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

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21   Challenges, Successes, and Resource Allocation This chapter provides a summary on the challenges in implementing Highway Safety Guide- line No. 13; successful approaches to implementation; outcome evaluations; and tools and methods for resource allocation. 4.1 Challenges in Implementing the Guidelines Information on the challenges facing SHSOs in implementing the recommendations in High- way Safety Guideline No. 13 were obtained from a survey sent to all offices. Seventeen SHSOs reported having an older driver safety program aiming to reduce older driver crashes, fatalities, and injuries. The research team analyzed the survey responses to identify the strength of the states’ older driver safety programs and nine states were selected for further in-depth interviews: four states (FL, MD, MO, and NY) with more active programs and five states (MS, ND, NE, WI, and WV) with less active programs. The challenges in implementing Highway Safety Guideline No. 13 by the active and less active older driver programming states are summarized below. Program Management • Challenge: Lack of dedicated funding that makes state funds essential to build a robust older driver safety program. Though Florida can use state funds to operate the older driver pro- gram, Mississippi, one of the less active state older driver programs, does not receive any state funds for programming to supplement the NHTSA funds. • Solution: Remove restrictions on how SHSOs can use NHTSA funding for older driver initiatives. • Challenge: Older driver safety falls short when compared to other program areas such as bicycles and pedestrians in safety plans. With limited fiscal resources, efforts focus on the most pressing traffic safety problems as determined by data. Older driver crashes do not represent as large a problem as other program areas, such as impaired driving, so efforts con- centrate on the higher priority areas. • Solution: Integrate older driver safety with other programs, e.g., when conducting impaired driving programs, talk about the dangers of prescription and over-the-counter medications and how they can impair driving ability. When grandparents bring grandchildren to child safety seat checks, provide them information about CarFit, why it is important, and CarFit events in their area. • Challenge: Lack of staffing to manage or run the SHSO’s older driver safety program area. A lack of staff may be due to limited funding, staffing cuts, or retirement of key staff members. The other responsibilities of a SHSO program manager make it difficult to find time to develop and implement an older driver program in states with less active older driver programming. C H A P T E R 4

22 Promoting Older Driver Safety: Guide for State Practices • Solution: Provide older driver tips, social media, and other resources states can use to pro- mote older driver safety and integrate into other SHSO programs and outreach efforts. Driver Licensing • Challenge: Lack of training for licensing personnel on recognizing at-risk drivers (only eight states provide training). • Solution: Add 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. • Challenge: Lack of a comprehensive state program to provide more information to a vari- ety of participants and stakeholders on all aspects of licensing and medical evaluation procedures. • Solution: Leverage the fact most states have some form of an organized review process to evaluate referred drivers, with 35 states and the District of Columbia having a more formal medical review process. • Challenge: The impact of new in-vehicle technology on the driving abilities, patterns, and safety of older drivers is not widely known. • Solution: While the full impact of new in-vehicle technology is not yet fully known, signs indicate these additions can benefit older drivers and improve their safety on the road. Under- standing new in-vehicle technology may require state licensing agencies, physicians, and other medical personnel to reassess how they determine the fitness of individual drivers to drive. Medical Providers • Challenge: Some medical professionals do not test for functional limitations with their older patients, even patients with one or more serious medical conditions. This may be due to overlap- ping factors including the physicians’ lack of awareness of the impact of medical conditions on driving, their lack of trust in available tools to assess fitness-to-drive, and the fear such discussions will strain the doctor-patient relationship. • Solution: Encourage physicians who treat older patients to use the latest edition of the Clinician’s Guide to Assessing and Counseling Older Drivers. Law Enforcement • Challenge: Limited research addressing the training of law enforcement officers to recognize and refer medically at-risk drivers is available except for the Driver Orientation Screening for Cognitive Impairment (DOSCI) tool. • Solution: Investigate the potential of the NHTSA-developed course, Educating Law Enforce- ment Officers on Older Driver Issues; it is unclear whether this program has been updated or used. Additionally, the NHTSA publication, Countermeasures That Work, rates the effective- ness of enforcement of traffic laws, the identification of drivers with potential driving impair- ments and referral to licensing agencies, and providing information and education to law enforcement on older driver safety, as “likely to be effective based on the balance of evidence from high-quality evaluations or other sources.” Social and Aging Services Providers • Challenge: Older drivers do not have sufficient alternative mobility options in most commu- nities, which makes it impractical to say older drivers will retain mobility when they reduce or retire from driving.

Challenges, Successes, and Resource Allocation 23 • Solution: Encourage collaboration among a range of stakeholders to expand the financial and other resources required to make communities accessible to those who cannot drive. Increase and improve public transit options to serve the locations and schedules older drivers desire. Expand special transportation options for those who need accessible vehicles or assistance in boarding and disembarking. Provide information and assistance on the use of new mobility technologies, including ride share, which must be readily available until the time when safe and accessible autonomous vehicles are widespread and affordable. In addition, support occu- pational therapists and driver rehabilitation specialists who can help older drivers drive for as long as it is safe to do so and optimize mobility options by working with individuals who can no longer drive. Communications Programs • Challenge: The absence of dedicated NHTSA funding makes it difficult for SHSOs to conduct continuing and structured communication. Additional funding could help SHSOs achieve the programs and policies recommended by the NHTSA Guideline No. 13. Maintaining viable communications programs involving multiple stakeholders requires substantial atten- tion to the intersection of sometimes conflicting institutional objectives, unequal distribu- tion of resources, multiple perspectives on best practices, and wide variations in institutional resources and methods of resource allocation. • Solution: Consider Florida’s Safe Mobility for Life program’s use of state, not NHTSA, fund- ing for communications efforts, providing more latitude to bring on a consultant to develop creative messaging. The program also pays to implement and distribute messaging to the public. • Challenge: It is difficult to obtain participation from older drivers in community-based pro- grams or to provide them with information because they are hard to reach and may be fearful of losing their license if they do participate in safety related activities. • Solution: Gain older drivers’ trust and participation by sending staff and volunteers directly to where older drivers are located, such as senior centers or religious groups, to speak with them in person. Program Evaluation and Data • Challenge: Little is known about all the programs and policies detailed in NHTSA Guideline No. 13. It is necessary to begin any evaluation by being clear what the performance metrics are and how easily they can be evaluated. • Solution: Utilize the NHTSA publication, Art of Evaluation, A Guide for Highway Safety Pro­ gram Managers, which was updated in 2008 and includes steps to conduct an evaluation and case studies providing more information. This publication could provide valuable informa- tion for individuals conducting evaluations of older driver safety programs. 4.2 Successful Approaches Following is a listing of successful approaches and examples identified from the research that SHSOs can undertake to develop and implement an older driver safety program. The approaches and examples are listed by NHTSA Guideline No. 13 elements. Program Management • Partner with outside organizations who work on older driver issues or with older individuals. • Obtain state and other funding for older driver program efforts.

24 Promoting Older Driver Safety: Guide for State Practices • Develop a specific older driver strategic plan rather than relying on older driver goals in other plans like the state’s SHSP. • Collaborate with other offices within the SHSO’s state agency. • Conduct regular meetings on older driver safety. • Dedicate a staff member to older driver issues and programming. Examples Kansas Uses Data to Identify Older Driver Issues. The Kansas DOT maintains the Kansas Crash Analysis and Reporting System (KCARS) used by Kansas State University (KSU) (2018) to identify older driver crash characteristics. Kansas conducted the work because one in five fatali- ties in the state between 2010–2014 involved older drivers, and those older drivers accounted for twice as many fatalities as did all drivers. The KSU researchers found older drivers were overrepresented in crashes involving driving in heavy traffic, merging into traffic, moving away from traffic, and misjudging traffic gaps. The researchers suggested, consistent with the NHTSA Guideline No. 13 requirements, the state use these data to structure safety and training programs for older drivers. Michigan’s Safe Drivers Smart Options Program. Michigan used a three-year federal grant to develop a program, Safe Drivers Smart Options: Key to Lifelong Mobility. The program works with a variety of public and private stakeholders to develop “a sustainable state strategy to enhance older driver safety and mobility.” Participants include state aging organizations, the Michigan DOT, Area Agencies on Aging, and FHWA. The Michigan program developed a website with operating support from the Traffic Safety Section of Michigan DOT that assisted older drivers who wanted to maintain their safe driving skills or transition to alternative mobility options. An operating committee meets annually and subcommittees work to promote the overall strategy, update the materials on the website, and provide guidance on annually revising an action plan. Roadway Design • NHTSA Guideline No. 13 recommends finding ways to encourage states to adopt some or all FHWA guidelines developed for older road users. The guidelines include standards, treat- ments, and warrants to not only help older drivers but help all road users. They may not have been adopted by states since many have not been included in the MUTCD and the HCM. It may be states have adopted them but not widely published findings on their evaluation or the appropriateness and outcomes of using these standards instead of more traditional ones. Example Florida Makes Improvements to Address Age-Related Changes. The impetus for the Florida Safe Mobility for Life program began 20 years ago when the Florida DOT conducted a pilot program to identify highway safety improvements to enhance the safety and mobility of older drivers. These improvements address natural age-related changes by providing increased visibility (pavement markings width increased, spacing of reflective pavement markers reduced, larger lettering on guide signs based on the speed of the road); pedestrian features at intersections (countdown pedestrian signals, refuge islands, high-emphasis crosswalks, longer walk times); and advance notification (advance street name signs, advance warning signs, i.e., stop, yield, and signal ahead). To help older drivers more, the Safe Mobility for Life Coalition developed tip cards and graphics for the following roadways and traffic control devices: • Flashing Yellow Arrows, • Right-Turn-on-Red,

Challenges, Successes, and Resource Allocation 25 • Roundabouts, and • Wrong-Way Driving on the Interstate. Driver Licensing • Ensure law enforcement uses a screening tool, such as the DOSCI, as a guide for officers in assessing cognitive impairment. • Provide older driver safety tips and other information on self-assessments, evaluation of driving skills, driver safety courses, and the impact of medication on driving abilities. • Increase dissemination of information on the driver’s license renewal process for older drivers. • Develop and disseminate information on vehicle safety features and new in-vehicle technolo- gies to increase driver safety and comfort behind the wheel. Update the information as the technology progresses and more information becomes available. Examples State License Renewal Approaches. In Illinois, drivers ages 81 to 86 can be issued a two- year license renewal but drivers age 87 and older can only be issued a one-year license. In Penn- sylvania, the licensing authority can choose to renew an older driver’s license at age 65 for only two years or for the standard four-year period. Other states require all renewals to be in-person starting at a certain age. In California, this requirement starts at age 70. California Driver Safety Hearing Office. A Driver Safety Hearing Officer (DSHO) is an employee of the California DMV who conducts interviews, reexaminations, and hearings for the modification, reinstatement, granting, or withdrawal of driving privilege for drivers with physical or mental problems and other issues, such as negligent vehicle operation. They receive specialized training on how to observe applicants for conditions that could impair their ability to drive safely. New York State DMV. Recognizing drivers of any age may be at risk, the New York State DMV requires all drivers whose skills and abilities are in doubt to participate in a re-evaluation. The DMV must have a “specific reason” related to driving performance to contact a driver for a driving re-evaluation, such as a driving incident, behavior, action or other cause reported to the DMV by a physician, a police officer, or someone who knows or has observed the driver. If the driver fails the test, the DMV revokes the license. When the report is from a physician the DMV immediately suspends the driver’s license until an examination has been conducted. Medical Providers • Collaborate with and involve health care professionals in older driver efforts. In Florida, the involvement of health care professionals helped the Safe Mobility for Life Coalition learn how to reach out to older drivers with content and information. Their involvement resulted in a range of Resources for Health Care Providers, available on the Coalition’s website. • Ensure medical personnel, law enforcement, family members, and caregivers can report an older driver if they have concerns regarding their ability to drive safely to the DMV, and allow a medical examiner to review information. Example Missouri’s Keep Your Keys and Occupational Tool Kit. The Keep Your Keys program is a driver safety course in Missouri, geared toward people 55 and older, caregivers and facilitators, health educators, nurses, and highway patrol officers. The Occupational Therapy Toolkit is a

26 Promoting Older Driver Safety: Guide for State Practices collection of 354 full-page illustrated handouts for adults with physical disabilities, chronic con- ditions, and other geriatric disorders that physicians can print and give to their patients. Law Enforcement • Increase involvement of law enforcement in older driver safety issues. Examples Florida’s Law Enforcement Toolkit. The Florida Safe Mobility for Life Coalition identified a need to better involve law enforcement in older driver safety and developed a Law Enforcement Toolkit to help officers across the state identify and respond to at-risk older drivers. The toolkit includes a Driver Medical Referral Visor Card to provide officers quick access to available infor- mation and resources on referring unsafe drivers for medical review. Maryland’s Training Program. In Maryland, the focused law enforcement outreach and training is part of required professional development credits/hours. Implementation of the elec- tronic referrals system has tripled the number of referrals from law enforcement for medical advisory panel review. ChORUS Resources. The Law Enforcement Driver Guide by Clearinghouse for Older Road User Safety (ChORUS) provides nationwide practical and proven resources to support law enforcement officers as they assist older drivers in their communities. The guide contains assessment tools, quick training videos to show and discuss during daily roll call, quick reference guides, and community outreach tools. Missouri and Kentucky Law Enforcement Older Driver Programs. The Missouri State Highway Patrol has a senior drivers program in which state troopers speak to a variety of local and regional senior groups on topics like occupant safety, defensive driving, and winter driving hazards. The Kentucky State Police provide traffic safety tips and instruction annually at the state’s Senior Center Safety Day, demonstrating to grandparents how to safely install child safety seats when transporting grandchildren. Waltham, MA, Police Department Training Program. In Massachusetts, a Waltham Police Department training program teaches officers to identify and assist problem drivers, such as those with Alzheimer’s disease, before they become an “immediate threat.” The program instructs officers to create a written record of impaired driving by writing warnings or citations so it is pos- sible to track drivers with reduced capacity. In addition, they review all traffic collisions involving older drivers to determine whether there is a need for action; if so, they work with a Geriatric Task Force to refer those drivers to alternative transportation providers. Social and Aging Services Providers Conduct or sponsor a CarFit program to help older drivers find a better “fit” in their car and ensure it is properly adjusted for them. CarFit is administered nationally by AAA, American Association of Retired Persons (AARP), and the American Occupational Therapy Association (AOTA). Florida and Maryland have robust CarFit programs. Examples Florida’s Find-a-Ride Program and Tips on Transportation Options. Florida Safe Mobility for Life Coalition has built a comprehensive database of all transportation options available to older drivers in each of the state’s 67 counties through their Find-a-Ride program. This resource helps older adults transitioning from driving find transportation options to take them to visit

Challenges, Successes, and Resource Allocation 27 with family and friends, shop at the mall, or go to a doctor. The Coalition also has developed a series of tip cards and educational materials, “Tips on How to Use Transportation Options in Florida,” to empower road users with the ideas and resources needed to safely get where they need to go with or without a personal vehicle. ChORUS Transportation Planning Tool. The ChORUS Older Driver Transportation Plan- ning Tool provides older drivers with instructions for developing a transportation plan for when safe driving is no longer an option. A Community-Based Transportation Option. GoGoGrandparent (GoGo) intercedes for seniors with the actual TNCs across the United States. The service facilitates a wide variety of delivery and online services for seniors and usually requires a smartphone app and pre-entered credit card information. The company states they vet TNC drivers by checking their history. GoGo claims to continue the trip search process until they connect an older traveler to a driver with a vehicle large enough to accommodate mobility devices when needed. Communications Programs • Develop a unique message and branding people easily recognize and remember. • Develop a website where older drivers can find information on safe driving. Examples Florida’s You Hold the Keys to Your Transportation Future. The Florida Safe Mobility for Life Coalition has built a brand for their outreach with the message, “You Hold the Keys to Your Transportation Future.” They found the message resonates more with older drivers because it keeps ageism out of the discussion. Missouri Communication Plan. The Missouri SHSO develops an annual communications plan with an Older Driver Subcommittee. Input from the committee ensures resources are pro- vided to the SHSO regions on older driver safety including paid and social media advertisements. Older Driver Safety Awareness Week. The AOTA has designated the first full week of December as Older Driver Safety Awareness Week to encourage older residents to seek mobil- ity independence, understand the risk factors of driving as they age, and build a well-rounded transportation plan. Several states (FL, MD, and MO) have promoted the week-long campaign, sharing tips and guidelines, toolkits, and information with the media to raise awareness on issues including community-based transportation and mobility options. Program Evaluation and Data • Keep track of pass/fail rates on driver reexaminations of older drivers conducted by the DMV. It may also make sense to keep track of revoked licenses. Examples Wisconsin Community Maps. The Wisconsin SHSO and public have access to a software package, Community Maps, that allows them to look at crash history by demographics such as drivers aged 65+. They can review older driver fatalities, injuries, and property damage and determine the location of these crashes. Florida Data Web Page. The Florida Safe Mobility for Life Coalition website’s Data Web page features urban and rural priority counties within the state, which is analyzed using a 5-year

28 Promoting Older Driver Safety: Guide for State Practices average of the crash rate involving individuals aged 65+ compared to the population of 65+ in urban and rural counties. Identification of yearly priority counties helps the Coalition focus efforts on improving older driver safety in those regions. New York DMV. For evaluation purposes, the New York DMV keeps track of pass/fail rates by age, locations for reexaminations, and the number of referrals. 4.3 Resource Allocation Currently no opportunities exist to fund older driver safety programs through the federal funding SHSOs receive from NHTSA. However, SHSOs can conduct a variety of activities or provide age-specific resources under existing program areas even without a dedicated stream of money. Following are some suggested approaches. • Alcohol- and drug-impaired driving—Develop and distribute information to older drivers on the possible dangers of prescription and over-the-counter drugs and their impact on safe driving. • Occupant protection—Reach out to older drivers as grandparents or older relatives who transport children and provide them with information on child passenger safety and where they can go to have a child safety seat properly installed. Remind the older drivers about the importance of buckling up, not only to set a good example for their grandchild and younger relative, but for their own safety as well. Take the opportunity to provide them information and resources on the state’s CarFit program and encourage them to attend so they know they have the proper “fit” in their vehicle just like their grandchild or younger relative does in their car seat. • Motorcycle safety—Many “new” motorcycle riders are older riders who are returning to this mode of transportation. Unfortunately, motorcycle safety experts find many riders in this demographic may believe they do not need any training or assistance since they have ridden a motorcycle in the past. Since this may be the first roadway safety course they have taken in a long time, or have ever taken, providing information on advancements or changes in roadway design, vehicle technology, and protective gear improvements is important. • Pedestrian and bicycle safety—Walking and biking are increasingly common modes of transportation for older adults particularly those who are limiting their driving. These walkers and bicyclists, however, may have unique needs. Safety issues when walking or riding are important to this age group and helping them feel safe is vital. • Enforcement of traffic safety laws—Law enforcement officers need information on what to look for if they encounter an older driver who may not be safe behind the wheel, and where and how they should refer the individual. • Driver performance—Aging impacts aspects of safe driving including vision, strength, flex- ibility, reaction time, and judgment. Encourage community traffic safety program grantees to partner with the AARP, AAA, or other community agencies and organizations on creating and distributing a self-assessment checklist, which is an effective way to reach the older driver population and provide them with additional resources. Conclusion This chapter detailed challenges facing SHSOs such as a lack of dedicated funding for older driver programs, staffing issues, insufficient training for law enforcement and licensing personnel on recognizing at-risk drivers, and the need for a medical community more active in addressing older driver safety issues. Along with the challenges, however, this chapter laid out solutions and provided insight into successful approaches already being conducted by states

Challenges, Successes, and Resource Allocation 29 across the United States. This includes Maryland’s outreach and training for law enforcement, Missouri’s Keep Your Keys program, California’s DOSCI screening tool for law enforcement, and Florida’s Find-a-Ride program. In terms of lessons learned, more information would be helpful on the extent to which the NHTSA Guideline No. 13 recommendations have been adopted. The advancements in vehicle technology point to the need for more information on the impact of these technologies on older driver safety as well as more education for the older driver on the use of these improvements. Finally, the research revealed the difficulty SHSOs have in funding programs to address all the traffic safety problems in a state. However, this guide details ways existing SHSO programs can be expanded to provide more information and educa- tion to older drivers. While difficulties exist, the research also indicated there are ways to start a program aimed at keeping older drivers mobile and safe.