Occupational Therapy In Health Care, 28(2):203–206, 2014 C 2014 by Informa Healthcare USA, Inc. Available online at http://informahealthcare.com/othc DOI: 10.3109/07380577.2014.903450
ARTICLE
Gaps and Pathways Project: Driving Pathways by Diagnosis Sheets Susan Touchinsky1 , Felicia Chew2 , & Elin Schold Davis3 1 2
Driving Rehabilitation by Genesis Rehab Services, Kennett Square, Pennsylvania, USA, Genesis Rehab Services, Kennett Square, Pennysylvania,USA, 3 American Occupational Therapy Association, Bethesda, Maryland, USA
ABSTRACT. This paper describes the development and use of information sheets for occupational therapy practitioners to use as guides for evaluation and intervention planning to address their client’s driving and community mobility needs. Called Driving Pathways by Diagnosis Sheets, the information assists therapists with direction to connect impairment to driving risk and incorporate intervention to client goals and priorities related to driving and community mobility. An example of one of the sheets for the diagnosis of arthritis is highlighted and implications for use are discussed. KEYWORDS.
Diagnosis Sheets, driving pathways, driving rehab
BACKGROUND As a growing rehabilitation company, meeting the needs of adults with medical issues and focused on the continuum of care, particularly older adults, Genesis Rehab Services (GRS) recognized the need to address all areas of activities of daily living (ADL) and instrumental activities of daily living (IADL) as defined by the domain of practice (AOTA, 2014). With large numbers of occupational therapy practitioners employed, traditional evaluation and intervention of occupational therapy services is well developed and practiced. However, based on the increasing emphasis on “aging in place” and the growing attention on the need to keep elders active in the community, it was recognized that driving as a means of community mobility was not being addressed by the majority of the occupational therapy practitioners in settings across the 46 states in which GRS is established. Thus, in 2010, there was a conscious effort to develop and establish community mobility and driving as part of the evaluation and intervention plan for occupational therapy throughout the company. As part of the Gaps and Pathways Project, GRS was willing to participate by developing strategies to empower the generalist practitioner to address driving Address correspondence to: Mrs Susan Touchinsky, GRS, 225 Clark Drive, Orwigsburg, PA 17961, USA. (E-mail: [email protected]). (Received 4 March 2014; accepted 8 March 2014)
203
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Touchinsky et al.
and community mobility in their current practice. Addressing one of the identified “gaps” (see Dickerson & Schold Davis, this issue), the goal was to develop a structured system or pathway for treatment planning and intervention. As a result of invested staff time and expertise, GRS developed the Driving Pathways by Diagnosis Sheets resource to support all occupational therapy practitioners. GRS has an advantage of unifying the process of evaluation and therapy intervention through the use of an electronic clinical documentation and billing system customized for their services. Thus, all practitioners using the GRS evaluation are required to address each area of occupation (ADLs and IADLs) identified in the system. With the addition of a few questions, the standard evaluation form prompted therapists to address whether the client was currently a driver and if so, did they plan to return to driving. This driving and community mobility area was further detailed in the body of the evaluation. However, with this addition to the evaluation, treatment planning support was requested to ensure that the wide range of occupational therapy practitioners could appropriately address impairments by diagnostic group when considering fitness to drive. Description The objective of the Driving Pathways by Diagnosis Sheets is to demonstrate to the generalist that evaluation and intervention with a particular diagnosis does carryover to driving and community mobility. The information on the diagnosis sheets gives the occupational therapy practitioner direction connecting impairment and goals to driving and community mobility. Specifically the information on the documents connects impairment ascertained in the evaluation, to intervention that would optimize skills and abilities in preparation for a decision about fitness to drive. The pathways clarify that treatment addressing impairments in visual, physical, and cognitive abilities were in actuality addressing readiness. By connecting treatment intervention to driving readiness the information on the sheets provides clinical guidance to the practitioners addressing driving and community mobility. In addition, the diagnosis sheets also distinguish the role of the generalist and driving rehabilitation specialist by clearly giving examples of intervention for each. Finally, by defining the role of the generalist and the driving rehabilitation specialist, the diagnosis sheets gives “permission” to the generalist to embrace this area of practice by intervening within their scope of practice and referring when specialized evaluation and intervention is required. Consistency of format for the diagnosis sheets was important. Each diagnosis sheet begins with general information (see the Appendix: Driving Pathways by Diagnosis: Arthritis) such as state licensing and the need to council for transportation alternatives. Each document includes three columns with the headings of: Areas of Focus, Generalist Treatment or Assessment Focus, and Recommendation/ Considerations/Justification for referral a driver rehabilitation specialist (DRS). For example, with a diagnosis of arthritis, range of motion (ROM) is often limited. If limited ROM interferes with the performance of basic ADL, it will likely have negative implications for driving as well. The table provides a list of typical impairments associated with a particular diagnosis followed by generalist treatment suggestions. In this example, the recommendation/considerations/justification for referral to DRS addresses the simple accommodations that can be made by
Genesis Rehab Services and AOTA
205
generalists as well as criteria to consider for when a referral to the DRS may be warranted. Additional Driving Pathways by Diagnosis Sheets were developed for orthopedic conditions, cerebrovascular accident one-sided impairment, dementia, Parkinson’s disease, neuromuscular diseases, mental illness, cardio pulmonary, medical complexity, and general conditions. As experience and confidence grows, clinicians will be encouraged to build this resource through the application of this framework to more diagnostic groups. Development The content for the diagnosis worksheets was developed by experienced general practice occupational therapists. Small groups of four to five occupational therapists were given a diagnosis and a case study for review. The case study offered a structure to assist in facilitating critical reasoning of connecting impairments to driving risk. It was natural to begin with a known population and conduct an activity analysis exploring typical deficits and strengths experienced by a diagnostic group. The therapists were asked to generate all their ideas related to the areas of focus for evaluation and intervention. They were also asked to consider how they could treat deficit areas that would likely impact driving and community mobility performance. The therapists created a wealth of information that needed to be organized into a usable format. Proceeding one diagnosis at a time, these skilled therapists rapidly identified potential impairment, intervention and outcome related to that diagnosis’ impact on vision, physical ability and cognition, all linked to the IADL of driving and community mobility. The momentum of the work began to take shape and concepts such as readiness, optimizing abilities, timing, and cessation strategies became obvious. Through this clinical reasoning process, not only were the Driving Pathways by Diagnosis Sheets established, but the group of therapists became committed to the process of incorporating driving and community mobility into their practice (Dickerson, Chew, Schold Davis & Touchinsky, 2013). Generally, the process of development was similar for each sheet. For ADLs or IADLs, the first step is remediation of an identified impairment, designed to strengthen the paralyzed limb, improve scanning frequency and automaticity, or build insight and understanding of the impact of impairment on functional abilities. During the period of recovery or as the client reaches a plateau, therapists explore a range of interventions that include adaptation and compensation. Once “driving” was conceptualized more broadly as a process, the roles of the general practice occupational therapist (i.e., generalist) to address driving and community mobility as an IADL naturally emerged. The Driving Pathways by Diagnosis Sheet included referral criteria when considering recommendations including referral for specialized services such as the comprehensive driving evaluation by a specialist in driver rehabilitation. This process could be applied to any clinical population, “connecting the dots” between identification and evaluation of impairment, intervention and the goal of driving or mobility outside of the home. The Driving Pathways by Diagnosis Sheets are currently being used by a select group of therapists with an interest in driving and community mobility. These individuals acknowledge driving and community mobility in their practice and are using the sheets to expand their practice and clinical skills. With this use, the therapists provided valuable feedback regarding missing information and clarity of
206
Touchinsky et al.
presentation, which has been used in subsequent revisions. The therapists have also used the diagnosis sheets in the training and mentoring of the other occupational therapy practitioners in their facilities to expand their focus to include driving and community mobility. Summary This brief paper describes the Driving Pathways by Diagnosis Sheets, developed by GRS through a collaborative effort with the Gaps and Pathways Project (see Schold Davis, this issue) as a means to assist occupational therapists in meeting driving and community mobility needs of older adults. In addition, this paper describes the development and format of the sheets, with an example in the appendix. The goal is to provide the Driving Pathways by Diagnosis Sheets to all occupational therapy practitioners and require complimentary education to ensure that “generalists” understand the concept of the sheets and utilize them correctly in clinical practice. GRS plans to distribute these resources internally through their intranet site, making them available across the organization. As a product of the Gaps and Pathways Project, the Driving Pathways by Diagnosis Sheets will be made available to all occupational therapy practitioners as a resource to bridge the gap to address driving and community mobility in occupational therapy at the generalist and specialist level. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. ABOUT THE AUTHORS Mrs Susan Touchinsky, GRS, 225 Clark Drive, Orwigsburg, 17961 USA. E-mail: [email protected]. Felicia Chew, Genesis Rehab Services, Kennett Square, USA. Elin Schold Davis, American Occupational Therapy Association, Bethesda, USA. REFERENCES American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy 68(Suppl. 1). Dickerson AE, Chew F, Touchinsky S, & Schold Davis E. (November 21, 2013). Evidence for a Successful Focused Education Program to Meet the Needs of the Older Driver in Medical Settings. Paper presented at the Gerontological Society of America Annual Conference, New Orleans, LA.
Genesis Rehab Services and AOTA
207
APPENDIX
Driving Pathways Diagnosis: Arthritis
• Know your state specific requirements regarding driving – access via link and reference chapter 8 http://www.nhtsa.gov/staticfiles/nti/older drivers/pdf/ 811298.pdf • Observe and document strengths/deficits occurring during all ADL and IADL tasks in conjunction with your comprehensive evaluation and standardized tests/measures as they relate to driving. • You have a responsibility to council client and family regarding pass/fail risk associated with formal driving evaluation. You also have a responsibility to council client and family regarding transportation alternatives. • Severe impairments will result in, at a minimum, temporary driving cessation until remediation of deficits or further evaluation and training by Driving Rehab Specialist (DRS).
208
Patient education for body mechanics for transfers into and out of the car, positioning, and energy conservation Assess and treat for balance, strength, ability to load and unload mobility device, basic and car transfers; utilize the chair rise assessment, timed up and go, rapid pace walk, BERG balance scale. Consult PT for LE strengthening, balance, etc. Assess UE/LE ROM, strength, and flexibility; considerations for reaction time, ability to grasp, fine motor control and strength, measure grip and pinch strength; cervical ROM; Arm Curl Test, chair rise Education on resources, senior driving friendly places, valet parking, fuller services gas stations, and grocery stores Vision, cognition, perception
Strength, ROM, pain
Work simplification
Community accessibility/ occupational justice Comorbidities
Caregiver issues
Refer to DRS for specialty mirrors that are needed to compensate for decreased cervical ROM, refer to DRS if need for spinner knob or turn signal extender. OT may recommend use of seat belt pull to help reach seat belt, gas cap release, built up key Tap into AARP, state association, AAA, insurance companies, local business owners, local chamber of commerce Check state guidelines, refer to additional resources for comorbidities Refer to DRS if need for adaptations/equipment and/or restrictions Help identify alternative modes of transportation; modifications for significant other (ex: swing out seats on passenger side, transportation wheelchairs, community resources)
OT may recommend use of handybar and/or leg lifter to assist with transfers
Potentially refer to DRS if presenting with safety concerns and poor self awareness Assistance to identify periods of increased pain during the day and help for structuring driving and mobility routine around periods of pain; provide patient education on safety concerns with home modifications with cushions in car Refer to DRS if specialty adaptations are needed for seating Education for safe loading of mobility equipment, transfers in/out vehicle
Recommendation/considerations/justification for referral DRS
The development of the Driving Pathways by Diagnosis series was funded, in part, through the National Highway Safety Administration (NHTSA) Gaps and Pathways Project through cooperative agreement with The American Occupational Therapy Association (AOTA). Reproduce with permission from AOTA and Genesis Rehab Services. Questions contact Driving Rehabilitation by GRS 1.800.992.9711.
ROM/strength
Transfers
Pain
Assess occupational performance for safety, adaptive equipment, and need for assistance Use of pain assessment scale, utilization of modalities to reduce pain, consideration for positioning options, exercise, splinting, medications, and medication management
Generalist treatment or assessment focus
ADL/IADL performance
Areas of focus
Copyright of Occupational Therapy in Health Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
ARTICLE
Gaps and Pathways Project: Driving Pathways by Diagnosis Sheets Susan Touchinsky1 , Felicia Chew2 , & Elin Schold Davis3 1 2
Driving Rehabilitation by Genesis Rehab Services, Kennett Square, Pennsylvania, USA, Genesis Rehab Services, Kennett Square, Pennysylvania,USA, 3 American Occupational Therapy Association, Bethesda, Maryland, USA
ABSTRACT. This paper describes the development and use of information sheets for occupational therapy practitioners to use as guides for evaluation and intervention planning to address their client’s driving and community mobility needs. Called Driving Pathways by Diagnosis Sheets, the information assists therapists with direction to connect impairment to driving risk and incorporate intervention to client goals and priorities related to driving and community mobility. An example of one of the sheets for the diagnosis of arthritis is highlighted and implications for use are discussed. KEYWORDS.
Diagnosis Sheets, driving pathways, driving rehab
BACKGROUND As a growing rehabilitation company, meeting the needs of adults with medical issues and focused on the continuum of care, particularly older adults, Genesis Rehab Services (GRS) recognized the need to address all areas of activities of daily living (ADL) and instrumental activities of daily living (IADL) as defined by the domain of practice (AOTA, 2014). With large numbers of occupational therapy practitioners employed, traditional evaluation and intervention of occupational therapy services is well developed and practiced. However, based on the increasing emphasis on “aging in place” and the growing attention on the need to keep elders active in the community, it was recognized that driving as a means of community mobility was not being addressed by the majority of the occupational therapy practitioners in settings across the 46 states in which GRS is established. Thus, in 2010, there was a conscious effort to develop and establish community mobility and driving as part of the evaluation and intervention plan for occupational therapy throughout the company. As part of the Gaps and Pathways Project, GRS was willing to participate by developing strategies to empower the generalist practitioner to address driving Address correspondence to: Mrs Susan Touchinsky, GRS, 225 Clark Drive, Orwigsburg, PA 17961, USA. (E-mail: [email protected]). (Received 4 March 2014; accepted 8 March 2014)
203
204
Touchinsky et al.
and community mobility in their current practice. Addressing one of the identified “gaps” (see Dickerson & Schold Davis, this issue), the goal was to develop a structured system or pathway for treatment planning and intervention. As a result of invested staff time and expertise, GRS developed the Driving Pathways by Diagnosis Sheets resource to support all occupational therapy practitioners. GRS has an advantage of unifying the process of evaluation and therapy intervention through the use of an electronic clinical documentation and billing system customized for their services. Thus, all practitioners using the GRS evaluation are required to address each area of occupation (ADLs and IADLs) identified in the system. With the addition of a few questions, the standard evaluation form prompted therapists to address whether the client was currently a driver and if so, did they plan to return to driving. This driving and community mobility area was further detailed in the body of the evaluation. However, with this addition to the evaluation, treatment planning support was requested to ensure that the wide range of occupational therapy practitioners could appropriately address impairments by diagnostic group when considering fitness to drive. Description The objective of the Driving Pathways by Diagnosis Sheets is to demonstrate to the generalist that evaluation and intervention with a particular diagnosis does carryover to driving and community mobility. The information on the diagnosis sheets gives the occupational therapy practitioner direction connecting impairment and goals to driving and community mobility. Specifically the information on the documents connects impairment ascertained in the evaluation, to intervention that would optimize skills and abilities in preparation for a decision about fitness to drive. The pathways clarify that treatment addressing impairments in visual, physical, and cognitive abilities were in actuality addressing readiness. By connecting treatment intervention to driving readiness the information on the sheets provides clinical guidance to the practitioners addressing driving and community mobility. In addition, the diagnosis sheets also distinguish the role of the generalist and driving rehabilitation specialist by clearly giving examples of intervention for each. Finally, by defining the role of the generalist and the driving rehabilitation specialist, the diagnosis sheets gives “permission” to the generalist to embrace this area of practice by intervening within their scope of practice and referring when specialized evaluation and intervention is required. Consistency of format for the diagnosis sheets was important. Each diagnosis sheet begins with general information (see the Appendix: Driving Pathways by Diagnosis: Arthritis) such as state licensing and the need to council for transportation alternatives. Each document includes three columns with the headings of: Areas of Focus, Generalist Treatment or Assessment Focus, and Recommendation/ Considerations/Justification for referral a driver rehabilitation specialist (DRS). For example, with a diagnosis of arthritis, range of motion (ROM) is often limited. If limited ROM interferes with the performance of basic ADL, it will likely have negative implications for driving as well. The table provides a list of typical impairments associated with a particular diagnosis followed by generalist treatment suggestions. In this example, the recommendation/considerations/justification for referral to DRS addresses the simple accommodations that can be made by
Genesis Rehab Services and AOTA
205
generalists as well as criteria to consider for when a referral to the DRS may be warranted. Additional Driving Pathways by Diagnosis Sheets were developed for orthopedic conditions, cerebrovascular accident one-sided impairment, dementia, Parkinson’s disease, neuromuscular diseases, mental illness, cardio pulmonary, medical complexity, and general conditions. As experience and confidence grows, clinicians will be encouraged to build this resource through the application of this framework to more diagnostic groups. Development The content for the diagnosis worksheets was developed by experienced general practice occupational therapists. Small groups of four to five occupational therapists were given a diagnosis and a case study for review. The case study offered a structure to assist in facilitating critical reasoning of connecting impairments to driving risk. It was natural to begin with a known population and conduct an activity analysis exploring typical deficits and strengths experienced by a diagnostic group. The therapists were asked to generate all their ideas related to the areas of focus for evaluation and intervention. They were also asked to consider how they could treat deficit areas that would likely impact driving and community mobility performance. The therapists created a wealth of information that needed to be organized into a usable format. Proceeding one diagnosis at a time, these skilled therapists rapidly identified potential impairment, intervention and outcome related to that diagnosis’ impact on vision, physical ability and cognition, all linked to the IADL of driving and community mobility. The momentum of the work began to take shape and concepts such as readiness, optimizing abilities, timing, and cessation strategies became obvious. Through this clinical reasoning process, not only were the Driving Pathways by Diagnosis Sheets established, but the group of therapists became committed to the process of incorporating driving and community mobility into their practice (Dickerson, Chew, Schold Davis & Touchinsky, 2013). Generally, the process of development was similar for each sheet. For ADLs or IADLs, the first step is remediation of an identified impairment, designed to strengthen the paralyzed limb, improve scanning frequency and automaticity, or build insight and understanding of the impact of impairment on functional abilities. During the period of recovery or as the client reaches a plateau, therapists explore a range of interventions that include adaptation and compensation. Once “driving” was conceptualized more broadly as a process, the roles of the general practice occupational therapist (i.e., generalist) to address driving and community mobility as an IADL naturally emerged. The Driving Pathways by Diagnosis Sheet included referral criteria when considering recommendations including referral for specialized services such as the comprehensive driving evaluation by a specialist in driver rehabilitation. This process could be applied to any clinical population, “connecting the dots” between identification and evaluation of impairment, intervention and the goal of driving or mobility outside of the home. The Driving Pathways by Diagnosis Sheets are currently being used by a select group of therapists with an interest in driving and community mobility. These individuals acknowledge driving and community mobility in their practice and are using the sheets to expand their practice and clinical skills. With this use, the therapists provided valuable feedback regarding missing information and clarity of
206
Touchinsky et al.
presentation, which has been used in subsequent revisions. The therapists have also used the diagnosis sheets in the training and mentoring of the other occupational therapy practitioners in their facilities to expand their focus to include driving and community mobility. Summary This brief paper describes the Driving Pathways by Diagnosis Sheets, developed by GRS through a collaborative effort with the Gaps and Pathways Project (see Schold Davis, this issue) as a means to assist occupational therapists in meeting driving and community mobility needs of older adults. In addition, this paper describes the development and format of the sheets, with an example in the appendix. The goal is to provide the Driving Pathways by Diagnosis Sheets to all occupational therapy practitioners and require complimentary education to ensure that “generalists” understand the concept of the sheets and utilize them correctly in clinical practice. GRS plans to distribute these resources internally through their intranet site, making them available across the organization. As a product of the Gaps and Pathways Project, the Driving Pathways by Diagnosis Sheets will be made available to all occupational therapy practitioners as a resource to bridge the gap to address driving and community mobility in occupational therapy at the generalist and specialist level. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. ABOUT THE AUTHORS Mrs Susan Touchinsky, GRS, 225 Clark Drive, Orwigsburg, 17961 USA. E-mail: [email protected]. Felicia Chew, Genesis Rehab Services, Kennett Square, USA. Elin Schold Davis, American Occupational Therapy Association, Bethesda, USA. REFERENCES American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain and process (3rd ed.). American Journal of Occupational Therapy 68(Suppl. 1). Dickerson AE, Chew F, Touchinsky S, & Schold Davis E. (November 21, 2013). Evidence for a Successful Focused Education Program to Meet the Needs of the Older Driver in Medical Settings. Paper presented at the Gerontological Society of America Annual Conference, New Orleans, LA.
Genesis Rehab Services and AOTA
207
APPENDIX
Driving Pathways Diagnosis: Arthritis
• Know your state specific requirements regarding driving – access via link and reference chapter 8 http://www.nhtsa.gov/staticfiles/nti/older drivers/pdf/ 811298.pdf • Observe and document strengths/deficits occurring during all ADL and IADL tasks in conjunction with your comprehensive evaluation and standardized tests/measures as they relate to driving. • You have a responsibility to council client and family regarding pass/fail risk associated with formal driving evaluation. You also have a responsibility to council client and family regarding transportation alternatives. • Severe impairments will result in, at a minimum, temporary driving cessation until remediation of deficits or further evaluation and training by Driving Rehab Specialist (DRS).
208
Patient education for body mechanics for transfers into and out of the car, positioning, and energy conservation Assess and treat for balance, strength, ability to load and unload mobility device, basic and car transfers; utilize the chair rise assessment, timed up and go, rapid pace walk, BERG balance scale. Consult PT for LE strengthening, balance, etc. Assess UE/LE ROM, strength, and flexibility; considerations for reaction time, ability to grasp, fine motor control and strength, measure grip and pinch strength; cervical ROM; Arm Curl Test, chair rise Education on resources, senior driving friendly places, valet parking, fuller services gas stations, and grocery stores Vision, cognition, perception
Strength, ROM, pain
Work simplification
Community accessibility/ occupational justice Comorbidities
Caregiver issues
Refer to DRS for specialty mirrors that are needed to compensate for decreased cervical ROM, refer to DRS if need for spinner knob or turn signal extender. OT may recommend use of seat belt pull to help reach seat belt, gas cap release, built up key Tap into AARP, state association, AAA, insurance companies, local business owners, local chamber of commerce Check state guidelines, refer to additional resources for comorbidities Refer to DRS if need for adaptations/equipment and/or restrictions Help identify alternative modes of transportation; modifications for significant other (ex: swing out seats on passenger side, transportation wheelchairs, community resources)
OT may recommend use of handybar and/or leg lifter to assist with transfers
Potentially refer to DRS if presenting with safety concerns and poor self awareness Assistance to identify periods of increased pain during the day and help for structuring driving and mobility routine around periods of pain; provide patient education on safety concerns with home modifications with cushions in car Refer to DRS if specialty adaptations are needed for seating Education for safe loading of mobility equipment, transfers in/out vehicle
Recommendation/considerations/justification for referral DRS
The development of the Driving Pathways by Diagnosis series was funded, in part, through the National Highway Safety Administration (NHTSA) Gaps and Pathways Project through cooperative agreement with The American Occupational Therapy Association (AOTA). Reproduce with permission from AOTA and Genesis Rehab Services. Questions contact Driving Rehabilitation by GRS 1.800.992.9711.
ROM/strength
Transfers
Pain
Assess occupational performance for safety, adaptive equipment, and need for assistance Use of pain assessment scale, utilization of modalities to reduce pain, consideration for positioning options, exercise, splinting, medications, and medication management
Generalist treatment or assessment focus
ADL/IADL performance
Areas of focus
Copyright of Occupational Therapy in Health Care is the property of Taylor & Francis Ltd and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
