After scoring Mr. Phillips’ performance on ADReS, you discuss the results with him. You assure him that he scored well on the cognitive tests, but that his performance on the visual and motor tasks signals the need for improvement.
You recommend that Mr. Phillips make an appointment to see his ophthalmologist, whom he has not seen in the past year. You also recommend that he begin exercising regularly by walking for 10-minute intervals, three times a day, and stretching gently afterwards. His son, who is present at the clinic visit, offers to walk and stretch with him several times a week. You ask Mr. Phillips to return to your office in one month.
When Mr. Phillips arrives for his follow-up appointment, he is wearing new glasses. His vision with the new glasses is 20/30 OU. You retest his motor skills, and he is now able to complete the Rapid Pace Walk in 8.0 seconds. His lower extremity strength has improved to 4+/5, but his range of motion on finger curl and neck rotation have not improved. With Mr. Phillips’ agreement, you refer him to a driver rehabilitation specialist for vehicle adaptive devices to help him improve his steering wheel grip and side and rear view.
Despite your interventions, your patient will sometimes continue to experience functional deficits that may impair his/her driving performance. In this case, a driver rehabilitation specialist (DRS) is an excellent resource. A DRS can perform a more in-depth functional assessment and evaluate your patient’s performance in the actual driving task. Based on the patient’s performance, the DRS may recommend that the patient continue driving with or without further restrictions or interventions, recommend adaptive techniques and devices to overcome functional deficits, or recommend that the patient retire from driving.
This chapter will provide you with information you should know before you refer your patient to a DRS.
A DRS is one who “plans, develops, coordinates, and implements driving services for individuals with disabilities.”1 DRSs are often, but not necessarily, occupational therapists who undergo additional training in driver rehabilitation. Aside from occupational therapy, DRSs also come from backgrounds such as physical therapy, kinesiotherapy, psychology, and driver education.
Many driver rehabilitation specialists receive certification from the Association for Driver Rehabilitation Specialists (ADED)* by fulfilling education and experience qualifications2 and passing a certification exam.3 Certified driver rehabilitation specialists (CDRS) renew their certification every three years by fulfilling a minimum amount of continuing education units. While many DRSs either hold certification or are in the process of obtaining the necessary education and experience, certification is not required to practice driver rehabilitation nor for ADED membership.
A DRS evaluates the client’s driving skills and provides rehabilitation as needed to enable the client to resume or continue driving safely. Although driver rehabilitation programs may vary, most typically include the elements listed in Figure 5.1 in their evaluation.
An initial driver evaluation can last one to four hours, depending on the client’s presenting disabilities and driving needs. Following the clinical assessment, clients undergo an on-road assessment if they meet the minimum state standards for health and vision, and the client holds a valid driver’s license or permit. The on-road assessment is performed in a driver rehabilitation vehicle equipped with dual brakes, rear-view mirror and eye-check mirror for the DRS, and any necessary adaptive equipment.
Please note that clients who perform poorly on the clinical assessment may still undergo on-road assessment. In these cases, the DRS may recommend on-road assessment for one of two reasons: (1) Clients who perform poorly on individual components of the clinical assessment may still demonstrate safe driving due to overlearning the driving task; and (2) clients and family members may need concrete evidence of unsafe driving, which can only be documented through observation of behind-the-wheel performance.
Driver assessment and rehabilitation are appropriate for a broad spectrum of physical and cognitive disabilities. DRSs work with clients who have dementia, stroke, arthritis, low vision, learning disabilities, limb amputations, neuromuscular disorders, spinal cord injuries, mental health problems, cardiovascular diseases, and other causes of functional deficits.
Driver rehabilitation can be as straightforward as providing extended gear shift levers, padded steering wheels, and extra mirrors to patients with arthritis, and training them in their use. It can also be as complex as working with a client with dementia and his/her caregivers to determine the client’s driving needs, plan driving routes for the client, supervise practice drives, and provide close and extended follow-up.
While the cost of driver assessment and rehabilitation varies between programs and according to the extent of services provided, it is typically $200 to $400+ for a full assessment and $100 an hour for rehabilitation. If adaptive equipment is required, it can cost approximately $70 for a spinner knob, $300 for a left foot accelerator, $700 for hand controls, and thousands of dollars for reduced-effort steering systems, wheelchair lifts, and raised roofs and dropped floors on vans.
Two programs consistently pay for all driver assessment, driver rehabilitation, and vehicle modifications; namely, each state’s Workers Compensation and Vocational Rehabilitation programs. Unfortunately, many older drivers do not qualify for either program, and insurance coverage from Medicare, Medicaid, and private insurance companies is variable. In general, Medicare does not reimburse for driving services, and private insurance companiesbasing their coverage on Medicare’s covered servicesact accordingly. However, some driver rehabilitation programs have successfully pursued insurance reimbursement from Medicare and other providers. (Note that while Medicare may provide partial or full reimbursement for driver assessment and rehabilitation, it does not cover the cost of adaptive equipment.) At present, the American Occupational Therapy Association (AOTA) is actively lobbying for consistent Medicare coverage of OT-performed driver assessment and rehabilitation, with the assertions that these services fall under the scope of OT practice and that driving is an instrumental activity of daily living (IADL).
Because rates and extent of insurance reimbursement vary between driver rehabilitation programs, you will need to ask each individual driver rehabilitation program about its rates, insurance coverage, and payment procedures (eg, patient pays up-front and is reimbursed when insurance payments are received, or payment is collected directly from the insurance provider).
Driver rehabilitation programs and DRSs in private practice are often affiliated with hospitals, rehabilitation centers, driving schools,† and state driver licensing agencies. DRSs can sometimes be found through Area Agencies on Aging, universities, and area Departments of Education as well.
To locate a DRS in your area, you may wish to start by calling the occupational therapy departments in your local hospitals and rehabilitation centers. The Association for Driver Rehabilitation Specialists’ (ADED) online directory is another good place to start. The directory, which can be found by clicking on the ‘Directory’ button at www.driver-ed.org or www.ADED.net, lists all 637 ADED members as of January 2003. You can search the directory by state, country, type of facility, services offered, and professional background of the DRS, as well as by name of the DRS or name of the driver rehabilitation program. Please note that not all ADED members provide assessment and rehabilitation services; some are involved solely in vehicle modification, as indicated in their ‘program and services’ field.
When selecting a DRS or driver rehabilitation program, there are several things you should ask:
Prior to making the referral, let your patient know why he/she is being referred, what the assessment and rehabilitation will accomplish, what these will consist of, and how much he/she can expect to pay out of pocket for these services.
For example, you could tell Mr. Phillips
“Mr. Phillips, I’m pleased that you can see better with your new glasses, and that your physical fitness has improved with your walking and stretching. I’d like you to keep up the good work. However, I’m worried about your poor hand grip and I’m concerned that you can’t see around you well enough to drive safely. I’d like to send you to someone who can help you with these things.”
“This person, who’s called a driver rehabilitation specialist, will ask you some questions about your medical history and test your vision, strength, range of motion, and thinking skillssimilar to what we did the last time you were here. He/she will also take you out on the road and watch you while you drive. Afterwards, he/she might recommend some accessories for your car, such as extra mirrors, and show you how to use them.”
“The cost of this assessment is $400. Training costs $100 an hour, and the car accessories may cost around $100 to $200. However, your insurance will pay for 80% of the assessment and training. This means that you’ll pay $80 for the assessment, andif you need them$20 an hour for training and $100 to $200 for accessories.††† I know this sounds like a lot of money, but I think this is important for your safety. If you were to ever get into a car crash, your medical bills could end up costing you more money, and you might suffer a great deal of pain and disability. I’d like to prevent that from happening.”
When writing the prescription, list a specific reason for assessment and rehabilitation. Assessment because the patient is “elderly,” “debilitated,” or “frail” does not provide much guidance to the DRS and can complicate insurance reimbursement. On the other hand, “OT driver evaluation for poor finger flexion and neck rotation secondary to arthritis,” “DRS evaluation for hemianopia secondary to stroke,” and “CDRS evaluation for cognitive deficits secondary to Alzheimer’s Disease” provide more guidance for the DRS and are more likely to be reimbursed by insurance.
Remind your patient to follow up with you after he/she undergoes evaluation. If your patient is safe to drive (with or without restrictions, adaptive devices, and/or rehabilitation), reinforce any recommendations made by the DRS. When applicable, family and caregivers should be informed of these recommendations. Also remember to counsel your patient on the Tips for Successful Aging and Safe Driving Tips, and encourage your patient to start planning alternative forms of transportation in case they ever become necessary. If your patient is not safe to drive, then you will need to counsel your patient on driving cessation. This is discussed in the following chapter.
Unfortunately, driver assessment and rehabilitation may not always be feasible options for your patients. In some areas, DRSs simply are not available. Even if a DRS is available, your patient may refuse further assessment or be unable to afford it.
If driver assessment is not an option, you have several choices:
1 Association for Driver Rehabilitation Specialists: Driver Rehabilitation Specialist Certification Exam fact sheet. Available at: http://www.driver-ed.org/public/articles/index.cfm?Cat=10 Accessed January 23, 2003.
2 “Candidates must fulfill one of the following requirements: A. An undergraduate degree or higher in a health related area of study with 1 year full time experience in degree area of study and an additional 1 year full time experience in the field of Driver Rehabilitation; B. Four-year undergraduate degree or higher with a major or minor in Traffic Safety and/or a Driver and Traffic Safety Endorsement with 1 year full time experience in Traffic Safety and an additional 2 years of full time experience in the field of Driver Rehabilitation; C. Two-year degree in health related area of study with 1 year experience in degree area of study and an additional 3 years full time experience in the field of Driver Rehabilitation; D. Five years of full time work experience in the field of Driver Rehabilitation.” Found in: Association for Driver Rehabilitation Specialists: Driver Rehabilitation Specialist Certification Exam fact sheet. Available at: http://www.driver-ed.org/public/articles/index.cfm?Cat=10. Accessed January 23, 2003.
3 Examination content includes (1) program administration, (2) the pre-driving assessment, (3) the in-vehicle assessment, (4) the on-road evaluation, (5) interpretation of assessment results, and (6) planning and implementation of recommendations. Found in: Association for Driver Rehabilitation Specialists: Driver Rehabilitation Specialist Certification Exam fact sheet. Available at: http://www.driver-ed.org/ public/articles/index.cfm?Cat=10. Accessed January 23, 2003.
4 This information is adapted from an overview of the program for the Sunnyview Rehabilitation Hospital’s Driving Center in Schenectady, New York
* The acronym ‘ADED’ was retained when the association changed its name from the Association of Driver Educators for the Disabled to its current name.
† Before referring patients to driving schools for driver assessment and rehabilitation, physicians are urged to ascertain that the staff has training and experience in driver rehabilitation. A background in driver education alone may be insufficient for appropriate assessment of medically impaired drivers and correct interpretation of the assessment.
†† Please note that DRS counseling does not preclude the need for physician follow-up. Many times, the patient may be too distressed at the time of DRS counseling to absorb information. Physician counseling is crucial for reinforcement of this information, and it demonstrates to the patient the physician’s involvement and support.
††† Please note that these costs are provided only as examples for this case scenario. The actual cost of assessment and training varies between driver rehabilitation programs, and insurance coverage is also variable.