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									       The OT Generalist Shifting into Gear
for the IADL of Driving and Community Mobility


     Carol Blackburn, OTR/L, CDRS
   Susan Pierce, OTR/L, SCDCM, CDRS
        Adaptive Mobility Services, Inc.
           Presented at FLOTA Conference
                     Orlando, FL
                   February 8, 2009
    The Objectives:
At the end of the presentation, the participant will:
 understand the value of OT in addressing driving &
  community mobility as an instrumental activity of
  daily living
 recognize the OT process for addressing driving &
  community mobility.
 understand the role of the OT Generalist and the OT
  Specialist in Driving &Community Mobility
  (SCDCM) regarding the occupation of driving
 experience the emotions of our clients as they gain
  their freedom and independence with driving
The OT Practice Framework –
Driving & Community Mobility




Sections adapted from the AOTA. (2002). Occupational therapy practice
framework: Domain and process. American Journal of Occupational
Therapy, 56, 609-639.
NOTE: will be referenced in text as OTPF, 2002 with page number.
Is Community Mobility within the
Domain of Occupational Therapy?

“Occupation is everything people do to
  occupy themselves, including looking after
  themselves…enjoying life…and
  contributing to the social and economic
  fabric of their communities.”
  OTPF (2002), pg 609–639.
Engagement in Occupations
   Occupational therapy supports “…engagement in
    occupations and in activities that allow desired or
    needed participation in home, school, workplace,
    and community life situations.” (OTPF, pg 611)

   OT addresses engagement in occupation from a
    dual and holistic perspective:
      Subjective (emotional and psychological)

      Objective (physically observable)
   With this perspective, OT addresses “all
    aspects of performance (physical, cognitive,
    psychosocial, and contextual) when
    providing interventions designed to support
    engagement in occupations and daily life
    activities.”
    (AOTA Framework, pg 611)
The difference between activities & occupations:


“Activity describes a general class of human
  actions that is goal directed. A person may
  participate in activities to achieve a goal,
  but these activities do not assume a place of
  central importance or meaning for the
  person.”
  (OTPF, 2002, pg 610)
Occupations are…

“…activities having unique meaning and purpose in a
  person’s life…central to a person’s identity and
  competence, and they influence how one spends time and
  makes decisions.”
  (OTPF, 2002, pg 610)

   When individuals engage in occupations, they are
    committed to performance as a result of self-choice,
    motivation, and meaning.
    (AOTA Framework, pg 611)
Areas of occupation in OTPF:
 Activities of daily living
 Instrumental activities of daily living
 Education
 Work
 Play/leisure
 Social participation
Instrumental Activities of Daily Living:
                                       care of others
                                       care of pets
“…are oriented toward
                                       child rearing
  interacting with the                 financial management
  environment and that
                                       community mobility
  are often complex –
                                       health management &
  generally optional in                 maintenance
  nature.”                             home establishment &
  (OT Practice Framework, pg 620)
                                        management
                                       meal preparation &
                                        cleaning
                                       safety procedures &
                                        emergency responses
                                       shopping
Relating the OTPF to Driving & Community Mobility:



Performance                                   Performance
Skills                                         Patterns
  motor                                            habits
  process                                          routines
  communication/interaction                        roles



Context           Activity Demands              Client Factors
                              adapted from OTPF, 2002, pg 611
OTPF defines 2 Types of Mobility that
are inter-related:


 Functional   Mobility as an BADL



 Community    Mobility as an IADL
Functional mobility includes “mobilizing
in the community”
:
“…moving from one position or place to
 another (during performance of everyday
 activities), such as in-bed mobility,
 wheelchair mobility, transfers…
 performing functional ambulation and
 transporting objects.”
    (OTPF, 2002, pg 620)
Community Mobility
“…moving self in the community and using public or
private transportation, such as driving, or accessing
buses, taxi cabs, or other public transportation
systems.”
      (OTPF, 2002, pg 620)
 Community mobility is a vital
 activity of life that allows a person
 to engage outside the home.


Vital: “essential to
 life, of greatest
 importance, &
 indispensable.”
  (Webster’s dictionary)
If community mobility & driving
is an IADL…
 …then OTs       …we must
  have an          include it as
  obligation to    routinely as
  treat it as any  the ADLs of
  other ADL.       bathing and
                   dressing.
THE FACTS:
   Driving is one of most complex IADL

   Driving should be one of the last ADL addressed

   Driving is an ADL skill that can kill so assessing
    readiness within a medical model is important.
    We have the skill set to address community
    mobility & driving.


   medical background.
   understands primary/secondary diagnoses and
    implications.
   understands aging process with or without a disability or
    chronic condition.
   understands the concept of the “whole person and the
    whole picture.”
   qualified to assess the motor, sensory and processing skills
    related to community mobility.
   Can break down a task into its integral areas of function.
The demographics of aging are
changing dramatically.

   Today: 35 million Americans are > age 65
   By 2030: 70 million Americans will be > age 65
   age 85 & > is growing faster than any other age group
   There will be more licensed drivers who will drive later in
    life, more frequently and for greater distances.
   Driving & community mobility will always be the key to
    independence in our society
Our holistic view allows us to understand the
BIG picture of community mobility.
 Client centered approach
 Consideration of:
   Performance skills

   Performance patterns

   Context or contexts

   Activity demands

   Client factors
An OT Team is usually necessary to address
driving on the IADL continuum.

The    OT Generalist

The OT Specialist in Driving
  & Community Mobility
During the ADL evaluation, the OT
Generalist should:
   Develop an occupational profile regarding
    the importance of community mobility &
    driving
      Identify the client’s needs, problems &
       concerns about driving
      Identify roles & priorities
 Evaluate occupational performance in
  regards to driving/CM skills
 Consider client factors
 Include treatment in the intervention plan to
  improve or enhance sub-skills needed for
  driving or CM
 Ask if person is or was a licensed driver or
  has interest in being evaluated for driving
  potential
 Discuss process for addressing driving
  issues
 Inform re: resources & referral to a
  specialist if necessary
 Communicate with other disciplines
 Determine readiness or appropriateness for
  referral to OT Specialist in Driving and
  Community Mobility
 Serve as “gate keeper” until ready for
  formal evaluation or for a recommendation
If struggling with a decision about driving for a
client, consider the conflicting values and exercise
reasonable judgment.




   The client’s independence vs potential
    danger to self and others

   The public’s safety vs the client’s right to
    confidentiality and independence.
In Considering Driver Readiness:



Use your common sense about what you
 know about the occupation of driving.

Use critical thinking skills and what you know
 about your client.

The OT process can assist for a good
 outcome.
   Counsel, inform & educate family/client not
    to drive until it has been approved or until
    appointment with OT Driving Specialist

   It is NOT the OT Generalist’s role to pass
    or fail for driving unless there are specific
    deficits that contraindicate safe driving
Consider vision &/or visual skills:

   State’s standards
      VA – 20/50

      FOV – continual 140 degrees

   visual neglect ?

   homonymous hemianopsia ?

   needs cataract surgery

   suspect for glaucoma, diabetic retinopathy,
    macular degeneration or other problem
You can report an unsafe driver in Florida!


 www.myflorida.com
 Click into driver license
 Go to link for reporting an unsafe driver
 Complete form and send to MAB with
  driver licensing
If driving retirement is the answer….
 Counsel and be a listening ear
 Look at transportation alternatives in
  client’s community
 Evaluate their ability to use transportation
  options
 Document all actions & recommendations
  in regards to driving and community
  mobility
    The OT Generalist’s responsibility is:
 to understand your role in addressing driving
  as an IADL as you do all other ADL.
 to know how & when to refer to the OT
  specialist in driving in your area for a
  comprehensive driver evaluation.
 to understand your limitations but to act
  when you should as the OT
 not to recommend adaptive equipment or
  where they go to get the equipment
Note of Caution:

   If you are providing  YOU are acting
    the clinical           in the role of the
    evaluation and         Specialist in
    referring to an
                           Driving &
    outside source for
    the in-car             Community
    evaluation:            Mobility
    Brief summary of the role of the OT specialist
    in driving & community mobility:


 To assist the OT generalist in determining if
  person meets state requirements
 When necessary, perform in-depth
  evaluation of performance skills & client
  factor and determine their effect on driving
  abilities
The OT Driving Evaluation Process

Step 1: Occupational Profile
Step 2: Analysis of Occupational Performance
Step 3: Vehicle Assessment
Step 4: Equipment Assessment
Step 5: In-Traffic Assessment
Step 6: Intervention
Step 7: Prescription
Step 8: Final Vehicle Fitting
   Provide on-road assessment with consideration of
    contextual factors, performance patterns and
    habits
   Provide in-car training or specialized driver
    education
   Determine if adaptive equipment is required and
    follow-up for vehicle adaptations
   Determine if person is at-risk, can continue to
    drive safely or has potential to learn to drive
Resources for finding an OT Specialist
in Driving & Community Mobility
   www.aota.org
     Older driver link



   www.aded.net
Don
                   59 YO male with C7 SCI
                   had not driven since injury
 Thepower of       onset in 2004
                   married to RN , 3 dogs
 occupational      power wheelchair
 therapy           hospital administrator, on
                    community boards
                   dependent upon wife for
                    transportation as public bus
                    was inadequate to meet his
                    needs/schedule
Margaret
                    41YO who had 10 TIAs in 1 year
 The               Had CVA while putting in
 functionality       sprinkler system in yard alone
                    Traveling Insurance agent
 of                 Uses folding manual w/c
 occupational       Missed being out and about, loved
                     her Wal-Mart
 therapy
Christine
                   15YO with dwarfism 3’8”, 59 lbs.,
 The               scoliosis, hearing aids
 adaptability      multiple orthopedic surgeries
                   never driven
 of                uses walker to carry school books
 occupational      uses w/c in community
                   active with school & friends
 therapy           supportive mother
                   now in college
Rita               33YO, 59 lbs., 3’9”
                   born in Indonesia, transported
 Theholistic       only in taxi or bus, never could
                    see out, never driven
 approach of       married to a person who is
                    blind
 occupational      co-operates a courthouse
 therapy            cafeteria and a vending co
                   job requires frequent
                    movement in the community
                    for inventory and re-stocking
Caroline
                   18YO with OI, able to walk
 Theultimate       but has had numerous fx
                   uses rigid frame manual w/c
 independence      parents divorced, living with
 of                 overbearing father
                   graduated with honors from
 occupational       high school and accepted and
                    U of F for Fall
 therapy           aspires to be architect
Celia
 The               36YO single mother
                    SMA muscular dystrophy
 excitement of      caregiver for mother & aunt
 occupational       power w/c
 therapy            hospital administrator
                    transportation by bus/train
                    never driven
Chuck                46YO with incomplete SCI
                      C4-5
 The   reality      Walked with cane then
                      scooter and now power w/c
                     Traveling/consulting pastor
 of                  Lives with wife who has
 occupational         limited her income in order
                      to transport him
 therapy             Drove well for 30 yrs before
                      began having driving
                      difficulties
                     Fundraisers bought his van,
                      VR modified the van
 Elyse             adopted from Vietnam by
                    parents who work with persons
                    who are deaf
 The              totally dependent, unable to walk
                    or talk when came to U.S.,
 perseverance       learned sign language before she
                    talked, now ADL independent
 of                loves school, aspires to have
                    college degree & teach special
 occupational       education
                   aspires to live on her own
 therapy           Was first turned down for
                    driving on 18th b’day but felt she
                    was not giving a fair chance
Nancy
                    69YO, divorced, retired
 The   normal      bilateral LE amputations
 of                 power w/c
                    moved into retirement center
 occupational       enjoys outdoors, church choir,
                     bridge, family & friends
 therapy            learned to take bus but yearned
                     for more freedom
                    working on second master’s
                     degree
Danny
 The              34YO with cerebral palsy,
                    power w/c
 teamwork of       never driven, was always told
                    he couldn’t
 occupational      lived with supportive parents
 therapy            who transported him to/from
                    work as computer draftsman in
                    county appraiser’s office
                   recently married
                   is now on 2nd adapted van
Justin
                        Spinal Meningitis when 13
 The   simplicity       months old
 of                     15YO with bil AE & LE
                         amputations
 occupational           ADL indep except w/
 therapy                 prostheses
                        active in sports, skateboard
                         champion
                        excellent problem solver &
                         quick learner
Elizabeth
                     26YO with Werdnig Hoffman’s
 The   freedom       MD, had never driven
                     Manager of Shakespearean
 of                   Festival, grant-writer
 occupational        single, family up north, many
                      friends, loves the arts and
 therapy              teaching
                     loves her scooter
                     has to live the distance to work
                      that her scooter charge will take
                      her
Sara
                   48YO, polio at age 3
 TheWOW of        Married to a retired
                    engineer
 occupational      Has companion dog
 therapy           Loves to socialize
                   Active in community
                   Recently moved to “The
                    Villages”
To learn more about the OT Generalist Role:




   Driving and Community Mobility for Older
    Adults: Occupational Therapy Roles,
    AOTA Online CEU Course, 2005,
    www.aota-learning.org. ($112.50 members)
    Free Information:
   Physician’s Guide to Assessing and Counseling Older Drivers
      http://www.ama-assn.org/go/olderdrivers

   How to Help an Older Driver: A Guide for Planning Safe
    Transportation
      www.seniordrivers.org

   Driving Safely While Aging Gracefully
      www.nhtsa.dot.gov

   Drivers 55 Plus: Check Your Own Performance
      www.aaafoundation.org

   When you are concerned: A guide for Families concerned
    about the safety of an older driver
      Nysofa@ofa.state.ny.us
                                             www.beverlyfoundation.org
      Websites                                  Template of

   www.aarp.org
                                                 transportation options
   www.niapublications.org                  www.asaging.org
   www.usaaedfoundation.org                    Promoting safety and
   www.ctaa.org                                 independence through
   www.seniordrivers.org                        older driver wellness
   www.nia.nih.gov/news                     www.granddriver.info/
   www.aaafoundation.org                            Driver refresher courses
   www.trb.org (Transportation Research             Finding a driver rehab specialist
    Board)                                           Alternative transportation
                                                      options
   www.uab.edu/safemobility                         Family resources
   www.seniordrivers.org                            Older driver facts
   www.thehartford.com
   www.iihs.org (Insurance Institute for
    Highway Safety)
References:
   American Occupational Therapy Association (2002). Occupational therapy
    practice framework: domain and process. American Journal of Occupational
    Therapy, 56, 609-639.
   American Occupational Therapy Association (2005). Driving and Community
    Mobility Statement. American Journal of Occupational Therapy, 59, 666-670.
   American Occupational Therapy Association (2005). Screening Driving and
    Community Mobility Status. OT Practice, March 21, 2005.
   Pierce, S.L. Driving as an Instrumental Activity of Daily Living. Glen Gillen
    & Ann Burkhardt (Eds.), 2004, Stroke Rehabilitation: A Function-Based
    Approach, Mosby
   Pierce, S.L. Restoring Competence in Mobility. C. A. Trombly & M. V.
    Radomski (Eds.), 2007, Occupational Therapy for Physical Dysfunction.
    Philadelphia: Lippincott Williams & Wilkins
   Hunt, LA, Weston, K: Assessment of Driving Capacity. Handbook of Geriatric
    Assessment, New York: John Wiley and Sons, Inc, Lichtenberg, PA, 1999.
   Driver Rehabilitation Across Age and Disability: A Occupational Therapy
    Guide by Sue Redepenning, OTR/L, CDRS. AOTA, 2006.
   Driver Rehabilitation and Community Mobility: Principles and Practice by
    Pellerito & multiple contributors. Published by Elsevier Mosby, 2006

								
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