Promoting Older Driver Safety: Guide for State Practices (2023)

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7   C H A P T E R 3 In addition to what was learned from the 44 SHSOs that responded to the survey, the project team conducted an extensive literature search as part of the research in each of the eight major highway safety elements identified in NHTSA’s Highway Safety Program Guideline No. 13, Older Driver Safety. Following is a synopsis of what the literature search and survey responses revealed. 3.1 Program Management NHTSA recommended states undertake the following projects and policies to meet the program management objectives. • Designate a lead state organization to develop resources and collect comprehensive data on older driver crashes, injuries, and fatalities. • Identify and establish priorities for addressing the state’s older driver safety problems and develop a range of resources. • Encourage meaningful collaborative arrangements between and among all relevant agencies addressing aging mobility, injuries, and medical conditions. • Coordinate older driver safety programs and policies with all highway safety efforts. • Increase awareness of alternatives to driving for at-risk drivers. • Integrate older driver safety concerns and interests into the state SHSP and all relevant safety efforts. • Establish ongoing and effective ways to consistently evaluate the state’s older driver safety programs and ensure a feedback loop to continually improve state efforts to improve older driver safety. The text highlights two specific areas where a body of research exists on implementation of at least some of these specific recommendations: • Collecting and using comprehensive older driver crash and safety data, and • Developing collaborative and coordinated arrangements. States have developed data-driven approaches to address road user safety issues, although they may have not focused specifically on older road users. Such approaches, however, may provide the framework for older road user data-driven safety efforts. Lessons Learned • Knowledge, data, or information. – The extent to which SHSOs have adopted any or all the NHTSA Guideline No. 13 recom- mendations and, if they have, what the outcomes have been is unknown. Research Findings

8 Promoting Older Driver Safety: Guide for State Practices – Attempts to collect older road user crash data and information and develop policies based on Guideline No. 13 have been minimal. – Few cooperative and collaborative activities involving SHSOs exist outside older driver safety groups. It is not known whether the cooperative activities in existence led to more projects, programs, and infrastructure investments targeting older road users, or if any of these actions have increased older road user safety. • Funding. – NHTSA provides no dedicated older driver safety funding. – Restrictions on how SHSOs can use NHTSA funding impede older driver initiatives and programs. – A general sense exists among SHSOs that older driver safety has lost out to other program areas such as bicycles and pedestrians in safety plans, like the HSP, SHSP, Highway Safety Improvement Program (HSIP), and Long-Range Transportation Plan (LRTP). – State funds are essential for building a robust older driver safety program under current NHTSA funding restrictions. • Resources/tools/information. – Create a template for an older driver plan with specific real-world examples and templates that can be modified to fit each state’s needs. – Provide older driver program contacts for states who conduct older driver projects or have coalitions so SHSOs can reach out to those individuals and exchange information. – Develop a guide outlining how SHSOs can coordinate with other state agencies like the Departments of Public Health and Motor Vehicles/Licensing on older driver safety. – Offer examples of the proper language to use in media and communications materials that does not accuse or belittle older road users. – Conduct, through the Governors Highway Safety Association (GHSA) or NHTSA, older driver education for interested SHSOs, via an online seminar or during conferences, that includes information on how to implement and fund programming within NHTSA parameters. – Develop a list of activities states can follow to reach older drivers, especially in rural areas. – Provide a synopsis of programs from other states, toolkits, and best practices on how to implement older driver programs. – Recognize and address the bureaucratic variety among agencies conducting older driver programs across states that makes it difficult to determine the true extent of the older driver safety problem and how the NHTSA recommendations are being implemented. Conclusion While most states collect data on fatalities and serious injuries by age, they do not effectively use data on older driver crash rates, types, and locations to develop comprehensive older-road-user safety policies, plans, and program infrastructure improvements, to address hot spots, or to develop targeted educational materials. Florida’s Safe Mobility for Life program does extensive data collection and analysis and could serve as a model for other states. States vary in how well they develop interagency collaboration and cooperation to address older-road-user safety and mobility. Even regular meetings, joint task forces, and official expressions of collaboration on older driver issues do not always, or even often, result in mean- ingful and sustained planning and programming efforts across state agencies, across levels of governments, and with a range of stakeholders. Most agencies concerned with some facet of older-road-user safety or mobility have different agendas, focus, and resource commitments, making these collaboration efforts difficult, time consuming, and even expensive to maintain. It would be helpful if information on successful models of interagency collaboration and on cross-agency and multi-jurisdictional older-road-user safety and mobility programs and policies with measurable outcomes were widely disseminated.

Research Findings 9 3.2 Roadway Design NHTSA recommended states undertake the following projects and policies to meet the road- way design objective: • Consider making older driver safety an emphasis area in the state SHSP if evidence supports the need to do so. • Develop and implement a plan to deploy guidelines to incorporate FHWA accommodations for older road users into new construction and spot improvements on state and local roadways. • Develop and implement a communications and education plan to assist local entities in applying FHWA guidelines and recommendations to address the needs of older drivers and pedestrians. Lessons Learned • Older drivers are mentioned twice, and older pedestrians once, in the Manual on Uniform Traffic Control Devices (MUTCD). Using left turn phasing in areas with many older drivers and recom- mending, but not requiring, the use of backplates to highlight traffic signal indications for older drivers is mentioned in the 2009 MUTCD. In addition, “An unacceptable number of pedestrian conflicts with right-turn-on-red maneuvers, especially involving children, older pedestrians, or persons with disabilities” is included in the current version of the MUTCD (July 2022). • None of the state survey respondents indicated they had approached or discussed older driver roadway design issues with the planners and engineers at the state DOT. Conclusion A substantial and growing body of human factors and engineering research builds on older work on design and other differences in the needs of older drivers, much of it sponsored or published by FHWA. NHTSA referenced the FHWA material in two of the three specific recom- mendations in this element of NHTSA Guideline No. 13. The publication most often referenced is the Highway Design Handbook for Older Drivers and Pedestrians (2011). NHTSA’s second and third recommendations for this element of Guideline No. 13 highlight the gap between emerging and established research on older driver needs, requirements, and suggested improvements, and whether the research is appropriately included in the MUTCD and the Highway Capacity Manual (HCM). Incorporating such improvements into standard engineering and design practices is important. Some state and local traffic engineers and planners may have limited knowledge about such improvements. As a result, there is still not enough operational experience with such design features to expedite their acceptance particularly as the number of older drivers grows over time. States, individually or collectively, should conduct more research on the range of older driver design standards and guidelines, carefully collecting and validating a variety of expected outcomes. Outcome data should be publicized and the suggested experimental older driver design features (those providing improved performance and better facilitating the driving task for older drivers) should be expedited into formal, mandatory traffic engineering design guidelines. Since this is not the function of the SHSO, the office could reach out to the DOT safety engineer to propose these activities or ensure they are discussed and addressed during the SHSP update process. 3.3 Driver Licensing NHTSA recommended states undertake the following projects and policies to meet the driver licensing objectives. • Require in-person renewal of individual drivers if analysis of the crash records show a dispro- portionate increase in older driver crashes.

10 Promoting Older Driver Safety: Guide for State Practices • Ensure state medical review practices align with the latest Driver Fitness Medical Guide­ lines published by NHTSA and the American Association of Motor Vehicle Administrators (AAMVA) in 2009. • Provide immunity from civil, criminal, and administrative liability to all medical and emer- gency services providers who refer drivers in good faith to the driver licensing authority. • Consider driver licensing restrictions to limit the risks posed by individual drivers while permitting them the greatest personal autonomy possible. • Establish a MAB of medical professionals to provide policy guidance to the driver licensing agency. • Include staff with medical expertise to review medically referred drivers as part of the driver licensing authority medical review function. • Regularly analyze and evaluate drivers referred to the medical review system to determine whether driver licensing authority procedures appropriately detect and regulate at-risk drivers. • Train driver licensing authority staff to identify medically at-risk drivers and refer them for medical review. • Provide simple, fast, and low-cost (if possible) ways for individuals to convert their drivers’ licenses to identification cards. Recommended driver licensing authority communications policies include • Ensure medical referral information and forms are easy to locate on the driver licensing authority website; • Reach out and provide training to medical professionals to refer medically at-risk drivers and to find resources on functional abilities and driving; and • Provide information on community transportation resources to drivers who submit to medical reviews. According to the research, 21 states have accelerated or added additional testing require- ments for older drivers, with most starting at 70 years of age, although the age varies among the states. The most impactful licensing requirement is mandating older drivers report in person to seek license renewal and include requirements to take additional vision, cognitive, and on-road testing. Yet these additional tests by themselves do not seem to have an independent impact on licensing outcomes. Since 2009, more states have relaxed their requirements on older drivers than have increased them. This may be because research suggests that more frequent and strin- gent licensing requirements, while removing older drivers from the road, have little to no impact on older driver crash or fatality rates. Almost every state surveyed also has a formal way to medically assess drivers referred by a variety of sources including physicians, law enforcement, driver licensing authority staff, and even family and friends. Some states have formal MABs, although almost all states can require drivers to be assessed by their physicians. Little evidence exists in the research that confirms medical assessments of drivers have significant or any impact on older driver crash or fatality rates, even though they do remove drivers who are assessed for medical fitness-to-drive from the road or restrict their allowable driving. Many studies suggest older drivers removed from the road by these processes may not have been driving much or had been self-regulating by avoiding challenging situations like driving at night, on freeways, in severe weather, or in unfamiliar or congested areas. So, restricting or removing their licenses might not translate into major reductions or changes in driving behavior and not result in major reductions in older driver crashes or fatalities. Little published research questions if drivers with restricted licenses do restrict or cease driving as required. Restricted licensing policies and medical assessments of fitness-to-drive affect older driver mobility in many ways. Some studies find drivers with restricted licenses drive more or longer

Research Findings 11 before cessation than those with no restrictions, which might be due to greater confidence in their own driving. Restricting or removing driving privileges is often associated with feelings of depression, lowered levels of social interaction, loneliness, loss of independence, and increased illness and early morbidity. This result should be balanced against the safety of the older drivers and of other road users. Finally, limited information exists on the impact of communications strategies, programs, and policies on how older drivers approach the driving task, reduce or modify their driving, or decide to cease driving. Improved vehicle adaptations and technology may hold the prom- ise of easing various driving tasks and making older drivers more comfortable driving. These technologies may offer safety advantages to older drivers, allowing them to drive longer and in situations they might have previously considered frightening or dangerous. The effective use of onboard technologies by older drivers will require communication, information, and training to ensure older drivers understand the potential of such technology and are willing to learn how to use it correctly and safely. Debate continues over the effectiveness of more frequent relicensing of older drivers and the kinds of mandatory vision, knowledge, and cognitive testing licensing agencies can undertake or impose. The body of research does not suggest the most current state licensing procedures and processes have a significant impact on older driver crash rates or outcomes from using age alone to trigger relicensing. The exceptions are drivers 85 and older and those with dementia. This information probably explains why fewer than half of states impose those restrictions or requirements. States can impose as many testing requirements as their laws allow. It is unclear which requirements improve safety. This is a difficult issue to study as the effects may be influ- enced by factors that differ among states, or even within states, making it difficult to conduct valid research. Most research shows few older drivers plan for driving cessation. Research and NHTSA Guideline No. 13, however, suggest older drivers should undertake more planning for the time when they must retire from driving because driving reduction or cessation can lead to social isolation, increased depression, morbidity, and early death, with outcomes that differ by gender. NHTSA Guideline No. 13 states the clear need to develop comprehensive programs to pro- vide more information to a variety of participants and stakeholders on all aspects of licensing and medical evaluation procedures. Recommendations range from developing tools to increas- ing the knowledge and expertise of regular licensing personnel, physicians interacting with their older patients, and older drivers themselves about licensing regulations and processes. Lessons Learned License Renewal • All states, except Rhode Island, have some form of restricted license for a variety of drivers. A restricted license is an outcome of a medical assessment of a driver referred by law enforce- ment, a personal physician, family members, and the public. Other outcomes may be no change, more frequent renewals, or license suspension or revocation. Among the restrictions often imposed on older drivers who are at risk, but not seriously enough to remove their license, are – Daylight driving only, – Corrective lenses required, – No freeway driving, – Outside mirrors required, – Speed restrictions, – Only specific destinations allowed,

12 Promoting Older Driver Safety: Guide for State Practices – No driving in severe weather, – Permission to drive only golf carts, and – Need for future re-evaluations. • Licensing restrictions and requirements may not be associated with changes in crash risks or outcomes because many older drivers restrict or reduce their driving while avoiding challeng- ing situations, independent of licensing requirements. At-Risk Drivers • Only eight states responding to the survey provide training for all licensing personnel on recognizing at-risk drivers. However, some states are adding training modules on the effects of normal aging on driving ability, the types of medical conditions that might impact driving, the use and benefits of restricted licenses, and when and how to refer drivers for medical examination. • All states surveyed allow physicians to report or refer medically at-risk drivers; only six states require physicians to report and only in certain circumstances (CA, DE, NV, NJ, OR, and PA). • All but three states responding to the survey reported law enforcement is allowed to report at-risk drivers; however, only 19 states train law enforcement officers to identify and report medically at-risk drivers. • The survey indicated almost all states allow family members to report at-risk drivers to state licensing agencies, but fewer allow friends and acquaintances to refer. Only five states accept anonymous referrals. • The survey also revealed most states have an organized medical review process to evaluate referred drivers. Thirty-five states and the District of Columbia have active MABs that pro- vide policy advice on how to address the medically at-risk driver. Vehicle Technology • Little is known about the impact of new vehicle technology on the safety of older driver driving abilities and patterns. • New in-vehicle technology such as automatic braking, lane keeping assist, obstacle detection, and blind spot warning may require state licensing agencies, physicians and other medical personnel, and even family and friends to reassess how they determine the fitness of indi- vidual drivers to drive. Conclusion No evidence in the United States or internationally supports the recommendation to require older drivers to have more frequent license renewal, or that special medical or other tests leads to lower crash rates or fatalities among older drivers. States should focus resources used for age-based licensing restrictions to educate all stake- holders in older road user safety to recognize, report, and address impaired fitness-to-drive in older drivers; develop effective outreach programs; distribute evidence-based educational materials; and utilize proven screening methods for personnel, law enforcement, medical providers, non- transportation aging organizations (e.g., Area Agencies on Aging), and older drivers and their families. States that do not have a MAB may want to consider establishing one assessment performed by medical personnel which may be better than administrative processes. Limited information is available on the actual driving behavior of at-risk older drivers whose driving licenses have been suspended or revoked, or who have had driving restrictions imposed on them. Data is lacking on whether such drivers cease to drive or change or do not change their behavior in response to licensing restrictions when they are allowed to continue to drive. With limited research or data, it is difficult to know if such official sanctions achieve their desired

Research Findings 13 impact of reducing or eliminating driving by at-risk drivers, and ultimately reducing older driver crashes and fatalities. States could conduct research, either alone or in collaboration with other states, to collect and analyze data on at-risk drivers to determine whether they cease to drive after a license revocation or if they abide by the restrictions imposed on their driving. States also should evaluate the extent the driving patterns of older at-risk drivers who are given a restricted license differ from their driving behavior before their licenses were restricted (i.e., before and after studies of at-risk drivers with restricted licenses). The results could lead states to consider other licensing restrictions that may be more beneficial to allow older drivers to maintain their driving privileges. Current age-based licensing restrictions and referrals of at-risk drivers may discourage drivers who could improve their driving through assessment, education, training, and the use of in-vehicle devices. Research suggests some older drivers, particularly women, who do not report for mandatory age-based relicensing or tests of fitness-to-drive, could be helped to continue driving through intervention by occupational therapists, education, and training programs (like CarFit), having a restricted license, or other options. Older drivers and stakeholders need more information on all aspects of licensing and medical evaluation procedures, as well as on how the referral process works. To address this issue, states could choose to expand and improve information and training programs to educate older drivers on the available options to drive for as long as it is safe. States can develop better information on the number of older and/or at-risk drivers, evaluate the out- come of programs designed to educate them about potential driving options, and determine what number undertake assessment and training, what their driving patterns then look like, and what their crash rates and outcomes are over time. 3.4 Medical Providers NHTSA recommended states undertake the following projects and policies to meet the medi- cal provider objectives. • Establish and implement a communications plan for reaching medical providers. • Disseminate educational materials for a wide range of medical providers who treat or interact with older people and/or their families. • Facilitate the award of continuing medical education (CME) credits for medical providers to learn about driving safety. • Facilitate referrals of medically at-risk drivers to the state driving licensing authority for review. Research on state processes for conducting medical assessments of older drivers referred for fitness-to-drive discussed in the previous section addresses three major questions about medical professionals: (1) whether they were required to refer their patients for assessment of fitness-to- drive; (2) their role in any medical assessments required by state licensing agencies; and (3) the licensing outcomes of medical provider referrals of at-risk drivers compared to referrals from other sources such as law enforcement or family members. The American Medical Association (AMA) first guidance to physicians, the Physician’s Guide to Assessing and Counseling Older Drivers, first edition, addressed driver safety in an office setting in 1958 in response to the aging of society. Later, the AMA in conjunction with NHTSA began a series of four sequentially updated manuals, with associated training courses, in response to physicians’ need to understand medical fitness-to-drive as their patients age. Research suggests physicians underreport older drivers to licensing authorities. Studies suggest several reasons why physicians do not assess or report older drivers. According to research

14 Promoting Older Driver Safety: Guide for State Practices reported in The Gerontologist (Gergerich 2016), a major reason is initiating such fitness-to-drive conversations changes the nature of the physicians’ relationship with their patients. Elgar and Smith (2018) reported in Internal Medical Journal indicates the mandatory reporting require- ments are unpopular among medical personnel and are applied inconsistently or simply ignored by some physicians. One of the reasons may be the belief reporting requirements would contrib- ute to the deterioration of the traditional doctor-patient relationship. Still, most research indicates many doctors do not test for or discuss the physical limitations that may undermine a patient’s driving ability or ask patients about instances when they do not feel safe driving. According to the research, doctors generally do not test for or even discuss driv- ing difficulties with their older patients, even those with one or more serious medical conditions and even when mandated to do so. Even when physicians do have concerns about a patient’s fitness-to-drive, they may not refer the patient for further tests (e.g., with physical or occupa- tional therapists) or to licensing authorities, even in states with mandates. The research suggests this is the result of several overlapping factors: physicians often are unaware that certain medical conditions (e.g., diabetes, heart disease, dementia) alone or in combination are linked to driving problems; they do not know about or lack trust in available tools to assess fitness-to-drive in an office or hospital setting; and they know or fear opening such discussions with patients will strain the doctor-patient relationship or cause patients to fail to report medical symptoms or conditions. The research and the explicit NHTSA Guideline No. 13 recommendations suggest states should provide more outreach to medical personnel on medical fitness-to-drive concerns, making clear the importance of their role while improving and expanding tools that physicians and other medical providers can use in an office setting to assess patient fitness-to-drive. Lessons Learned The research found several reasons physicians do not discuss fitness-to-drive issues, test their patients for medical fitness, or refer patients to licensing authorities; they include • Physicians often are unaware certain medical conditions (e.g., diabetes, heart disease, dementia) alone or in combination are linked to driving problems. • They do not know about or lack trust in available tools to assess fitness-to-drive in an office or hospital setting. • They fear opening such discussions with patients will strain the doctor-patient relationship or cause patients to fail to report medical symptoms or conditions. Clinician’s Guide to Assessing and Counseling Older Drivers, third edition, developed by NHTSA and the American Geriatrics Society, includes preventive practices such as assessment and counseling strategies, and has guidelines clinicians can use to better identify older drivers at risk for crashes. Some of the conditions that might affect fitness-to-drive include • Physical impairments, • Vision problems, • Medical conditions, and • Temporary conditions. Conclusion Research conducted for the project found most physicians and other medical personnel do not evaluate the fitness-to-drive of their older patients or even discuss these issues with their patients. Nor do most physicians refer older drivers they suspect might have driving problems to other

Research Findings 15 professionals (occupational or physical therapists or certified driver rehabilitation specialists) or to licensing authorities, even when mandated to do so. Medical personnel do not always know what medical conditions or medications alone or in combination might impair driving behavior. Inform- ing medical professionals of existing guidelines does not always help because they lack confidence in the fitness-to-drive-tests the guidelines suggest can be conducted (in theory) in an office setting. Today, physicians generally do not spend a lot of time with each patient and may be concerned dis- cussions about driving may dominate their appointments or induce patients to lie about their conditions. Some doctors report such discussions can disrupt a physician’s relationship with patients. States could provide more outreach to medical personnel on medical fitness-to-drive concerns, making clear the importance of their role. States could also improve and expand tools, using empirical and in-field testing, for physicians and other medical providers to use in an office setting to assess fitness-to-drive. 3.5 Law Enforcement NHTSA recommended states undertake the following projects and policies to meet its objectives for law enforcement. • Develop a communications plan for providing law enforcement officers with relevant infor- mation on medically at-risk drivers. • Provide training and education for law enforcement officers that emphasize “writing the citation” for older violators, how to identify medically at-risk drivers, and how to refer medically at-risk drivers to the driver licensing authority. • Establish a straightforward way for law enforcement officers in the field to make referrals of medically at-risk drivers to the driver licensing authority. Research conducted for the project revealed the following. • Law enforcement agencies were sometimes partners in statewide coordinated older driver safety programs and initiatives. • The literature review revealed all but three states require law enforcement to refer medically at-risk drivers to licensing agencies, but only 19 states provide any training to law enforce- ment officers on how to identify and refer such drivers. • Many law enforcement officers like the ability to report incidents electronically, finding it quicker and easier. Only six states, however, allow officers to report medically at-risk drivers online. The remainder of the states require law enforcement to submit paper reports using forms only occasionally available online. • Law enforcement is a major source of referrals of medically at-risk drivers in several states (28 percent in Texas, 66 percent in Wisconsin). • An NHTSA study in Virginia showed referrals by law enforcement officers of medically at-risk drivers are more likely to lead to licensing restrictions or removal than drivers referred by other sources (such as physicians or DMV counter personnel). • On-site electronic reporting systems make it easier for an officer to capture and report infor- mation on what occurred on the scene and to transmit the information quickly and easily. However, according to research, most states do not require or use on-site crash reporting systems that encourage or mandate law enforcement to evaluate the medical fitness of drivers involved in a crash when they are on the scene. Lessons Learned • There is limited research directly addressing how to train law enforcement officers to recog- nize medically at-risk drivers, the barriers they face in recognizing or reporting at-risk drivers,

16 Promoting Older Driver Safety: Guide for State Practices or ways to increase their referrals of medically at-risk drivers to appropriate licensing authori- ties. More importantly, officers are not aware of the impact aging can have on outcomes for older drivers, or how to use crash reporting data to identify at-risk drivers. • SHSOs can help by making state and local law enforcement agencies aware of any medically at-risk driver requirements, tools, and training programs when they become available. Conclusion Limited understanding exists of the impact or effectiveness of law enforcement training activ- ities on older driver crash rates or outcomes. NHTSA’s Countermeasures that Work rates the role of law enforcement as “effective” (3 stars out of 5) because law enforcement officers provide more than one-third of all driver referrals to licensing agencies. Many law enforcement officers come in contact with older drivers on a regular basis. How- ever, as the research shows, most do not know how to recognize if an older driver is at risk. While a training program for law enforcement does exist, no information indicates SHSOs are aware of it and use it. Tools also exist to assist law enforcement, but it is not clear these tools have wide distribution among older driver safety programs. SHSOs can reach out to NHTSA regional offices about law enforcement training programs on how to effectively interact with older drivers and recognize signs of an at-risk driver. Such a training program existed in the past, but it appears it is no longer available. SHSOs also can provide information to their state and local law enforcement agencies about available resources and training programs. 3.6 Social and Aging Services Providers NHTSA recommended states undertake the following projects and policies to meet its objec- tives for social and aging services providers. • Collaborate with state units on aging and other social services providing support to older drivers transitioning from driving. • Collaborate with state DOT transit offices and local planning organizations to provide infor- mation at the local level to individuals transitioning from driving. • Develop joint communications strategies and messages related to driver transition and encourage states to review and use strategies outlined in Countermeasures that Work. A constant theme in the previous elements in NHTSA Guideline No. 13, and the primary focus in this element of Guideline No. 13, is the need to encourage older drivers to stop driving when it is no longer safe to do so by providing them with timely information about available transportation options in their community. Assessing transportation options helps the older driver identify which trips are most important to their quality of life, which trips can be replaced with delivery services, which trips can be addressed through services available in the commu- nity, and how friends and family members can fill remaining gaps. Communities across the country support an array of transportation programs and services for which older drivers might qualify. However, few individual community-based transportation systems provide service to the range of destinations a senior retiring from driving might want to travel. The mobility options existing in most communities are not available to all older drivers or for all their trips, or on the days or hours when needed. In addition, such services often have strict eligibility requirements which screen out drivers who cannot safely drive but who are not disabled, or they are available only to individuals affiliated with the service provider (e.g., a reli- gious organization or senior center) and generally only for their specific programs. Older drivers

Research Findings 17 seeking a broad range of services would likely have to patch together a variety of subsidized and community transportation alternatives, each of which might impose trip purpose, geographic, or scheduling constraints on their travel. Personal safety can also be a concern when transitioning to other forms of transportation. Bus stops may not be located convenient to seniors’ residences and for seniors with limited mobility walking from their home to a bus stop is not an option. Often, the transportation infrastructure does not offer sidewalks from residents’ homes to a bus stop. It is important for social and aging service providers to demonstrate how personal safety concerns can be satisfied for seniors to feel comfortable using public transit options. In addition, information related to establishing eligibility for home pickup, either door- to-door (vehicle door to client’s door) or house-to-curb, may not be made readily avail- able to seniors, especially those without computers, computer skills, or Internet access. All transportation options need to be available to all seniors, not just those with computers or smartphones. It is unrealistic to expect older drivers to not be skeptical about these options despite—or maybe because of—educational campaigns urging them and their families to view these services as genuine mobility options. It will be necessary for a range of stakeholders to come together to expand the financial and other resources needed to make communities accessible to those who cannot drive, increase and improve public transit options so they serve the locations and schedules older drivers desire, expand special transportation options for those who need acces- sible vehicles or assistance in boarding and disembarking, and facilitate the use of new mobility technologies. Transportation networking companies (TNCs), such as Lyft and Uber, offer mobility options and challenges for older drivers just as they do for everyone. TNCs are becoming more geo- graphically available and provide food delivery and courier services in addition to ride hailing. Some aspects of TNCs limit participation, including the need for a smartphone or an under- standing of how to use a smartphone app, individual’s unwillingness to leave credit card infor- mation on file, or the expense for individuals living on a fixed income. While older drivers face challenges in identifying appropriate transportation options, some benefits to not driving exist, including gaining funds from the sale of a vehicle and saving money by no longer paying for gas, vehicle upkeep and repair, and insurance. This money could then be used to pay for TNC rides, taxi trips, or accessible transit options. Lessons Learned • Older drivers do not currently have sufficient alternative mobility options in most communi- ties to retain all their access and mobility if they reduce or retire from driving. They can, how- ever, begin to identify their transportation needs and options and determine what funding may be available for transportation when they no longer own or operate a vehicle. • Mobility options existing in many communities may not be offered to all older drivers due to the following reasons. – Strict eligibility requirements may screen out many older drivers who cannot safely drive but who are not disabled. – Many services are available only to older drivers affiliated with the service provider (a reli- gious organization or senior center) and only for their specific programs. – Many services operate in geographically limited service areas, provide service in narrow time windows, and are only available for limited trip purposes (medical or congregate meals only), or must be scheduled far in advance.

18 Promoting Older Driver Safety: Guide for State Practices Conclusion Most older driver safety programs recommend older drivers develop a plan for when it is no longer feasible or safe to drive. As the research showed, the options available to older drivers in most communities are lacking and do not meet the full needs of older drivers. Restrictions such as transportation for only people with disabilities or for participants in a particular religious organization or senior center program prohibit many from using these services, and cost can be prohibitive for TNCs like Uber and Lyft or taxi services. Public transit is an option where it is available, although older drivers may be apprehensive about using transit because they think it is not safe or have difficulties getting to and from transit facilities. States can expand financial and other resources needed to make communities accessible to people who cannot drive. Solutions include • Increase and improve public transit options so the locations and schedules seniors desire are served. • Expand special transportation options for people who need accessible vehicles or assistance in boarding and disembarking. • Facilitate the use of new mobility technologies until safe and accessible autonomous vehicles are available. 3.7 Communications Programs NHTSA recommended two approaches to support objectives for communications programs: • Establish working groups of state and local agencies and organizations with an interest in older driver safety and mobility to develop common themes for communications programs. • Focus communications efforts to support the overall policy and program. Research conducted for the other guideline elements revealed important practices for com- munications programs, including the following. • Create better, faster, more accurate procedures for collecting, synthesizing, and analyzing crash data with outreach and training for law enforcement. • Coordinate across agency and government silos to ensure safety programs and policies are based on timely and complete crash data. • Ensure medical providers understand state licensing laws and rules. Promote best practices in assessing medical fitness-to-drive, counseling older drivers on professional help that might improve their skills, and on mobility alternatives. Ensure medical providers have information about how to refer an older driver to an occupational therapist or certified driving rehabilita- tion specialist for further evaluation or to discuss mobility options. • Educate law enforcement on how to detect, counsel, and refer medically at-risk drivers, and support new methods of crash data reporting. • Confirm that planners, social and human service agencies, and transportation providers under- stand the magnitude of the number of drivers who must reduce and cease driving to better support them and their families. • Help older drivers and their families and caregivers make safe driving decisions based on understanding licensing requirements, their personal responsibility to evaluate the impact of their own medical conditions on their fitness-to-drive, and how to access information on driving safety and alternative mobility options. • Make it easier for older drivers and agencies and organizations working with and for older drivers to find useful information on all aspects of the driving and licensing process, including easy access to forms, documents, and resources.

Research Findings 19 • Develop materials and programs to teach older drivers how to use the increasing number of vehicle technological features, many of which are designed to increase driver safety and ease the driving task. • Make the transition to driving reduction and eventual cessation longer and more seamless. Provide ways for older drivers, their families, and caregivers to manage driving risks while making realistic assessments of the life changes that will be necessary with driving cessation, including non-transportation options like moving to more accessible communities. Lessons Learned • Communications alone are not sufficient to ensure all partners remain committed to safe and mobile futures for older drivers. • Achieving participation from older drivers is challenging because they are a difficult demo- graphic to reach and may be fearful of losing their license if they participate in community or educational programs. To gain their trust and participation, staff and volunteers must go directly to where older drivers are located and speak with them in person. This is time con- suming and expensive and reaches only a small portion of the older driver population. Conclusion Maintaining viable communications programs, as this element of the NHTSA Guideline No. 13 envisions, requires substantial attention to the intersection of sometimes conflicting objectives, unequal distribution of resources, multiple perspectives on best practices, and wide variations in institutional resources and methods of resource allocation. Some recommenda- tions include the following. • Create or ensure cross-institutional communications working groups coordinate and deliver consistent messages and address major older driver safety issues despite differences in the focus, perspective, objectives, and missions of the individuals and agencies and organizations involved. • Ensure continued and structured communication that is necessary to achieve the programs and policies NHTSA recommends. • Provide older driver tips and more user-friendly media, including social media in formats states can alter to fit their culture. 3.8 Program Evaluation and Data Seven specific recommendations to support the overall goals for program evaluation and data include • Support detailed analysis of police crash reporting involving older drivers. • Encourage local governments and organizations to evaluate the outcomes of local older driver programs by providing support and training. • Conduct and publicize statewide surveys of public knowledge and attitudes about older driver safety. • Evaluate the effectiveness of older driver educational programs by measuring behavior and attitudes. • Evaluate the use of older driver program resources and the effectiveness of existing counter- measures for the public and for high-risk populations. • Ensure the results of such evaluations are used to identify problems, identify new programs, and improve existing programs.

20 Promoting Older Driver Safety: Guide for State Practices • Maintain awareness of trends in older driver crashes at the national level and consider how these trends might influence activities statewide. Public programs based around communications strategies often count or assess input measures because they are the easiest and cheapest thing to measure. This could include the number of fliers produced and mailed, user requests for information, older driver events that law enforce- ment attended, or participants at each of these events. These measures, however, have a limited connection to reducing older driver crash rates and fatalities. Output measures also can be studied, but it is hard to know what reasonable metric really rep- resents desired changes. Output measures could include what participants in an activity wrote on the feedback cards, or how many planned to do something differently, like buy vehicle adap- tations, or how many said they knew traffic laws better or felt more confident in driving after an older driver safety program. The problem with output measures is sometimes they have a very indirect link to more basic or macro goals, like reducing older driver crash rates and fatalities. The research literature suggests a less than anticipated effect on crash rates because the older drivers identified for certain interventions either were not driving much or were heavily self- regulating. The best measure of programs and policies would be impact measures with the closest link to the ultimate policy goals, but those are difficult as well. It is easy to say goals are safety and mobility but increases in safety could be accomplished by restricting older driver mobility and vice versa. So, balancing the two goals becomes difficult and requires more research and study since it is unlikely the relationship between the two metrics is linear. Far less is known about all the programs and policies detailed in NHTSA Guideline No. 13 as the review of this large body of research on the eight elements in Guideline No. 13 makes clear, although there have been several major evaluations of the research based on these issues in the last 4 to 5 years. Lessons Learned • Far less is known about all the programs and policies detailed in NHTSA Guideline No. 13. • Any evaluation of the elements should be clear on the performance metrics and how they should be evaluated. • No formal review or evaluation process exists like NHTSA’s occupant protection and impaired driving assessments, which could help SHSOs evaluate and implement older driver programs. • States may collect data on the number and rate of older driver fatalities and serious injuries, but do not use the information to develop and evaluate an older driver safety program. Conclusion The research, and particularly the outreach to SHSOs, did not reveal any active evaluation efforts being conducted by SHSOs on the effectiveness of older driver safety programs. Some existing programs are identifying output measures to indicate the implementation status of the effort’s programs and policies. The research literature also revealed at-risk older drivers, who are most often targeted for interventions, tended not to drive or self-regulated when and where they drove.