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Article of the week: The road toward safe driving

Rehab Regs, July 13, 2007

Consider driver evaluations as a niche specialty

As more states begin passing driver evaluation laws, OTs have the chance to provide the community with a needed service while also finding a niche market to bring in extra revenue.

Creating a driver evaluation program or education class can help keep unsafe drivers off the road and teach these potential clients how to start driving safely again.

Oregon state laws mandate that physicians report at-risk drivers to the department of motor vehicles (DMV). OTs can provide the driving assessment to help the physician discern whether a patient can drive safely. The assessment looks at the patient's physical ability, cognitive awareness, and visual aptitude.

The OT will then give the referring physician a report that states whether the patient is safe to drive, needs to retest with the DMV, or is not safe. The physician then gives the report to the DMV, which can revoke driver's licenses of those unable or unwilling to pass the state's road test.

"We test for the standards that the DMV has set up," says Genevieve deRenne, MA, OTR/L, FAOTA, the clinical supervisor for occupational therapy at Providence Portland (OR) Medical Center (PPMC). "We're really looking for the abilities and limitations that people may have. We do not do on-road testing, but we do a variety of tests in each area that focus on the disability the patient has, which may be more telling than a quick driving test."

Although many of the patients to which the tests pertain are there because of their advanced age, the assessment also works for patients who have had a stroke, experienced a head trauma, lost limbs, or had childhood disabilities that never allowed them to drive in the first place.

Types of tests

Tests for stamina, response time, peripheral vision, cognition, and memory are common during driving evaluations.

One test that PPMC uses is the Dynavision, which is a comprehensive assessment that tests visual cognition and processing along with physical limitations. The test involves a wall-mounted board with 64 lights that have different sequences for the patient to complete within a timed period.

The BiVaba is another test that is used for visual limitations, while Trailmaking, Part B, and the Allen Cognitive Assessment are used for cognitive testing and memory.

The typical evaluation takes between one-and-a-half to two hours, making it a time-consuming program but one that can pay dividends.

"Most of our patients are self-pay, although occasionally an employer pays," says deRenne. "Medicare will pay sometimes if it's stroke-related, but because it's a one-time thing, getting reimbursed isn't typically an issue."

Providence charges $256 for the evaluation and, because its program began before the state laws existed, it's become a common facility for referrals.

Oregon set up the law in part to keep physicians from being considered the bad guys. Patients may be less likely to return to a doctor who told them they aren't allowed to drive anymore, so the state put the onus on OTs. That makes most of these clients not likely to be long-term patients. But they're also patients who you might not see any other way. OTs are also more qualified to test for driving skills than most general practices physicians.

Check your references

Physicians aren't the only ones referring patients to the assessment.

Healthcare professionals can refer patients directly, and sometimes the hospital's outpatient rehab therapists will refer their patients as they get ready to start driving again. But one of the more profitable referral bases are patients' families looking to get a loved one off the road.

"Giving up driving isn't easy for a lot of people, so sometimes hearing it from a specialist is the only way they'll listen. Families will pay just to make sure their parents are safe," says deRenne.

Because part of your job often consists of telling patients they're going to have to change how they function, visits to your office won't always be popular. In the long run, however, the patients, their families, and other drivers will appreciate your thorough evaluations.

"Taking away someone's ability to drive is not something to take lightly," says deRenne. "There are a lot of reasons people might not drive safely, so make sure you determine the exact reason. If you know what's wrong, you might be able to fix it."

Stronger patients=safer drivers

Although deRenne's clinic focuses strictly on evaluation, other clinics also offer driver education programs for patients deemed unfit to drive. This can help increase the likelihood of return patients, but it can also involve much more work and occasional outside resources.

At the Duke Medical Center in Durham, NC, OTs first evaluate patients thought to be unsafe drivers and then prescribe that the patient:

is unsafe to drive
needs adaptive equipment
needs retraining or initial training for someone who has never driven before but wants to learn (e.g., a patient with cerebral palsy)
can continue driving, but with restrictions
is a safe driver

Unlike PPMC, Duke offers road evaluations, although OTs do not perform the tests. The hospital hires an independent driving instructor, who conducts an initial test and then follow-up tests after the OTs work with the patients on their areas of need.

"We assess and evaluate the patient in the clinic to see where areas of improvement are needed and then the driving instructor does the same on the road," says Tina Lyons-Bowman, MS, OTR/L, an OT at the Lenox Baker Children's Hospital adult outpatient wings of the Duke Medical Center. "We combine both tests to give us a good picture for further treatment."

OTs will then work to help patients become accustomed to adaptive driving equipment or strengthen muscles, vision, or any other area that needs improvement.

"We can't always get the patient back to a safe driving level, but [the treatment] still helps improve [his or her] quality of life," says Lyons-Bowman. "And some of our most appreciative patients are the ones we get back on the road."

Lyons-Bowman says most insurance companies reimburse for the OT in-clinic treatment because the work is typically common occupational therapy, but designed for the specific purpose of driving. Road testing and any further education with the driver's instructor usually is not covered.

"I think the whole area of driver's safety is one that will be growing [during] the next several years," says deRenne. "As people live longer, they are going to have to get used to the idea they might not be able to drive for the last eight to 10 years of their lives. OTs should be prepared to offer ways of alternative transportation, because you're going to get people who don't know how to function without driving."