathering this information can rule out driving for severely impaired individuals (i.e., people with field cuts or severe physical or perceptual limitations). A screening could also help a client become familiar with what types of adapted equipment may be required. To determine driving readiness the vast majority of people referred will require an invehicle evaluation, perhaps at a nearby program that conducts on-road assessments. The person conducting the screenings in a clinic-only program should try to observe as many on-road evaluations as possible during the start-up phase to learn how clinical performance relates to actual driving skills. 3.3.2. Clinic screenings and simulator
Adding a simulator will allow a program to study driving performance in a limited way without taking the risk of conducting evaluations in traffic. Some simulators are ideally suited to pre-
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sent a standard stimulus and objectively measure a variety of responses. This quality can be especially suited for research, as the traffic environment is difficult to control in the real world. Assessing responses to emergency situations and demonstrating basic adapted equipment are other advantages. Despite these benefits, the simulator still does not answer the question 'Can this person drive in traffic?' From a cost perspective, the simulator may cost more than a car and it consumes floor space. Will clients pay for several lessons on a simulator? If a program had to choose between a car and a simulator, the more cost effective solution to meet the needs of the clients is most likely a car.
3.3.3. Clinic screenings and in-vehicle evaluations Providing both these services will allow the program to make valuable recommendations about the client's driving potential. An OT will likely perform the pre-driver screening in-house. There are several options for providing the invehicle portion of the evaluation (Erisman, 1987). If the volumes will be low (or during the start-up phase) the hospital might consider contracting with a local driving school for the in-vehicle portion of the evaluation. This will reduce the start-up costs, but the operating costs may be high depending on the fee charged by the school. Selecting a driving school that has the willingness, capacity, sensitivity and experience to deal with a wide variety of disabled clients is paramount. Scheduling, logistics, quality of instructors and communication with the client can be compromised when several people are involved in the process. The hospital may also be taking on additional liability by signing off on a client's driving skills without actually seeing the person drive. Ideally the OT would observe the in-vehicle evaluation from the back seat, especially if the client has neurological involvement. Pierce (1993) recommends that the therapist be involved in at least the first and last behind-the-wheel sessions when working with a contracted driving school. If an adequate driving school cannot be found, and the potential client volume supports it, the most efficient route may be for the hospital to conduct both the clinical and behind-the-wheel
portions of the program. The instructor could be hired full or part-time or a therapist could be licensed as an instructor. The feasibility of having the therapist as instructor will depend on the state's laws concerning the certification of the instructor. If extensive course work is required, providing driving instruction initially may not be feasible for the therapist. Therapists involved with adapted driving should become thoroughly familiar with driver education concepts, traffic law and any special regulations concerning the retesting of disabled drivers (Strano, 1987). Ideally, someone with experience in adapted driving could be hired to set up the program. If recruitment methods are not successful in hiring an experienced person there must be an interested in-house person committed to developing the program. A dedicated, interested person overseeing the operation is the most critical factor in the success or failure of the program. No one should be 'assigned' to the driving program, as high turnover in this position due to high stress could force the program to close during periods of recruitment and retraining of staff. Some programs make the mistake of purchasing only a van in the start up phase. More than 95% of the clients will likely use a car. Should the program invest significant dollars toward modifying a training van for quadriplegic and other severely disabled clients? It is highly recommended that the program start with only a car, as the van presents a level of complexity and expense that could be overwhelming initially. If no van programs are nearby and demand for the service is strong, a van component could be added as the program evolves. 4. Program implementation
4.1. Developing policies and procedures Before any clients are evaluated, the program's policies and procedures should be in place. Topics will likely include referral method and requirements, evaluation and training protocols, policies for writing adapted equipment prescriptions and reporting policies for impaired clients. These policies will likely be used in court if there
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is a lawsuit, so it is important that they be developed with care. Most programs will require a physician's referral. A basic prescription pad referral is usually not adequate if little is known about the client. Develop a one-page referral form that gathers the basic medical history in an easy to complete format. Include these important items: diagnosis, onset, prognosis, past medical history, visuallimitations, seizure history, cardiac and orthopedic precautions and medications. Asking the physician to comment on his or her concerns regarding the client's driving ability can help focus the evaluation. The protocols and documentation for the assessments and lessons will be the road-map for how the program operates. After consulting with other programs and attending workshops, the therapist will have a good idea of what should be included in the clinical screening and in-vehicle evaluation. How the information is documented may depend on the amount of clerical and computer support available. With the move toward computerized documentation, the information on the evaluations could be entered into a database linked to a word processor. In this way the reports are neatly printed out and the data is available for research and program evaluation (e.g., funding sources, referral sources, outcomes, etc.). Careful and complete documentation is essential due to the high risk nature of the activity and the implications of the findings. Pierce (1993) recommends that reports should be written as if a lawyer would be scrutinizing the details. When adapted equipment training is completed the client or funding source is provided with a detailed written prescription. This equipment prescription is usually written after the client has passed the state requirements for driving with adapted equipment. Whether preprinted forms or narrative prescriptions are used may depend on the requirements of the funding source. A prescription should include everything a client may require, regardless if a funding source will pay for the modification. The client may request items that are not covered by the payor. What should be done if a client fails the program and driving is not recommended? Does the
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state require reporting of impaired clients? Should a client be reported even if the state does not require a report? Who should report, the driving program or the referring physician? These difficult issues must be addressed with the assistance of legal counsel. Antrim and Engum (1989), Jacobs (1978) and Annas (1975) discuss these issues in further detail. 4.2. Vehicle selection
Careful research is required before purchasing or leasing a training car. The program must live with this decision for several years and the car must meet the needs of many different clients. A two-door car is generally recommended for ease of transfers and wheelchair loading when needed. Limiting the choices to two-door cars will narrow the options considerably. Important factors to consider are: visibility to the front and rear (for both the driver and the instructor), large side mirrors, room to install a left foot gas pedal to the left of the brake, an easy-to-read dashboard (especially the gear indicator)' accessibility to the gas pedal for the instructor (rules out consoles), a column mounted gear shift, split bench seats, and a power driver's seat. When the choices are narrowed to one or two cars, consult a vendor to see if installing hand controls in these vehicles is feasible. Consulting with other programs that have recently purchased vehicles might help verify the decision. Conducting the original research is important. Vehicles can change from year to year and programs have been known to make mistakes. Gathering this information will also help guide the clients when they ask for advice on vehicle selection. 4.3. Adapted equipment installation
The following recommendations assume that the reader is familiar with the basic adapted equipment available after doing the research recommended above. For maximum safety and reduced client anxiety, most adapted equipment in the training vehicle should be removable and custom installed for the individual client. Most clients will probably not need adapted equipment.
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Older clients especially are confused by unfamiliar devices and may inadvertently grab the hand controls instead of the turn signal. They will likely blame 'all that extra equipment' if they do not pass. The basic training car should be equipped with a left foot gas pedal, several types of hand controls, several steering devices, a right turn signal extension, a left gear shift extension and a hand parking brake. A removable chest strap is required for clients with reduced trunk stability. Several sizes of cushions will help shorter drivers gain better visibility. An automatic roof-top wheelchair carrier, though rarely used, is a dramatic example of assistive technology and usually impresses audiences during equipment demonstrations. The instructor should have a training brake, rear view mirror and an 'eye check' mirror that allows the instructor to monitor the client's eye movements. A turn signal and brake light indicator installed in a small box in fron\ of the instructor on the dash will quickly point out a wrong turn signal or improper use of the brake. The standard left foot gas pedal can be folded down when not in use, but a quick-release left foot gas pedal will eliminate the awkward bump under the floor mat. A removable pedal shield that covers the gas pedal is highly recommended for amputees and others that may touch the gas pedal by mistake. The shield will also allow the client to rest the foot in a comfortable position safely. With the right equipment and a good measure of creativity by an experienced vendor, configuring the hand control mountings to allow for quick release installation of three different hand controls is possible (push-pull and push-right angle controls on the left and right, and the new 'Sure Grip' hand control on the left). If set up correctly, it is possible for the therapist to install the controls in less than 5 min and take them out in less than 1 min, without tools. This flexibility allows the client to tty different hand controls during one session if he or she is not pleased with the initial choice. At a minimum, the car should have at least two removable hand controls available for the left side. A right-sided hand control will rarely
be used, but having it for the occasional client that needs one is worthwhile. Carefully research the options and order the specific controls that other programs have found reliable. Specifying only 'hand controls' on the bid list may lead to disappointments. Before driving away from the shop the instructor/therapist should know how to install and adjust the controls.
4.4. Program evaluation Programs evolve over time, so program evaluation should be an ongoing activity. Tracking referral and funding sources will identify trends and help measure the success of marketing efforts. Tracking non-materialized referrals will shed light on why clients did not participate in the program. Outcome studies will monitor the effectiveness of the training sessions and yield estimates of how many lessons a particular diagnostic group may require. Surveying clients after discharge will determine if they ultimately met their driving goals and how the adapted equipment performed over time. Information gained can be passed on to future clients. Payor and referral sources could be surveyed to see if the program is meeting their needs. 5. Marketing A well conceived driver rehabilitation program will not meet its goals unless it is effectively promoted both internally and in the community. Fortunately, this specialized program is easy to promote because nearly evetyone can relate to the importance of driving. A marketing campaign will promote the hospital as a provider of comprehensive care. A driver rehabilitation program is an important market differentia tor in an increasingly competitive health care environment. The marketing plan should draw heavily from the needs assessment. The potential consumers were identified; now they must be made aware of the program. The program should only market internally during the start-up phase when the program is still developing (Kalina, 1993). An external marketing campaign, developed with the public relations department, should be launched
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when all the 'bugs' are worked out of the young program. Promotional materials will be essential for targeted mailings, inservices and public exhibits. A general brochure that explains the basics can be complemented by specialty handouts (i.e., 'Should My Parent Be Driving?', 'Can My Learning Disabled Child Learn to Drive?', 'Driving With Adapted Equipment: What's Involved?'). The many interesting stories of helping people return to driving will generate newspaper articles that can be reprinted for distribution. A marketing folder with promotional materials, referral forms and state law information can be a useful tool for physicians and other referral sources. Slide shows and videos will illustrate the evaluation process and equipment options during inservices. A video could be left behind after an inservice so future clients and health care practitioners could learn about the program. Local and/or national television exposure is possible, especially for a unique client or a pressing topic like older driver issues. The public relations aspect of the program is one of its greatest assets. To grow the program must devote time and resources to marketing.
client (physicians, therapists, instructors, vendors, funding sources) and the corresponding institutions could be cited in a suit. Whether the suit is successful will largely depend on the level of reasonable care exercised. The greatest protection from liability will come from having a qualified staff and sound procedures and practices. Recommending a return to driving based solely on a clinic examination could certainly expose a program to liability. Some programs rely on the state test for protection, assuming that if the state passes the client then the program is absolved of any liability. This argument is weak, as the state test is not geared specifically for disabled drivers and the state usually cannot be sued. A disabled client comes to the program for a professional opinion. If the program passes a client who should not be driving, passing the state test will provide little protection. Because a program must be accountable for the results, the evaluation should be complete and comparable to the general standard of practice in other programs (Pierce, 1993).
6. Liability
Starting a driver rehabilitation program will require careful research to match the community's needs with the facility's capabilities. Administrative support, staff training, sound procedures and proper equipment are all essential components of a successful program. Early practitioners had to start programs with little guidance; now there are mUltiple resources available to help people interested in this rewarding and essential service. The fear of liability should not stop a facility from starting a driving program. If liability were the primary concern, a hospital would advise all patients with a disability to stop driving. This is clearly not an acceptable solution in a society where the car is considered essential. A driver rehabilitation program will help those who can return to driving and clarify, with evidence, those who should not. Helping restore transportation independence will complete the rehabilitation process that otherwise would fall short of meeting the client's critical goals.
The prevalence of TV commercials starting with 'Have you been injured in an accident?' points to the increasing trend toward litigation. Is the driver rehabilitation specialist at fault if in the future the client is ever involved in an accident? If the equipment fails, who is at fault: the manufacturer, the vendor that installed the device, the evaluator who recommended the adapted equipment or the driver that failed to maintain the equipment properly? Should a therapist avoid recommending a custom modification out of a fear of liability? Is a rehabilitation professional liable if he or she is aware that an impaired individual is driving and does not advise the person to stop driving? Should the state be notified, even if reporting is not mandatory? Some of these ethical dilemmas are discussed by Cook and Semmler (1991) and Antrim and Engum (1989). One can likely assume that anyone who interacted with the
7. Summary
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References Annas, GJ. (1975) Confidentiality and the public: When must the physician warn others of the potential dangerollsness of his patient's condition? Orthop. Rev. 4(5), 55-57. Antrim, J.M. and Engum, E.S. (1989) The driving dilemma and the law: Patients' striving for independence vs. public safety. Cognit. Rehabi!. 7(2), 16-19. Association of Driver Educators for the Disabled (1993). ADED Membership Resource Guide. (Available from ADED, P.O. Box 49, Edgerton, WI 53534.) Cook, c.A. and Semmler, CJ. (1991) Ethical dilemmas in driver rehabilitation. Am. J. Occup. Ther. 45(6), 517-522. Erisman, c.L. (1987) Disabled drivers program: In house versus contract service. Phys. Disabi!. Special Interest Sect. News!., 10(4), 2. Jacobs, S. (1978) Reporting the handicapped driver. Arch. Phys. Med. Rehabi!. 59, 387-390.
Kalina, T.D. (1993) Expanding opportunities: Marketing your driving program. Phys. Disabi!. Special Interest Sect. News!. 16(1), 6-7. McFarland, S. (1982, June). Personal licensed vehicles for disabled persons. Paraplegia News 33-40. Pierce, S. (1987). Formula for developing a driving program for the disabled. Phys. Disabi!. Special Interest Sect. News!. 10(4),3. Pierce, S. (1993). Legal considerations for a driver rehabilitation program. Phys. Disabil. Special Interest Sect. News!. 16(1), 1-4. Sprigle, S., Morris, B.O., Nowachek, G. and Karg, P.E. (1995) Assessment of the evaluation procedures of drivers with disabilities. Occup. Ther. J. Res. 15(3), 147-164. Strano, C. (1987). Evaluation and training of physically disabled drivers: Additional comments. Phys. Disabil. Special Interest Sect. News!. 10(4), 6-7.
