HomeVA ProstheticsVA Handbook 1173.16 - Driver Rehabilitation for Veterans with Disabilities ProgramOperational Guidelines

16.15. Operational Guidelines

a. Instructor-Patient Relationship. The heart of the VA Driver Rehabilitation Program is the actual instructor-patient relationship during the period between the receipt of the physician's referral to the attainment of a Certificate of Training. The driver rehabilitation specialist is well- versed in treating disabilities and in identifying residuals and/or deficits that may affect a patient's driving capabilities. This guidance in this Handbook is critical to the driver rehabilitation specialist in eliciting a Driver Rehabilitation Program specific to the needs of each patient and within the patient's physical and emotional capabilities.

b. Types of Disabilities that are Treated in the VA Driver Rehabilitation Program

(1) Paraplegia;

(2) Tetraplegia;

(3) Traumatic Brain Injury (TBI);

(4) Hemiplegia;

(5) Neurological and brain disorders;

(6) Amputation, i.e., upper and lower extremities;

(7) Orthopedic problems;

(8) Mental health problems;

(9) Disabilities associated with aging.

c. General Behavioral Objectives Expected of Patients

(1) The patient must acquire knowledge of all areas of the Driver Rehabilitation Program specific to their individual needs. Both didactic theory and practical experience must be provided.

(2) Psychomotor improvements in handling the segments of the driver rehabilitation task (e.g., space-cushioned driving) may be noted by comparison of function before and after completion of the Driver Rehabilitation Program.

(3) The patient needs to develop a favorable psychological attitude toward the everyday driving responsibilities.

(4) The patient is to become as proficient a driver as possible through the use of the most modern education, teaching, and rehabilitation techniques (e.g., search, identify, predict, decide, execute (SIPDE)). NOTE: The use of adaptive equipment and vehicle modification enables as many disabled individuals as possible to become independent in their transportation needs.

d. Pre-driving Assessment and Evaluation. The Driver Rehabilitation Specialist must ensure the following areas are addressed as part of the initial assessment and evaluation:

(1) Initial Contact. Have the initial contact with patient (driver rehabilitation candidate) in an interview atmosphere.

(2) VA Form 10-9028, Driver Training Functional Evaluation Record. This form is available for use or may be used as a guide for the assessment process.

(3) History. Obtain from patient the history of the patient's driving record, including any citations, accidents, or suspensions, as well as military defensive driving strategies which may have been taught to the Veteran.

(4) Medical Clearance. Inform patient of steps to be taken to obtain medical clearance, if such is required from the State medical authority.

(5) Pre-driving Testing

(a) Performed by Driver Rehabilitation Specialist

1. Visual acuity, depth-perception, color-vision, peripheral-vision, night acuity, and glare recovery (tests may be administered by use of visual screening tools).

2. Functional muscle testing.

3. Basic perceptual test (e.g., dynamic figure-ground).

4. Range of motion of all extremities, plus neck, if feasible. If lower extremities are non- functional, emphasis on exactness of upper extremity range of motion becomes greater.

5. Coordination testing.

6. Hearing (subjective).

7. Balance (static and dynamic).

8. Activity tolerance and susceptibility to fatigue.

9. Spasticity.

10. Bowel or bladder control.

11. Reaction time, i.e., response time from accelerator to brake.

12. Sensation and proprioception.

13. Functional activities of daily living (ADL).

14. Educational training (classroom portion).

(b) To be Performed by other Service Staff Members, as appropriate, to the Patient's Medical and/or Mental Health Diagnosis

1. Standard psychological tests, if applicable, administered by a staff psychologist and/or neuropsychologist to determine candidate's emotional and mental capacities to operate a motor vehicle.

2. Extensive perceptual tests given by qualified allied health care professional.

3. Evaluation of patient's communication and hearing potential, to be administered by Audiology and Speech Pathology.

4. Advanced visual evaluation as indicated by an Optometrist or Ophthalmologist.

(6) Driving Simulator. The driver rehabilitation specialist needs to be aware of the many benefits and limitations of the driver simulator as an evaluation tool and instructional device. Included in this understanding of the simulator are its design, concepts, capabilities, limitations, and preventive maintenance.

(7) Valid Driver's License. The driver rehabilitation specialist must be sure the patient has a valid driver's license or valid learner's permit before beginning on-the-road driving. Coordination with the local DMV is essential. NOTE: Some patients may not be required to take written, vision, and/or driving examination at the DMV. If it is determined that the patient's license had been suspended or revoked, the patient must be discontinued from the program until such time as permission has been obtained from the DMV to resume the training.

(8) Counseling and Education. In counseling the patient, it is essential to:

(a) Remind patients of the patient's responsibilities.

(b) Discuss the perils of being under the influence of alcohol and illicit drugs, as well as prescribed and non-prescription medications, when driving.

(c) Review potential distractions during driving such as cell phone use, setting GPS systems, passenger behavior, etc.

(d) Educate the individual about strategies to eliminate potentially dangerous compensatory mechanisms learned while on active duty when driving in the civilian world.

(e) Elaborate on the statement, "Driving is a privilege, not a right."

e. Four Phases of In-Vehicle Instruction. During all four phases the instructor must continually emphasize the benefits of defensive driving.

(1) Phase One Instructions. Phase One instruction includes:

(a) Training in transferring to and from vehicle.

(b) Evaluating the need for assistive and prosthetic devices.

(c) Orienting the patient to vehicle controls and add-on adaptive equipment.

(d) Assisting the patient to assume proper body positioning and alignment (e.g., seat height, position of legs).

(e) Teaching mirror references, including "blind spot" checks and tests.

(f) Noting passenger responsibilities (e.g., seat belts, lock doors).

(g) Emphasizing pre-driving check which includes external (e.g., lights) and internal (e.g., gas supply) considerations.

(h) Practicing ingress and egress of mobility aids.

(i) Preparing lesson plans and course routes for all steps of vehicle in motion training, such as:

1. Starting and stopping;

2. Right and left turns;

3. Centrifugal forces;

4. Backing-up;

5. Parking with no obstacles;

6. Reaction time (gas to brake);

7. Smooth acceleration and braking; and

8. Visual tracking.

(2) Phase Two Instructions. NOTE: Enter this phase only after student has mastered all steps in Phase One. Phase Two is carried out in a quiet residential area with light traffic and no hills, and includes:

(a) Limit-line approaches to intersections.

(b) Intersections.

(c) SIPDE Drills. Search (visual scanning), Identify (possible hazards), Predict (possible consequences of hazards), Decide (what to do if potential hazard becomes a reality), Execute (carry out planned action).

(d) Two-second rule.

(e) Lane changes.

(f) U-turns and three-point turnabouts.

(g) Parallel parking.

(h) Emotional stability behind the wheel.

(i) Training in the Smith System by:

1. Aiming high in steering,

2. Getting the big picture,

3. Keeping your eyes moving,

4. Making sure on coming traffic can see you, and

5. Leaving yourself an "out."

(3) Phase Three Instructions. Complex driving includes taking the patient downtown, on hills, in traffic circles, and on congested roads:

(a) Hill driving; Uphill and downhill parking, speed control.

(b) Passing other vehicles.

(c) Hazardous driving situations (e.g., inclement weather, stuck accelerator, brake failure, flat tire).

(d) Changing traffic flows.

(e) Awareness of pedestrian hazards.

(4) Phase Four Instructions. Phase four includes:

(a) Freeway entry and exit.

(b) Car control.

(c) Emergency stops.

(d) Night driving, to include: glare avoidance, visibility reduction, and fatigue with extended trips. NOTE: In all lessons, goals and expectations must be discussed with the patient prior to in- vehicle training and a critique must follow road performance. Specifics of driving techniques not included in the preceding are to be covered as road conditions arise. No specific number of lessons is prescribed for a patient with a certain disability. It may take a spinal cord injured patient (X) lessons to adjust to using hand controls, or it may take a stroke victim (Y) lessons to learn to compensate for the patient's affected side.

f. Certificate of Training. Upon completion of the in-car training, the patient may be scheduled for a driving examination at the DMV. A Certificate of Training is given to the patient at this time, signifying successful completion of the course.

g. Selection of Vehicle. The driver rehabilitation specialist assists the patient in the selection of an appropriate vehicle, vehicle modification, and proper add-on adaptive equipment to meet the patient's needs according to current eligibility requirements, either as a driver, or as a passenger.

h. Documentation of Clinical Chart. The patient's progress must be documented in the medical record from time of initial evaluation and/or assessment until completion of the Driver Rehabilitation Program. Documentation must follow local medical facility policy and be in compliance with appropriate accreditation standards (i.e., the Joint Commission and the Commission on the Accreditation of Rehabilitation Facilities (CARF).

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