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

1. 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

2. 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

3. 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.

4. 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.

5. 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)

6. 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.” (AOTAFramework, pg 611)

7. 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)

8. 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)

9. Areas of occupation in OTPF: • Activities of daily living • Instrumental activities of daily living • Education • Work • Play/leisure • Social participation

10. “…are oriented toward interacting with the environment and that are often complex – generally optional in nature.” (OT Practice Framework, pg 620) care of others care of pets child rearing financial management community mobility health management & maintenance home establishment & management meal preparation & cleaning safety procedures & emergency responses shopping Instrumental Activities of Daily Living:

11. 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

12. OTPF defines 2 Types of Mobility that are inter-related: • Functional Mobility as an BADL • Community Mobility as an IADL

13. 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)

14. 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)

15. Vital: “essential to life, of greatest importance, & indispensable.” (Webster’s dictionary) Community mobility is a vital activity of life that allows a person to engage outside the home.

16. …then OTs have an obligation to treat it as any other ADL. …we must include it as routinely as the ADLs of bathing and dressing. If community mobility & driving is an IADL…

17. 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.

18. 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.

19. 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

20. 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

21. An OT Team is usually necessary to address driving on the IADL continuum. • The OT Generalist • The OT Specialist in Driving & Community Mobility

22. 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

23. 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

24. 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

25. 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

26. 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.

27. 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.

28. 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

29. 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

30. 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

31. 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

32. 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

33. If you are providing the clinical evaluation and referring to an outside source for the in-car evaluation: YOU are acting in the role of the Specialist in Driving & Community Mobility Note of Caution:

34. 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

35. 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

36. 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

37. Resources for finding an OT Specialist in Driving & Community Mobility • www.aota.org • Older driver link • www.aded.net

38. The power of occupational therapy 59 YO male with C7 SCI had not driven since injury onset in 2004 married to RN , 3 dogs power wheelchair hospital administrator, on community boards dependent upon wife for transportation as public bus was inadequate to meet his needs/schedule Don

39. The functionality of occupational therapy 41YO who had 10 TIAs in 1 year Had CVA while putting in sprinkler system in yard alone Traveling Insurance agent Uses folding manual w/c Missed being out and about, loved her Wal-Mart Margaret

40. The adaptability of occupational therapy 15YO with dwarfism 3’8”, 59 lbs., scoliosis, hearing aids multiple orthopedic surgeries never driven uses walker to carry school books uses w/c in community active with school & friends supportive mother now in college Christine

41. The holistic approach of occupational therapy 33YO, 59 lbs., 3’9” born in Indonesia, transported only in taxi or bus, never could see out, never driven married to a person who is blind co-operates a courthouse cafeteria and a vending co job requires frequent movement in the community for inventory and re-stocking Rita

42. The ultimate independence of occupational therapy 18YO with OI, able to walk but has had numerous fx uses rigid frame manual w/c parents divorced, living with overbearing father graduated with honors from high school and accepted and U of F for Fall aspires to be architect Caroline

43. The excitement of occupational therapy 36YO single mother SMA muscular dystrophy caregiver for mother & aunt power w/c hospital administrator transportation by bus/train never driven Celia

44. The reality of occupational therapy 46YO with incomplete SCI C4-5 Walked with cane then scooter and now power w/c Traveling/consulting pastor Lives with wife who has limited her income in order to transport him Drove well for 30 yrs before began having driving difficulties Fundraisers bought his van, VR modified the van Chuck

45. The perseverance of occupational therapy adopted from Vietnam by parents who work with persons who are deaf totally dependent, unable to walk or talk when came to U.S., learned sign language before she talked, now ADL independent loves school, aspires to have college degree & teach special education aspires to live on her own Was first turned down for driving on 18th b’day but felt she was not giving a fair chance Elyse

46. The normal of occupational therapy 69YO, divorced, retired bilateral LE amputations power w/c moved into retirement center enjoys outdoors, church choir, bridge, family & friends learned to take bus but yearned for more freedom working on second master’s degree Nancy

47. The teamwork of occupational therapy 34YO with cerebral palsy, power w/c never driven, was always told he couldn’t lived with supportive parents who transported him to/from work as computer draftsman in county appraiser’s office recently married is now on 2nd adapted van Danny

48. The simplicity of occupational therapy Spinal Meningitis when 13 months old 15YO with bil AE & LE amputations ADL indep except w/ prostheses active in sports, skateboard champion excellent problem solver & quick learner Justin

49. The freedom of occupational therapy 26YO with Werdnig Hoffman’s MD, had never driven Manager of Shakespearean Festival, grant-writer single, family up north, many friends, loves the arts and teaching loves her scooter has to live the distance to work that her scooter charge will take her Elizabeth

50. The WOW of occupational therapy 48YO, polio at age 3 Married to a retired engineer Has companion dog Loves to socialize Active in community Recently moved to “The Villages” Sara