Driving and Community Mobility

OT Practitioner Role

• Case study example from OTPF-4: a stroke survivor who wishes to resume driving. (In my practice in ARU, this is actually quite common.)
• Community mobility as an occupation: falls under IADLS as driving and community mobility.
• Defined as “planning and moving around in the community using public or private transportation, such as driving, walking, bicycling, or accessing and riding in buses, taxi cabs, ride shares, or other transportation systems.”¹ 
• AOTA Website: Although the mode of transportation may change, the meaning remains constant: transport from one location to another enables participation in the things we want and need to do (occupations).

• Case example: occupational therapy can contribute to an adolescent’s potential to drive by addressing the following pre-driving skills:

  • Promoting independence, such as coordination and quick use of the extremities.
  • Crossing streets.
  • Managing social interactions.
  • Managing time and money.
  • Handling an emergency, and self-care when alone.
  • Managing impulse control
  • Reducing stress.
  • Regulating sensory input (essential for all adolescents, regardless of functional status or disability).
• Community mobility is not just driving. The skills addressed by occupational therapy may include:
  • Navigating the environment as a pedestrian safely.
  • Reading maps or navigating with the aid of a GPS.
  • Preparing for and obtaining a first driver’s license.
  • Using a range of paratransit and public transportation options.
• Is driving and community mobility the sole responsibility of a specialist, e.g., CDRS? No. A generalist OT (what you will be when you pass the boards and become certified) should (under the AOTA’s scope of practice, which technically varies by state) consider the community mobility needs of the client. This may include evaluation, intervention, and referral.² 
• General-practice occupational therapists have the skills and knowledge to identify potentially at-risk drivers and engage in a clinical reasoning process to determine occupational therapy services for community mobility and when a referral to a driver specialist is warranted.³ 
• “Occupational therapists in both general and specialized practice with older drivers must continually monitor the growing body of evidence for effective interventions for personal factors such as cognition, vision, and motor and driving skills, as well as educational interventions focused on older drivers’ beliefs, awareness, and self-regulation.”⁴ 

A Model of Practice

The determinants of community mobility (similar to the social determinants of health) can help guide the OTP for practice.⁵ 

Social Implications and Barriers

• The 2005 White House Conference on Aging identified mobility and transportation options for older Americans as a critical priority.
• Twelve million baby boomers will already have turned 65 by 2015, with 66 million more to follow.
• This generation, which has a rich history of social activism, will influence public, social, and economic policies to ensure their ability to drive and engage in the civic and social life of their communities.
• Driving means independence to many women.
• In the older adult population, the driver’s license symbolizes functional and social competency, and the task of driving is linked to independence, feelings of freedom, and the ability to participate in meaningful occupations and social roles closely linked to self-perceived health and well-being.
• Often referred to as an enabling occupation, driving supports older adults’ ability to obtain the goods and access the services needed to support healthy aging.⁶ 
• Barriers to client driving and community mobility reported in one study include:
  • Fear of losing driver’s license (most common)
  • Lack of insight about deficits (2nd most common)
  • Lack of alternative transportation options (3rd most common)
  • Reluctance to adhere to recommendations (4th, etc.)
  • Shortage of programs
  • Lack of assessment tools
  • Cost of services
  • Lack of reimbursement⁷ 

Driving Evaluation

1. Demographics
2. Medical history
3. Driving history
4. Vehicle information
5. Environmental (e.g., routes)
6. Relevant clinical data, e.g., vision, cognition, physical, mental.

Assessment

• “When addressing community mobility and driving, occupational therapy practitioners assess the client’s sensory, cognitive, and motor performance skills; performance patterns; safety concerns; the contextual and environment supports or barriers; and the influence of community mobility and driving on the client’s ability to participate in daily life.”
• “Occupational therapy practitioners also address mental health issues that may arise when community mobility is compromised.”⁸ 
• “No single assessment exists that predicts behind-the-wheel performance or when a driver should stop driving, although several assessments have significant research supporting their use in the decision regarding driving status.”⁹ 
• Assessments most frequently used –

  

Driving Intervention

• One study demonstrated the effectiveness of driving simulator training for improving driving abilities poststroke.¹⁰ 
• Behind-the-wheel: Driver rehabilitation typically involves behind-the-wheel training sessions with a driver rehabilitation specialist.¹¹ 
• Several Level I studies provided strong evidence that combining behind-the-wheel training with classroom educational sessions can significantly increase road test scores and result in 36% fewer critical errors, predicted to equal a 9.5% reduction in crash risk.^12 13 14 
• Family involvement: Families and caregivers of drivers with dementia may need to assist the driver in deciding when and how to reduce or stop driving to protect themselves and others.¹⁵ 
• Cognitive-Perceptual Training^16 17 18 
• Physical Fitness and Ability^19 20 
• Adaptive equipment, vehicles, and assistive technologies: also include driving controls and safety features. There are primary controls (directly controls the vehicle e.g., steering wheel), secondary controls (e.g., turn signal), and tertiary (e.g., AC climate control).
• Other interventions include low vision rehab²¹ , driver education programs ^22 23 , and low-vision devices such as bioptics and prisms²⁴ .

Driving Documentation and Reporting

• Evaluation results
• Progress reports
• Reporting to: DMV, Medical advisory board, payer sources (this may also be done by the physician).

Specific Conditions

The evaluation, intervention, and considerations for the following specific conditions when it comes to driving and community mobility are beyond the scope of this review (and it would take forever).

• Spinal Cord Injury (SCI)
• Stroke (CVA)
• Traumatic Brain Injury (TBI)
• Muscular Dystrophy (MD)
• Cerebral Palsy (CP)
• Rheumatoid arthritis
• Developmental disabilities
• Mental illness

Quickly think about each of these specific conditions and the barriers that these conditions would uniquely pose and how you would solve them. Some considerations include:

• Demands for driving or community mobility
• Occupational profile
• Wheelchair use
• School bus use
• Parent and caregiver education
• Passenger safety education
• Infant car seat use
• Travel training
• Social interactions
• Family support
• Modifications of the community mobility context
• Alternative options
• Collaboration and referrals

Methods of Transportation

• Private, e.g., car, vs. Public (Mass) Transit
• Mass Transit: buses, trains, subways, and light rail systems.
• Also: volunteer, nonprofit, and community-based, government, e.g., Medicaid, and private insurance.
• Walking!
• Wheelchair, and other related devices.
• Don’t forget skateboards, bicycles, scooters, etc., e.g., college students going from class to class after an injury.
• Nowadays also: Uber, Lyft, etc. – falls under DRT (see below).

Terminology

These are pretty self-explanatory, examples included:

• Demand-responsive transport (DRT) services: think Uber, unlike a fixed bus route.^25 26  DRT can take many forms, including ride-sharing services, taxi-like services, shuttle services, and paratransit services for people with disabilities. Additional benefit: access to community mobility in rural and remote areas compared to urban.
• Curb-to-curb, e.g., Uber, but drivers may physically assist clients in/out of vehicle, but not into buildings.
• Door-to-door, e.g., driver gets out of car; e.g., client assisted from the door of home up to the entrance of a medical building.
• Door-through-door, e.g., similar to door-to-door, but driver actually assists and enters the building.
• Arm-through-arm, e.g., the manner of physical assistance, think low vision.
• Walkability, e.g., think high-crime neighborhood.
• Livability factors: affordable, accessible, inclusive, opportunities for work/education/volunteering, access to health management, and participation social-cultural-recreational activities.²⁷ 

Legal Issues and Client Resources

1. Americans with Disabilities Act (ADA) of 1990
   • Established guidelines for public transportation, e.g, wheelchair ramps
   • Established guidelines for seating, handrails, stop controls, etc.
   • Established a mandate for paratransit services and eligibility.
2. SAFETEA-LU Act (Safe, Accountable, Flexible, Efficient Transportation Equity Act): funded the Safe Routes to School program.
3. Medicare and Medicaid provisions, e.g., Medicaid recipients may be eligible for trips.
4. Private Insurance: some private insurance plans provide members with a quota of rides they can use for medical appointments and trips such as to the pharmacy. Random Fun fact: I drove for an EMT/Transportation company that provided private transport under these insurance plans for clients and I drove these clients from curb-to-curb, e.g., home to doctor’s office. It was like a private Uber before there was Uber. Fun times!

• 5 A’s: availability, acceptability, accessibility, adaptability, and affordability²⁸ 
• In several counties in New York, occupational therapists serve on Older Driver Family Assistance Networks, hosted through regional county Departments of Senior Programs and Services.
• These coalitions educate older adults and their caregivers about driving safety, offer information on driving assessment and rehabilitation services, host CarFit events, train law enforcement officers to recognize medically at-risk drivers, encourage regional physicians and health care providers to standardly ask clients about driving skills and screen for conditions potentially affecting driving, advocate for legislative changes to support reporting of medically at-risk drivers and foster the development of both public and private alternative transportation options for people who have “retired” from driving.
• In collaboration with these coalitions, occupational therapy students have completed health promotion projects through CarFit events and community presentations during National Older Driver Safety Week.⁶ 

Additional Resources

AOTA Page on Driving and Community Mobility

Bookmark

1. American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001[↩]
2. Stav, W. B., & McGuire, M. J. (2012). Introduction to community mobility and driving. In M. J. McGuire & E. S. Davis (Eds.), Driving and community mobility: Occupational therapy strategies across the lifespan (pp. 1–18). Bethesda, MD: AOTA Press.[↩]
3. Dickerson, A. E., Reistetter, T., Schold Davis, E., & Monahan, M. (2011). Evaluating driving as a valued instrumental activity of daily living. American Journal of Occupational Therapy, 65, 64–75. http://dx.doi.org/10.5014/ajot.2011.09052[↩]
4. Golisz, K. (2014). Occupational therapy interventions to improve driving performance in older adults: A systematic review. American Journal of Occupational Therapy, 68, 662–669. http://dx.doi.org/10.5014/ajot.2014.011247[↩]
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8. DEd, Janet DeLany. “Driving and community mobility.” The American Journal of Occupational Therapy 64.6 (2010): S112.[↩]
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10. kinwuntan, A. E., De Weerdt, W., Feys, H., Pauwels, J., Baten, G., Arno, P., & Kiekens, C. (2005). Effect of simulator training on driving after stroke: A randomized controlled trial. Neurology, 65, 843–850. http://dx.doi.org/10.1212/01.wnl.0000171749.71919.fa[↩]
11. Stanton, N. A., Walker, G. H., Young, M. S., Kazi, T., & Salmon, P. M. (2007). Changing drivers’ minds: The evaluation of an advanced driver coaching system. Ergonomics, 50, 1209–1234. http://dx.doi.org/10.1080/00140130701322592[↩]
12. Marottoli, R. A., Ness, P. H., Araujo, K. L., Iannone, L. P., Acampora, D., Charpentier, P., & Peduzzi, P. (2007). A randomized trial of an education program to enhance older driver performance. Journal of Gerontology, 62, 1113–1119. http://dx.doi.org/10.1093/gerona/62.10.1113[↩]
13. Bédard, M., Porter, M. M., Marshall, S., Isherwood, I., Riendeau, J., Weaver, B., …, Miller-Polgar, J. (2008). The combination of two training approaches to improve older adults’ driving safety. Traffic Injury Prevention, 9, 70–76. http://dx.doi.org/10.1080/15389580701670705[↩]
14. Romoser, M. R. E., & Fisher, D. L. (2009). The effect of active versus passive training strategies on improving older drivers’ scanning in intersections. Human Factors, 51, 652–668. http://dx.doi.org/10.1177/0018720809352654[↩]
15. Stern, R. A., D’Ambrosio, L. A., Mohyde, M., Carruth, A., Tracton-Bishop, B., Hunter, J. C., …, Coughlin, J. F. (2008). At the crossroads: Development and evaluation of a dementia caregiver group intervention to assist in driving cessation. Gerontology and Geriatrics Education, 29, 363–382. http://dx.doi.org/10.1080/02701960802497936[↩]
16. Ball, K., Edwards, J. D., Ross, L. A., & McGwin, G., Jr. (2010). Cognitive training decreases motor vehicle collision involvement of older drivers. Journal of the American Geriatrics Society, 58, 2107–2113. http://dx.doi.org/10.1111/j.1532-5415.2010.03138.x[↩]
17. Edwards, J. D., Delahunt, P. B., & Mahncke, H. W. (2009). Cognitive speed of processing training delays driving cessation. Journals of Gerontology, Series A: Biological Sciences and Medical Sciences, 64, 1262–1267. http://dx.doi.org/10.1093/gerona/glp131[↩]
18. Edwards, J. D., Myers, C., Ross, L. A., Roenker, D. L., Cissell, G. M., McLaughlin, A. M., & Ball, K. K. (2009). The longitudinal impact of cognitive speed of processing training on driving mobility. Gerontologist, 49, 485–494. http://dx.doi.org/10.1093/geront/gnp042[↩]
19. Marottoli, R. A., Allore, H., Araujo, K. L. B., Iannone, L. P., Acampora, D., Gottschalk, M., …, Peduzzi, P. (2007). A randomized trial of a physical conditioning program to enhance the driving performance of older persons. Journal of General Internal Medicine, 22, 590–597. http://dx.doi.org/10.1007/s11606-007-0134-3[↩]
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21. Lamoureux, E. L., Pallant, J. F., Pesudovs, K., Rees, G., Hassell, J. B., & Keeffe, J. E. (2007). The effectiveness of low-vision rehabilitation on participation in daily living and quality of life. Investigative Ophthalmology and Visual Science, 48, 1476–1482. http://dx.doi.org/10.1167/iovs.06-0610[↩]
22. Owsley, C., McGwin, G., Jr., Phillips, J. M., McNeal, S. F., & Stalvey, B. T. (2004). Impact of an educational program on the safety of high-risk, visually impaired, older drivers. American Journal of Preventive Medicine, 26, 222–229. http://dx.doi.org/10.1016/j.amepre.2003.12.005[↩]
23. Stalvey, B. T., & Owsley, C. (2003). The development and efficacy of a theory-based educational curriculum to promote self-regulation among high-risk older drivers. Health Promotion Practice, 4, 109–119. http://dx.doi.org/10.1177/1524839902250757[↩]
24. Szlyk, J. P., Seiple, W., Stelmack, J., & McMahon, T. (2005). Use of prisms for navigation and driving in hemianopic patients. Ophthalmic and Physiological Optics, 25, 128–135. http://dx.doi.org/10.1111/j.1475-1313.2004.00265.x[↩]
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28. Beverly Foundation. (2008). Supplemental transportation programs for seniors fact sheet. Albuquerque, NM: Author. Retrieved from http://beverlyfoundation.org/wp-content/uploads/Fact-Sheet-3-STPs- in-America.pdf[↩]