Building a Network of Convenient, Affordable and Trustworthy Driving Assessment and Evaluation Programs:

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1 Building a Network of Convenient, Affordable and Trustworthy Driving Assessment and Evaluation Programs: Reflections of California Occupational Therapists September 2005 Patti Yanochko, MPH Center for Injury Prevention Policy and Practice Graduate School of Public Health San Diego State University In Collaboration With The Occupational Therapy Association of California

2 About the Center for Injury Prevention Policy and Practice The Center for Injury Prevention Policy and Practice (CIPPP) is part of the Graduate School of Public Health at San Diego State University. Our mission is to reduce injury frequency and severity by helping government agencies and community programs incorporate injury prevention strategies into their ongoing efforts. CIPPP has been an injury prevention leader in California and nationally for more than 18 years. Throughout this time, CIPPP has advanced state-of-the-art in injury prevention through educational, policy, and capacity-building efforts. CIPPP has been actively promoting safe mobility for California s seniors since The mission of the Center s Senior Safe Mobility Programs is to facilitate a collaborative, public health systems approach that increases the number of California's seniors who remain safely mobile in their communities and are able to successfully age in place. About the Occupational Therapy Association of California The Occupational Therapy Association of California (OTAC) serves, supports and promotes the profession of occupational therapy and its practitioners. For more information Center for Injury Prevention Policy and Practice Graduate School of Public Health College of Health and Human Services San Diego State University 6475 Alvarado Road, Suite 105 San Diego, CA Acknowledgements The author wishes to extend appreciation to the Occupational Therapy Association of California for their assistance in producing this report and their commitment to enhancing the safe mobility of California s seniors. Special thanks also goes to Elin Schold Davis, Brenda Collins, Farrell Sheffield and Charles Strauch for lending their time and expertise to this report. Funding for this program was provided by a grant from the California Office of Traffic Safety, through the Business, Transportation and Housing Agency.

3 Table of Contents Executive Summary.. 1 Background. 3 Methodology 5 Overview of the System of California OT Driving Assessment and Evaluation Programs... 6 Results of Focus Groups and Key Informant Interviews. 9 Conclusion References.. 20 Appendix: Statement on Driving and Community Mobility, American Occupational Therapy Association.. 21 Tables and Figures Table 1: Continuum of OT Specialization in Driving... 5 Table 2: California OT Driving Programs by County.. 6 Table 3: Services Offered by California OT Driving Programs. 7 Table 4: Barriers to Generalists Addressing Driving Table 5: Barriers to Becoming a Driving Specialist. 12 Table 6: Methods to Encourage Specialty Certification. 15 Table 7: Barriers to Seniors Utilizing OT Driving Programs.. 17 Figure 1: California OT Driving Assessment and Evaluation Programs by County, September Figure 2: Current Evaluation Capacity of OT Driving Programs... 8 Figure 3: How Participants Address Driving in Their Practice.. 9 Figure 4: Professional Association Memberships of Participants. 9

4 Executive Summary The question centers on how to build sufficient capacity to ensure that individuals can conveniently avail themselves of affordable, trustworthy assessments that measure their functional ability and, if appropriate, that can provide them training to remediate or compensate for functional declines. --Jeff Finn, MA, American Occupational Therapy Association Declining health is a major contributing factor to driving cessation and mobility declines among California s seniors. As such, health care providers are in a unique and critical position to help reduce the impact of health impairments on mobility. Occupational Therapists (OT) in particular have a vital role in addressing the driving and community mobility needs of seniors. OT s across all practice areas have a unique set of skills that enable them to evaluate and enhance senior driving and mobility. Driving assessment and evaluation programs staffed by trained OT s can evaluate functional driving ability, provide driver remediation or retraining, and provide mobility training to assist seniors in utilizing transportation services. California has 24 OT driving programs distributed throughout 11 of California s 58 counties; with the majority of programs located in San Diego and Los Angeles counties. While California has a relatively large number of programs compared with most other states, large geographic portions of the state remain without this important service. This creates large service gaps as seniors and providers who want to utilize the services of OT driving programs often simply do not have access to one. OT driving programs offer a variety of services including clinical evaluation of driving, in-vehicle evaluations, clinical and in-vehicle training, mobility training on the use of transportation services, and information about transportation alternatives to driving. Many of these programs face barriers to increasing the number of driving assessments and evaluations they perform each month; barriers such as lack of trained therapists and driving instructors. To get first-hand information from California OT s on how to enhance the network of OT driving programs in California, CIPPP conducted key informant interviews and focus groups in April and May of Fourteen OT s from throughout California were interviewed or participated in the focus groups. These OT s cited several major barriers to increasing the number and utilization of OT driving programs in California, including: lack of accessible, affordable training for Generalist and Specialist OT s; the economics of establishing and maintaining a driving program; lack of support from facilities; and limited knowledge and awareness of entry-level OT s that driving should be part of a holistic Instrumental Activity of Daily Living (IADL) evaluation. OT s also looked ahead, proposing solutions to these barriers. They suggested creating a formal certificate program for OT Generalists in California, as well as making Specialist-level trainings available in California or on the west coast. Participants urged the creation of a broad action plan to address this issue in California and to encourage collaboration between the state and OT associations like the 1

5 Occupational Therapy Association of California (OTAC) and the American Occupational Therapy Association (AOTA). As an important and immediate next step, OT s emphasized the need to build capacity of the OT field to address driving, coupled with targeted public information to encourage seniors and their families to see OT s for driving and mobility concerns. With California s senior population growing, the mobility needs of our aging population are greater than ever. OT s can provide an important service to California s seniors, addressing their driving and community mobility needs and providing an important avenue to help them stay independent and connected to their communities. By working to eliminate the barriers, and employ the solutions, laid out in this report we can help build the network of OT driving programs and help seniors stay safely mobile for life. 2

6 Background Driving is a fundamental part of life in California; enabling people of all ages to stay connected to their communities and to live independently where they chose. It is also the way California s older adults prefer to get around. Whether going shopping, visiting family and friends, running errands, or going to the doctor, older adults make almost 90% of their travel in personal vehicles (1). While health status varies greatly among individuals of any age, declining health is a major contributing factor to driving cessation and mobility problems among California s seniors. Medical conditions, as well as the normal changes associated with aging, can make driving difficult and lead to reductions in day-to-day travel. Studies have shown that self-reported medical conditions lead nearly 36% of seniors to stop driving (2). In addition, some older adults, particularly women, stop driving earlier than is necessary due to declining confidence. Whether it is by choice or a lack of availability, few older adults who stop driving turn to other forms of transportation, such as walking or public transit, to fulfill their travel needs. In fact, more than half of older adults who do not drive stay home on any given day because they lack transportation (3). Seniors living in rural communities, as well as African-Americans, Latinos and Asian Americans, are particularly vulnerable to isolation caused by lack of transportation (4). Occupational therapists (OT s) can address the driving and community mobility needs of seniors; providing an important avenue to help older adults stay safely mobile and avoid the isolation that comes with driving cessation. OT s across all practice areas have a unique set of skills that enable them to evaluate and enhance senior driving and mobility. If they pursue advanced training in driving and community mobility, an OT can assess actual driving capability and provide seniors with an accurate picture of his or her skills. These OT driving evaluations do not simply provide Pass, OK to drive or Fail, not OK to drive results. Rather, the results of an evaluation are used to develop an individualized intervention plan which may consist of options for: 1) remediation (e.g. improve strength or flexibility); 2) adaptation (e.g. adaptive devices for vehicles such as steering knobs); 3) compensation (e.g. individualized recommendations for routes that avoid unprotected left turns or use of a cushion to improve line of sight); or 4) exploration of transportation alternatives when cessation is recommended by the evaluation. While California has a relatively large number of driving programs compared with most other states, significant geographic portions of the state remain without these important programs. This creates large service gaps as seniors and providers who want to utilize the services of OT driving programs often simply do not have access to one. A growing senior population in California coupled with efforts by the American Medical Association (AMA) to improve physician knowledge of OT and referrals to OT driving programs is leading to increasing demand for these programs in all reaches of the state. Efforts are underway to expand the network of OT Driving Programs across the United States. The American Occupational Therapy Association (AOTA) has identified driving as one of the top 10 emerging practice area for OT s. Driving is one part of the larger Instrumental Activity of Daily Living 3

7 (IADL) of Community Mobility, which involves moving one s self in the community and using public or private transportation (5). In the article, Defining OT Roles in Driving, AOTA distinguishes two roles for OT s in driving: the Generalist in Driving (a subset of OT s who have pursued advanced training) and the Specialist in Driving (6). 1 The Generalist in Driving looks at driving and community mobility as part of comprehensive practice, addressing the client s access to mobility and its impact on activities of daily living. The Specialist in Driving has advanced training required to conduct an evaluation consisting of clinical and on-road assessments. (See Table 1.) Despite recent efforts by organizations like AOTA, in both California and across the United States there remains a woefully inadequate network of OT driving programs. In fact, OT s face many barriers to creating a network of convenient, affordable and trustworthy driving programs. To help facilitate the successful expansion of California s network of OT driving programs, this report begins a formal discussion of the barriers the California OT community faces in addressing older driver safety and mobility. It also attempts to uncover potential solutions to help alleviate those barriers. Specific goals of this report are to: Identify barriers to the provision and utilization of OT driving assessment and rehabilitation services in California; Identify education and training needs to increase the number of California OT s with advanced or specialized training in driving; Give focus to California efforts to expand the network of OT driving programs and increase the number of seniors who utilize the programs; and Provide information to support initiatives that will address barriers to enhancing the system of OT driving programs in California. To obtain this information first-hand from California OT s, a series of focus groups and key informant interviews were conducted in April and May 2005, in which OT s identified ways to enhance the system of OT driving programs in California. This report summarizes the results of those discussions. 1 This report does not separate out the important role OT Assistants play in driving assessment and rehabilitation programs. 4

8 Table 1: Continuum of OT Specialization in Driving OT Level Generalist in Driving Level of Training Has standard OT training and may have additional education and training in driving and mobility Definition of Level This level encompasses all OT s across all practice areas. All OT s at this level should be addressing driving as an IADL. OT s at the Generalist level with additional education in driving and mobility can: evaluate the integration of, and train clients in, specific sub-skills associated with driving, optimizing readiness for referral to a specialized driving assessment; guide facilities in establishing protocols for addressing driving; and counsel clients about driving and mobility, including providing referrals for specialized evaluation and exploring training in transportation alternatives. Following an evaluation by a Specialist, clients may also return to the Generalist to address specific impairments that were identified as barriers to driving. Specialist in Driving Advanced; has advanced or specialty training in driving and mobility An OT Driving Specialist has advanced training in how to evaluate and train drivers. Many OT s at this level are certified as a Certified Driver Rehabilitation Specialist (CDRS) or Driving Instructor. They can perform targeted clinical evaluations using an array of tools that measure driving sub-skills such as attention and memory. In addition to the activities performed at less specialized levels, specialists can perform on-road assessments**, driver training and retraining, and prescribe and train clients on adaptive equipment. From: Schold Davis, Elin. Defining OT Roles in Driving, AOTA OT Practice Online, accessed 5/10/05. ** Each state has specific laws governing the qualifications necessary to perform an on-road evaluation and in-vehicle training (for more information contact the state Department of Motor Vehicles). Methodology Two different methods were utilized to collect data for this report: a survey of California OT driving programs; and focus groups and key informant interviews. Survey of California OT Driving Programs To gather detailed information about California OT driving programs, a survey, originally developed by the AOTA Driving Program, was ed in June 2005 to all known California OT s who address driving either at a Specialist or Generalist level. Survey recipients were identified using databases from AOTA and the California Board of Occupational Therapy. The purpose of this survey was to: 1) gather information about OT driving programs in California; and 2) determine the current and potential capacity of the OT driving assessment and evaluation system in California. In such cases when more than one OT worked for the same driving program, their responses were consolidated into a single survey for their driving program. Consolidated surveys listed all the OT s affiliated with a given program. OT s from 17 of California s 24 driving programs responded to the survey. 5

9 Focus Groups and Key Informant Interviews Focus groups and key informant interviews were conducted with both Driving Specialists and Generalist OT s to collect first-hand information on ways to improve the system of OT driving programs in California. Participants were recruited using the Occupational Therapy Association of California (OTAC) electronic mailing list and at the 2005 AOTA Conference in Long Beach, California. Two focus groups were conducted, one for OT s who currently perform driving evaluations (Specialist-Level Group) and another for OT s who do NOT currently perform driving evaluations (Generalist-Level Group). Due to several last minute cancellations, the Specialist group had only 3 participants. The Generalist group had 6 participants. Each focus group lasted about 2 hours. The Generalist focus group was held in Sacramento, California; the Specialist focus group was held in Los Angeles, California. Information was also gathered from additional specialist and generalist OT s via telephone key informant interviews. Five key informant interviews were conducted. In total, 14 OT s were interviewed or participated in focus groups. Each focus group and key informant interview began with the collection of demographic information in a written survey. This was followed by 10 open-ended questions. The focus groups were recorded to ensure all information was collected. Overview of the System of California OT Driving Assessment and Evaluation Programs This section of the report provides an overview of the network of OT driving programs in California. California has 24 OT programs in which an OT is addressing driving either as a Generalist or a Specialist, and which offer a range of assessment, training and rehabilitation services. Fifteen of these programs are based in a hospital or community clinic, 8 are private, and 1 is a state rehabilitation facility. The vast majority of these programs are located in Southern California, with Los Angeles County having the highest number of programs at 7, followed by San Diego County with 4. (See Table 2) Table 2: California OT Driving Programs by County County Number of Programs County Number of Programs Los Angeles 7 San Diego 4 Marin 1 Santa Barbara 1 Monterey 1 Santa Clara 3 Nevada 1 Sonoma 1 Orange 3 Tulare 1 Placer 1 TOTAL 24 Note: OT Driving Program is used to describe programs in which an OT is addressing driving in the practice either as a specialist (driving evaluation programs) or generalist (driving assessment programs). 6

10 Figure 1: California OT Driving Assessment and Evaluation Programs by County, September 2005 Number of Programs Pr epar ed by Cal i f or ni a Depar t ment of Health Services, EPICBr anch California s OT driving programs do not consistently offer the same services. All of the 17 programs responding to the OT Driving Program Survey conducted clinical evaluations and offered information about alternative transportation, however only 14 programs offered an in-vehicle evaluation, and even fewer provided clinical or in-vehicle training. Only 11 programs offered mobility training. (See Table 3) Table 3: Services Offered by California OT Driving Programs Number Providing Services Offered by Programs Service (N=17) Clinical Evaluation of Driving 17 In-Vehicle Evaluation of Driving 14 Clinical Training 11 In-Vehicle Training 11 Mobility Training 11 Provide Information About Alternative 17 Transportation These results vary somewhat from driving programs surveyed in AOTA s report, Driving Evaluation & Retraining Programs: A Report of Good Practices, This report, which included both OT and non-ot programs, found that 37% of programs referred clients out to another program for the invehicle evaluation (7). In contrast, 82% of the programs in our survey conducted both clinical and invehicle evaluations, suggesting that most of California s OT driving programs provide comprehensive services. The standard training that all OT s receive provides the basic skills necessary to perform the clinical assessment portion of driving evaluations and, with advanced training in the area of driving and community mobility, some programs utilize these basic skills to offer clinical assessments of driving 7

11 function and work with another program that has a vehicle, such as a driving school, to conduct the onroad portion of the driving evaluation. To provide in-vehicle driving evaluations, individual states have established requirements regulating the credentials required to take a client on the road to evaluate driving. In California, licensed OT s can perform in-vehicle driving evaluations for the general public without additional certification. 2 However, to evaluate on-the-road driving performance, most OT s receive Certified Driver Rehabilitation Specialist (CDRS) credentials from the Association for Driver Rehabilitation Specialists (ADED). The ADED website lists 244 Certified Driver Rehabilitation Specialists in the United States. While most of these are OT s, one does not need to be an OT to be a CDRS. The ADED database lists 9 CDRS in California, 6 of which have an OT background (as of 8/11/05). However, this database only contains individuals who belong to the ADED professional association. In comparison, AOTA lists 7 OT s in California with their CDRS (as of 8/11/05), one more than ADED. Current System Capacity Information from the survey of California OT driving programs was used to quantify the capacity of California s current occupational therapy system to address driving and community mobility. Current capacity was determined by asking survey respondents for the average number of evaluations being conducted each month by their driving programs. Figure 2: Current Evaluation Capacity of OT Driving Programs Number of Programs to 5 6 to to Number of Driving Evaluations Per Month The most driving evaluations are conducted in Los Angeles (LA), San Diego and Orange Counties, which also have the greatest number of driving programs. The two programs in Orange County each conduct 16 or more evaluations a month, while 3 of the 7 programs in LA County indicated that they conduct 16 or more evaluations each month. The fewest number of evaluations were conducted in Nevada and Santa Barbara Counties, with each program conducting only 1 to 5 evaluations a month. 2 Certain restrictions apply to this requirement; contact the California Department of Motor Vehicles for more information. 8

12 Programs in San Diego and Los Angeles Counties also indicated the greatest ability to conduct additional evaluations if referrals were to suddenly increase. To conduct additional driving evaluations, most respondents indicated a need for additional staff and access to more trained driving instructors. Other factors needed were: an additional workday for part-time staff, a larger referral base, and the addition of an on-the-road program with a vehicle. The most frequently cited response, additional staff, indicates the need for more training in driving safety and community mobility at both the generalist and specialist levels in California. Results of Focus Groups and Key Informant Interviews Overview This section of the report summarizes the results of focus groups and key informant interviews with California OT s. A total of 14 OT s from throughout California participated in focus groups and key informant interviews. The OT s were very experienced, with 11 having 20 or more years of OT experience, and half having taken continuing education or advanced training courses in driving. Half the participants were from Los Angeles County. The most common practice areas of participants were neurological rehabilitation, adult rehabilitation/physical disabilities, and driving rehabilitation, followed by acute rehabilitation, education, and vision rehabilitation. The vast majority of participants (9) practiced in a hospital setting, followed by private practice, and an educational institution. Eight participants addressed driving in their practice as a Generalist, two were Specialists, two were educators whose curricula included driving and community mobility, and two participants did not address driving in their current practice. Figure 3: How Participants Address Driving Figure 4: Professional Association in Their Practice Memberships of Participants Generalist Specialist Educator Do Not Address AOTA OTAC ADED CADPD Opinions and Concerns: California OT s Reflect on Ways to Improve the Network of OT Driving Programs 3 Description of Legend Abbreviations: AOTA, American Occupational Therapy Association; OTAC, Occupational Therapy Association of California; ADED, Association for Driver Rehabilitation Specialists; CADPD, California Association of Driving Programs for the Disabled. 9

13 What prevents OT generalists from addressing driving? Participants felt there were numerous barriers preventing OT Generalists from addressing driving in their regular practice. Main barriers can be grouped into several distinct themes: 1) limited knowledge and narrow focus of entry-level OT's; 2) concerns over reimbursement for services, including limited referrals from doctors; 3) time and productivity issues; and 4) training and awareness of experienced OT s. Once barriers were identified, participants were asked for suggestions on how to eliminate or lessen the impact of the barriers. OT s stressed the importance of exposing undergraduate OT students to the field of driving and the importance of driving as an IADL. Driving, they felt, should be part of a standard holistic assessment that OT s should do with all of their patients. To do this, participants felt there needed to be easy-to-find online resources that would make it more efficient for OT s to learn about driving and mobility resources. Barrier themes and a selection of representative participant responses to this question are found in Table 4. What prevents OT s from becoming Specialists in Driving, such as a CDRS? The main barriers cited by the participants can be grouped into several categories: 1) economics of establishing and maintaining a driving program; 2) location and cost of specialist training courses; 3) lack of trained driving instructors; and 4) structural barriers to effective programs, including lack of referrals and issues involving the state Department of Motor Vehicles (DMV). Participants suggested ways to help reduce the barriers to OT s becoming Specialists in Driving. To reduce the costs associated with the vehicle portion of a driving program, participants suggested partnering with reputable driving instructors who have experience working with adaptive driving and seniors, but also emphasized the need for a bigger pool of trained driving instructors to work with. To help ensure additional OT s receive the necessary specialist training, participants suggested making more specialist-level training affordable and available on the west coast. Barrier themes and a selection of representative participant responses to this question are found in Table 5. 10

14 Table 4: Barriers to Generalists Addressing Driving Barriers: Themes and Representative Responses Limited knowledge and narrow focus of entry level OT s Limited knowledge and narrow focus of entry level OT s and no training in OT school. Lack of confidence is a major barrier. (OT s) not aware of issue. Concerns Over Reimbursement for Services Most OT practices are referral driven. If there is a different issue other than what they were referred for, OTs will not investigate further due to lack of reimbursement. Time and Productivity Issues It takes extra time to find out where resources are. Have a limited time w/patient, and facility may be focused on ADL only and discourages looking at IADL (e.g. in acute care). Training and Awareness of Experienced OT s OT s do this as only a small fraction of what they do so (they) only address (driving) when something comes up that relates. It is hard to stay current in knowledge; DMV rules and laws change. OT s are not doing a holistic evaluation. Solutions: Representative Responses Have entry level OT s take additional courses on driving evaluations and learn more about the laws and requirements for driving safety. Provide training at undergrad level; AOTA should address it in their curriculum requirements and establish standard requirements across the country. Provide information on what it would take to move to advanced training. "Contact Medicare and figure out what is available and then speak to their doctor about services the patient could receive. Develop a targeted or newsletter to give people resources. Revise the guidelines and allow the professional to determine the amount of time with patients. When OT does an evaluation in acute care, they should be given time to do a more thorough evaluation, including an interview of patient goals and asking the question, Do you want/need to be able to drive again? Make sure driving is part of the whole assessment process. (Need to know) how to find resources especially if there is no driving program in your facility. OTAC should have something on their website that could link OT s to current answers for frequently asked questions. Add the mobility component to the standard evaluation. Create new guidelines for health care professionals to go by to be able to treat what the patient needs. 11

15 Table 5: Barriers to Becoming a Driving Specialist Barriers: Themes and Representative Responses Economics of Program Prohibitive cost of getting the specialty training to do a driving program. Hospitals cannot afford equipment for on-road evaluations. Education/Training Issues No trainings offered on West Coast. Competence; not enough courses in OT schools or continuing education. Economics of training; classes cost a lot of money. Lack of Trained Driving Instructors Lack of referral sources for driver training and follow-up. Lack of driver instructors that are trained on adaptive driving and seniors; we can identify the problem, but there is no one to refer it to. Structural Barriers to Effective Programs Can meet needs of most clients, but higher level needs, such as vans, are difficult to meet. Need better communication between programs & DMV. Referrals have to come from a doctor and not enough doctors know about driving issues. Solutions: Representative Responses Collaborate with a driving instructor w/experience in adaptive driving. Have programs use driving simulators. In OT school, (students) need to be exposed to theory and practical part of what happens; need to be set up to explore option as a career, such as field work placement. Make specialty training available on west coast region so travel is less expensive. Make training (available in small, stand-alone) modules so that the OT can take each module as their finances allow as most will be paying on their own. Driving schools need to dedicate one or two seasoned driving instructors to this; send to ADED continuing education so they can become more knowledgeable and so OT s can work with the (driving) schools to do a behind-the-wheel assessment. Need more driving instructors trained to work with seniors; lots don t stay in the business but there needs to be a bigger effort to recruit trained instructors. (Within DMV) things should be explained better for limited & restricted licenses. Change format of questionnaire on drivers license renewal form. People who are cognitive impaired do not have insight into problems. To develop a program, need to establish rapport with (local) DMV (field offices). What type of training would help Generalists address driving? Participants supported more education in driving and community mobility for OT Generalists, beginning at the undergraduate level. They stressed the need for hands-on experience; trying out specific assessments either in a training workshop or in a vehicle or clinic with an actual patient. This was particularly important for Specialist-level training, which participants felt required significant fieldwork and mentoring. Generalist participants in particular felt that a major goal of training should be to give OT s the confidence to apply their general assessment skills to driving and to understand how the impairments they see everyday relate to driving. 12

16 OT s gave specific suggestions for the content of a Generalist-level training, including: Overview of OT specialty levels (Generalist to Specialist): Clarify how you go through the levels; what your role is at each level; and what your skills at each level qualify you to do. Information on how to address patients more holistically and how to market this approach to outpatients. Understanding the psychological aspect of what driving means to seniors; how aging and disease processes relate to driving function; and how specific functional issues affect driving. A psychosocial assessment for OT s to help them know tolerance for frustration and ability to remain calm in stressful situations, which is important for in-vehicle evaluations. Use of videos to demonstrate assessments and driving evaluations. Basic and advanced training on specific assessments. How far would OT s travel to access training? Participants stressed the need for trainings to be held within California. Regional trainings, such as in Arizona or Nevada, were also suggested as possibilities. What is the best way to provide training to OT s (consider format and outreach)? Participants recommended a range of possible training formats, including online trainings and regional in-person trainings. Online training was more popular for the Generalist level than the Specialist level training however, a blended course, that combines online and in-person weekend sections, was also suggested. Participants emphasized that specialist training should be hands-on. OT s stated the importance of a formal layout and a 2-day maximum for the program, given on a Friday and Saturday. Generalists indicated that a formal certificate program with continuing education credit may help give OT s the confidence they need to address driving and give them an incentive for participation. Other potential avenues for training included: having OTAC create a grant-funded committee of OT s that would be traveling trainers; and conducting presentations within facilities and at OTAC meetings. Participants suggested marketing trainings to OT s through direct mailings, possibly through the Board of Occupational Therapy, as many OT s do not belong to professional associations. Making trainings free or low-cost was cited as a good way to attract OT s to training. 13

17 What would encourage more Generalist-level OT s to incorporate driving and community mobility into their practice? Participants cited several ways to encourage more OT Generalists to incorporate driving into their practice: 1) more education on driving and its importance at all education levels, from OT school to regular facility in-services; 2) better information on how to be reimbursed for services (to enhance facility support for the program); 3) institutional support from facilities and professional associations; 4) improving public demand for the service; and 5) making driving recommendations a standard part of each OT evaluation and identifying valid, easily accessible assessment tools that correlate to driving performance. Most participant comments centered on education, financial, and institutional support issues. Participants stressed the confusion in the field over reimbursement for driving assessments. They stated that in order for OT s and facilities to address driving, a driving program needs to be a lucrative business that will be reimbursed. However other participants suggested that the facility could do it as a community service rather than for financial gain. OT s also felt that professional associations need to emphasize driving as a practice expectation. Participants expressed that Generalists and new therapists often don t realize how important (driving) is in terms of quality of life and independence and that they don t think about driving so somehow it needs to be prompted. How could more OT s be encouraged to receive specialty certification in driving? Participants cited several methods to encourage more OT s to become Specialists in Driving, including providing: 1) more public awareness of the service availability; 2) more education for OT s and referrers; 3) reimbursement for services; and 4) facility/institutional support for both the program and necessary training. A selection of representative participant responses is found in Table 6. 14

18 Table 6: Methods to Encourage Specialty Certification Theme Representative Responses Public Awareness of Service More organizations need to know OT s exist and that they can be in this role (of evaluating driving). Supply and demand there has to be a need (for the service). Education for OT s and Referrers (Need ) information on how to start own practice. Educate physicians and seniors that service is available. A recognized advanced practice area in driving would create more prestige. Reimbursement for Services Could be a source of revenue for a hospital or rehabilitation facility, if it is then the facility will make it a priority and it will be emphasized in the clinic. Programs need to be self-supporting with reimbursement and referrals. Institutional Support (Facility and Professional Association) for Program and Training Support for training, both economically and time-wise. Some facilities don t want to have a separate driving instructor. OT s often not willing to finance what it takes to become a CDRS on their own; it needs to be funded by hospitals. What would build capacity for OT s to address driving as both Generalists and Specialists? To enhance community and statewide capacity for OT s to address driving in their practice, participants most often stressed the need to build partnerships between the state and the OT community. ( State was assumed to mean state government agencies.) They also emphasized the need to build capacity of OT schools to enable them to teach driving and community mobility. Participants provided several specific examples of how to build partnerships between the state and the OT Community: Create a statewide task force of OT s, including a combination of Specialists and Generalists, to do strategic planning for the field, connect specialists at different facilities, and begin addressing the problems associated with creating a successful network of driving programs. Create social norm change to make driving assessment a priority. Develop a collaborative relationship between the state, OTAC and AOTA to develop classes that are economically reasonable and become a part of standard Generalist training. Participants also cited the need for: 1) better public education for and about older drivers so that when there is a question about driving, people go to OT s who can then determine the need for preparatory rehabilitation, timing for evaluation, or appropriate interventions; 2) an information campaign for OT; 3) more research and data collection within programs; and 4) working collaboratively with DMV and insurance companies to support driving evaluations. 15

19 What next steps are needed to move this emerging OT practice area forward in California? Participants emphasized several important next steps to move the emerging OT practice area of driving forward in California, including: 1) increasing education opportunities; 2) building the capacity of the OT-field; 3) more public information about the benefit of OT driving programs; and 4) building the network of qualified driving instructors. Most participants saw capacity building of the OT field as the most pressing next step. Suggestions for next steps to help build capacity include: Creating a traveling task force with a diverse, multidisciplinary group that could educate both OT s and the community about driving programs and their benefits. Building a network across professional groups so people are referred to the correct place. Developing a broad plan for OT s in partnership with the state; needs to include support from a governmental body and OT s; include legislative representatives, doctors and medical associations. More opportunities for education and training also rose to the front of importance in discussions of next steps. Particularly important was improving community and provider education to enhance referrals to OT driving programs (from DMV and OT Generalists specifically), and creating a special practice area or advanced certification in driving. Why are seniors not utilizing the services of OT driving programs? Participants suggested several potential barriers that prevent seniors from seeking OT driving assessment and rehabilitation services. These barriers include: 1) the cost of services; 2) denial of problems and a misperception of personal risk; 3) fear of being reported to DMV and losing license; and 4) families and providers not discussing driving with seniors. One OT suggested that seniors are not sure what OT s do and how OT s can help with driving. She suggested the need for increased awareness among seniors of how they would benefit from an OT driving evaluation. Another participant cited a lack of trained therapists as a reason seniors are not accessing driving assessments and rehabilitation more often. OT s also provided potential ways to help reduce these barriers. As cost is a major barrier for seniors, participants suggested marketing program services to the children and families of seniors. OT s also felt public education and social norm change were important to help alleviate the fear of going to an OT driving program and to start educating folks on how OT driving programs may be able to help extend safe driving years. A selection of representative participant responses is found in Table 7. 16

20 Table 7: Barriers to Seniors Utilizing OT Driving Programs Barriers: Themes and Representative Responses Cost of Service Who will pay for it? Denial of problems Fear of learning something they don t want to know. Seniors look at driving from an egocentric point of view; they think it will hurt them, not people around them. (Driving is) perceived as being not that complicated of a task. Fear of Losing License Why would they pay for someone to take their license away? If seeking (services) as prevention and they do poorly it could send them DMV. Families and Providers Do Not Discuss Driving Doctors need to start being more involved, taking a more practice stance regarding driving, and refer if they see deficits. Solutions: Representative Responses Sell services to children of seniors. 3 rd party payers need to pay for assessment, then families would send a person/patient in for evaluation. OT s need to understand what driving means to the elderly. Public education and social norm change. More contact with OT s in health fair setting rather than in a hospital-based setting. Lots of education for seniors through friendly venues; educate (groups like) AARP so they understand OT s are there to help people drive safely and independently, not to take their license away. Give them the idea (of having an evaluation), it can take 6 months of talking before they make that change. Public education and social norm change; (need) education targeted at families and seniors. Doctors need to have information about the family so they can talk with them in addition to the patient. Could OT s be more involved in screening to help seniors identify that they may be candidates? Individuals are usually referred to OT s once they have been diagnosed with impairment. Could OT driving programs provide services to well-elderly as a form of early prevention to prevent or reduce mobility problems? Is this something an OT Generalist could do or only a Specialist? How could this service be marketed to OT s, seniors and their families? Participants were in favor of OT s evaluating seniors in order to prevent driving problems. They suggested a first step would be offering group classes through a hospital facility, AARP, or community colleges to present general issues and introduce the concept of occupational therapy addressing driving and community mobility as part of wellness initiatives or rehabilitation. The informed senior could elect to take an actual driving evaluation if they are interested. Participants stressed the need to provide seniors with incentives to do this, one incentive being that they may keep their driving ability longer. All participants felt OT Generalists with some advanced training in driving could do a preventive driving screen, with the expectation that they would refer to a driving specialist for a comprehensive evaluation if warranted. (An) OT with advanced training could do a series of screening measures to identify deficits and strengths; if deficits were overwhelming, they could refer out to a specialist. To market this preventive service to OT s, participants suggested using OTAC, local OT meetings, newsletters, articles in professional journals, and targeted educational pamphlets mailed to 17

21 OTs who are already interested and looking to build (their) practice. Participants also had suggestions on how to market this preventive service to seniors and their families. Most participants felt the service should be marketed through doctors, AARP, senior service providers (like Area Agencies on Aging and senior centers), church groups, and DMV. Would OT s be willing to volunteer their time to participate in a community event, such as a CarFit 4 event? What would entice OT s to volunteer? All participants felt OT s would be willing to volunteer their time to participate in a community event such as the CarFit program. To entice OT s to volunteer their time for such an event, participants suggested offering professional development/continuing education units for the volunteer time and allowing OT s to market their program at the event to increase referrals. Another suggestion was to involve OT students at the event to do the checklist. What would OT s do if a well-elder self-refers into a driving program? Driving specialists in the focus group indicated they are seeing more and more well elderly selfrefer, and be referred from their family and their physician. In order to see well-elderly in hospital facilities, seniors require a physician referral with a diagnosis. While this is necessary for their reimbursement and for medical follow-up that arises, the OT s felt there was another important reason to have a physician referral. Even with the well-elderly, we have very little clout with a patient. The patient has a tendency to follow the doctor s orders even if they don t agree with the doctor. All of the specialist OT s in the focus group indicated that they would conduct a full functional assessment on wellelders, because if there are concerns about driving, there are likely concerns with other activities of daily living as well. Finally, the specialists in the focus group indicated that it would be important to collect data on well-elderly to illustrate the need for services and determine the outcomes of visits which would help build OT driving programs. As one OT put it, We have to find out if the outcome is beneficial. However these hospital-based OT s indicated it is hard to find which are well-elderly when they are all coming in with a prescription. This may point to the need for a formal research study conducted across a variety of settings, with standards for well-elderly, and outcomes collected based on referral diagnosis. 4 The CarFit Program is designed to give seniors a quick and comprehensive check of how well they work with their vehicle. The check-up process takes about 15 minutes and includes recommendations from an occupational therapist about car adjustments and adaptations. It prompts older adults to start thinking positively about how they can maintain their driving skills. CarFit is a collaborative effort of the American Society on Aging, the AARP, the American Occupational Therapy Association, and the Automobile Club. 18

22 Conclusion It is vital that California enhance its network of affordable, convenient and trustworthy OT driving programs to help its growing senior population stay safely mobile and age successfully in their homes and communities. While the state has many holes in its network of OT driving programs, the OT s who participated in this effort demonstrated a commitment and desire to help eliminate barriers to a successful system of programs. AOTA and OTAC have already demonstrated a commitment to enhancing this emerging practice area for OT s, but more remains to be done. Several key themes emerged from these conversations with California s OT community. First, better education and awareness at the undergraduate level is critical to increasing the number of generalists who recognize their role in driving, and of specialists who are trained to provide assessments, rehabilitation, and retraining. This training and education should be affordable and accessible; located within California. In addition, stronger collaboration between OTAC and the state government, possibly through a state-level task force, is needed. Public education and social norm change are critical in this effort and can help build a referral base for programs and identify the field of OT with driving. As one OT put it, when people think of driving, they should think of OT. Much more work needs to be done to explore practical and creative solutions to the barriers discussed in this report. Structural and institutional barriers that prevent driving programs from being effective and successful, some of which were discussed in this report, must be overcome before a strong network can be in place. Some of the key structural barriers include: 1) acquiring liability insurance for a vehicle program; 2) lack of reimbursement by insurance or private payers for assessment, training and follow-up time; and 3) procedural roadblocks, such as hospital-based programs requiring physician referral. Finally, several important issues were not addressed in this report and should be explored as part of future efforts. Of particular importance are: The role of OT Assistants in driving programs and in capacity building efforts for these programs. Marketing strategies to assist OT s in getting the support of facility administrators. How to attain funding for a driving program. Overcoming the barriers described in this report will require the commitment of funding agencies, professional associations, private and government sector stakeholders, and OT s themselves. However, the benefits of eliminating the barriers to a successful network of affordable, convenient and trustworthy OT driving programs will far out weigh the costs. 19

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