Presentation on theme: "International Classification of Function, Disability and Health (ICF)"— Presentation transcript:
1 International Classification of Function, Disability and Health (ICF) Dr Ger Craddock
2 International Classifications World Health Organization Classification Assessment Surveys & Terminology GroupICFWHO Family ofInternational ClassificationsGreetings ,I am happy to greet you on behalf of the World Health Organization and it is my pleasure to provide you with this introduction on the WHO Family of International Classifications (WHO- FIC)We are now in an upgrading process and moving towards the a unified concept of integrated classification systems for health information.In this presentation, I would like to address the following points:What is the WHO Family of International Classifications ?Why is there a need for the WHO FIC ?What are the key concepts of WHO FIC And the underlying principles of family ?How can we use the WHO FIC to improve people’s health?For your information, a copy of the slides used in this presentation is available from WHO or over the INTERNET. The contact addresses are found at the end of this presentation.
3 International Classification of Functioning, Disability and Health 3333
4 ICF Applications Health sector Social security Education sector Labour sectorEconomics & development sectorLegislation & lawOther ….44
5 Definitions Impairment Activity Limitations Participation Restrictions Loss or abnormality in body structure or function (including mental function)Activity LimitationsDifficulties individual may have in executing activities in terms of quantity or qualityParticipation RestrictionsProblems an individual may experience in involvement in life situationsFacilitators & BarriersEnvironmental factors may be a facilitator for one person & barrier for another555
6 ICF Components Body functions Physiological functions of body systems Body Structures Structural or anatomical parts of the bodyActivities Execution of a task or action by an individual (individual perspective)Participation Persons involvement in a life situation (societal perspective)Environmental Factors All aspects of the external world that impact on the person’s functioning666
7 ICF Structure Two parts: 1. Functioning and Disability a) Body functions and structuresb) Activities and Participation2. Contextual Factorsa) Environmental factorb) Personal factors77
8 Family of Who Classifications ICF belongs to the WHO family of international classifications, the best known member of which is the ICD-10 (the International Statistical Classification of Diseases and Related Health Problems). ICD-10 gives users an etiological framework for the classification, by diagnosis, of diseases, disorders and other health conditions.
9 WHO FamilyBy contrast, ICF classifies functioning and disability associated with health conditions. The ICD-10 and ICF are complementary.Encouraged to use them together to create a broader and more meaningful picture of the experience of health of individuals and populations.In short, ICD-10 is mainly used to classify causes of death, but ICF classifies health.
10 International Classification of Function, Disability and Health (ICF) Originally ICIDH (international Classification of Impairments, disabilities and Handicaps 1980) now ICF (International Classification of Function, disability and health 2001)Classification was conceived as means to evaluate the effectiveness of health care processes
11 International Classification of Function, Disability and Health (ICF) Classification envisioned for three usesStatistics on the consequences of diseaseStatistics on use of health servicesConditions classified according to categories
12 Why ICF?There is also an increased recognition among policy makers and service agencies that reductions in the incidence and severity of disability in a population can be brought about by1)enhancing the functional capacity of the person and2) by improving performance by modifying features of the social and physical environment.To analyze the impact of these different interventions, we need a way of classifying domains of areas of life as well as the environmental factors that improve performance.ICF allows us to record this information.
13 THE MODEL OF ICFThe medical model views disability as a feature of the person, directly caused by disease, trauma or other health condition, which requires medical care provided in the form of individual treatment by professionals. Disability, in this model, calls for medical or other treatment or intervention, to 'correct' the problem with the individual
14 The ICF ModelThe social model of disability, on the other hand, sees disability as a socially created problem and not at all an attribute of an individual. On the social model, disability demands a political response, since the problem is created by an unaccommodating physical environment brought about by attitudes and other features of the social environment.
15 The ICF ModelOn their own, neither model is adequate, although both are partially valid.Disability is a complex phenomena that is both a problem at the level of a person's body, and a complex and primarily social phenomena. Disability is an interaction between features of the person and features of the overall context in which the person lives, but some aspects of disability are almost entirely internal to the person, while another aspect is almost entirely external.Summary: Both medical and social responses are appropriate to the problems associated with disability; we cannot wholly reject either kind of intervention.
16 The ICF ModelA better model of disability,? synthesize what is true in the medical and social models, without making the mistake each makes in reducing the whole, complex notion of disability to one of its aspects.This model of disability is called the biopsychosocial model.ICF is based on this model, an integration of medical and social. This provides a coherent view of different perspectives of health: biological, individual and social.
17 International Classification of Function, Disability and Health (ICF) The ICF was given a mandate to develop a “global common language” in the field of health and disability. The overall objective of the ICF was to develop an operational classification system on human functioning and disability thatWas applicable to every human being. (universality)Addressed multiple dimensions regarding the ‘person’ and ‘environment’ (at body, person and society levels)Was sensitive to International practices,Was based on user needsWas empirically based with field trials on applicability, reliability and utility.
18 Cultural Applicability [Keywords] concept###[Narration] ###Conceptual and functional equivalence of ClassificationTranslatabilityUsabilityInternational Comparisons
19 Foundations of ICF Human Functioning - not merely disability Universal Model not a minority modelIntegrative Model not merely medical or socialInteractive Model not linear progressiveParity not etiological causalityContext - inclusive not person aloneCultural applicability - not western concepts ?Operational not theory driven aloneLife span coverage not adult driven ?[Keywords] concept###[Narration] ###19
20 The ICFUses neutral terms to identify function at the Body function, activity and participation level rather that impairment, disability and handicap
21 The ICFThe addition of the emphasis on the interaction of environmental features, both physical and social, adds an important context within which persons with disabilities can be evaluatedIncreased emphasis on function i.e. does the intervention you propose maintain or improve functionAccordingly when measuring outcomes, the effectiveness of the intervention must be seen in the context of the user’s environments
23 ICF Components Body Functions & Structures Activities & Participation Environmental FactorsFunctionsStructuresCapacityPerformanceBarriersFacilitatorsNach den Ausfuehrungen zum Kontext und Konzept des ICIDH-2 moechte ich Ihnen nun auf die Inhalte, Begriffsdefinitionen und Kodierungschema vorstellen.Der ICIDH-2 unterscheidet zwischen drei Dimensionen…
24 Activity & Participation Body functions& structures
25 Limitation in activity Restriction in participationImpairedbody functions& structures
28 Participation is involvement in a life situation. Activity is the execution of a task or action by an individual.It represents the individual perspective of functioning.Participation is involvement in a life situation.It represents the societal perspective of functioning.
29 Body structures and functions The ICF includes 4 dimensionsImpairments at a body levelActivities at the person level (formerly disability)Participation at the social level (formerly handicap)Contextual factors which list physical environment factors, such social environment factors, laws, attitudesInteraction of the environmental factors with the 3 levels result in functioning that is either positive or negative
30 ActivitiesActivities are performance of person-level tasks or activities undertaken by the personDomains of activity are communication, movement, self care, interpersonal and performing the simple to complex tasks involved in major life activitiesActivities are the observable and reportable performance of actions of individuals in the context of their culture
31 ParticipationParticipation is defined as “individual’s involvement in life situations in relation to health conditions, body functions and structures, activities and contextual factorsA key term is Involvement “means inclusion of the individual in life activities in the context of how and where they live”
32 ParticipationThe classification of participation restriction is assessed on desired participation of the individual’s life activities within societyIt is measured by placing the observed involvement in a life activity in 1- 9 participation domains that include personal maintenance, mobility, exchange of information, social relationships, home life and assistance to others, education, work and employment, economic life, community, social and civic life
33 ParticipationParticipation is qualified by the degree of restriction experiencedFor example, if mobility outside the home is moderately restricted as a function of the lack of the availability of accessible transport, then the participation code (p) would be assigned as follows: chapter 2 (participation in mobility) under the 2nd level heading (230) titled “Participation in mobility outside the home and other buildings” and restriction qualifier of moderate (2) resulting in the full code of p230.2
34 ICF Mechanisms for Documenting Disability Status .0= No Barrier .1= Mild Barrier .2= Moderate Barrier .3= Severe Barrier .4= Complete BarrierEnvironment+0= No Facilitator+1= Mild Facilitator+2= Moderate Facilitator+3= Severe Facilitator+4= Complete FacilitatorPSI LDSIG 16/04/201034
35 Contextual Factors Environment Person Products Milieu Institutions Social NormsCultureBuilt-environmentPolitical factorsNaturePersongenderageother health conditionscoping stylesocial backgroundeducationprofessionpast experiencecharacter style[Keywords] structure###[Narration] ###
36 Functioning and Disability StructureICFClassificationPart 1:Functioning and DisabilityPart 2:Contextual FactorsPartsBody Functionsand StructuresActivities andParticipationEnvironmentalFactorsPersonalFactorsComponentsChange inBodyFunctionsChange inBodyStructuresCapacityPerformanceFacilitator/BarrierConstructs/qualifiersICIDH categories are organized in a "nested" approach Broader Category detailed subcategoryThe classification has two parts, each with two components.[An example may help to illustrate the point:The universe of health and disability is being classified (this is the forest). Within that forest we classify the dimensions of Impairments, Activities and Participation (the trees). In the Activities dimension we have several chapters or domains ranging from simple to complex activities - from sensing and recognizing to interpersonal behaviours (the trunks). Within, for example, the chapter on Interpersonal Behaviours are included activities such as general interactive skills (the branch) and included in that broad category are behaviours such as initiating social contact, responding to cues and so on (the leaves).]Item levels:1st2nd3rd4thItem levels:1st2nd3rd4thItem levels:1st2nd3rd4thItem levels:1st2nd3rd4thItem levels:1st2nd3rd4thDomains and categoriesat different levels
37 THE DOMAINS OF ICFThe domains of ICF are arranged in a hierarchy (Chapter, second, third and fourth level domains), which is reflected in the coding:e.g.
38 The QualifiersThe list of domains in ICF becomes a classification when qualifiers are used. Qualifiers record the presence and severity of a problem in functioning at the body, person and societal levels.
39 For body function and structure, the primary qualifier The primary qualifier indicates the presence of an impairment (5 point Scale)no impairment,mild,moderate,SevereComplete
40 Activity and Participation domains, 2 Qualifiers The Performance qualifier describes what an individual does in his or her current environment. Since the current environment always includes the overall societal context, performance can also be understood as "involvement in a life situation" or "the lived experience" of people in their actual context. (The 'current environment' will be understood to include assistive devices or personal assistance, whenever the individual actually uses them to perform actions or tasks.)
41 Activity and Participation domains, 2 Qualifiers The Capacity qualifier describes an individual’s ability to execute a task or an action. This indicates the highest level of functioning of a person in a given domain at a given moment.
42 ICF Mechanisms for Documenting Disability Status FunctioningStructuresActivityParticipation0= No Problem 1= Mild Problem 2= Moderate Problem 3= Severe Problem 4= Complete ProblemCapacity: What a person can do without assistancePerformance: What a person can actually do42
43 Capacity and Performance Data Having access to both performance and capacity data enables ICF user to determine the 'gap' between capacity and performance.
44 Capacity and Performance Data? If capacity is less than performance, then the person's current environment has disabled/enabled him or her to perform better:??
45 Capacity And Performance: Answer the environment has facilitated performance.
46 Capacity And Performance:? If capacity is greater than performance??
47 Capacity And Performance: Answer Some aspect of the environment is a barrier to performance.
48 Questions re Defining Capacity? Mobility (1) In your present state of health, how much difficulty do you have walking longdistances (such as a kilometer or more) without assistance?(2) How does this compare with someone, just like yourself only without your healthcondition?(Or: "…than you had before you developed your health problem or had the accident?)
49 Questions defining Performance? mobility (1) In your present surroundings, how much of a problem do you actually have inwalking long distances (such as a kilometer or more)?(2) Is this problem walking made worse, or better, by your actual surroundings?(3) Is your capacity to walk long distances without assistance more or less than what you actually do in your present surroundings?
50 Questions Defining Capacity: Major Life Areas (1) In your present state of health, how much difficulty do you have getting done all thework you need to do for your job, without assistance?(2) How does this compare with someone, just like yourself only without your healthcondition?(Or: "…than you had before you developed your health problem or had the accident?)
51 Defining questions Re Performance: Major Life Areas (1) In your present surroundings, how much of a problem do you actually have gettingdone all the work you need to do for your job?(2) Is this problem fulfilling your job requirements made worse, or better, by the way thework environment is set up or the specially adapted tools you use?(3) Is your capacity to do your job, without assistance, more or less than what youactually do in your present surroundings?
56 ActivityFor example, inability to walk and use of a wheelchair for mobility would be classified as follows: chapter 4 (Activities of moving around under the level 2 heading of walking activities (410) level of difficulty qualifier (4) and assistance qualifier (1) for a resulting code of a410.41
57 Mapping ICF to an assessment forms - eligibility for benefits What, if any, movement difficulty is there? ICF – b (moderate impairment of one side of body)To what extent can you perform personal care?ICF – d (mild impairment maintaining one’s health)Do you require assistance to move from place to place inside your home/school/place of work?ICF– d (no problem moving around within buildings other than home)57
61 Examples of disabilities that may be associated with the three levels of functioning linked to a health condition.HEALTHCONDITIONIMPAIRMENTACTIVITYLIMITATIONPARTICIPATIONRESTRICTIONLeprosyLoss of sensation ofextremitiesDifficulties ingrasping objectsStigma of leprosyleads tounemploymentPanic DisorderAnxietyNot capable of goingout alonePeople's reactionsleads to no socialrelationshipsSpinal InjuryParalysisIncapable of usingpublic transportationLack ofaccommodations inleads to low participationJuvenile diabetesPancreaticdysfunctionNone (impairmentcontrolled bymedication)Does not go to schoolbecause of stereotypes about diseaseVitiligoFacial disfigurementNoneparticipation in social relations owing to fears of contagionPerson who formallyhad a mental healthproblem and wastreated for apsychotic disorderDenied employmentbecause ofemployer's prejudice
62 The levels of disability linked to three different levels of intervention.
63 The levels of disability linked to three different levels of intervention. Activity Limitation??
64 The levels of disability linked to three different levels of intervention.
65 The levels of disability linked to three different levels of intervention. Participation Restriction??
66 The levels of disability linked to three different levels of intervention.
67 ICF in policy making assessment of population health impact of disabilityeconomicsocialevidence-base for policy makers on different policy interventionsresponsiveness of servicesefficiencyperformance assessmentGesundheitspolitik, Sozialpolitik, Behindertenpolitik and Menschenrechtspolitik (keine Entsprechung von Bedurfnisslagen, Problemlagen, Ressourcenvereilung)
69 ICF in clinical practice & management Needs assessmentOutcome assessmentUtilization patternsComparison of different interventionsConsumer satisfactionService performanceoutcomescost-effectivenessElectronic recordsClinical terminology(Vorhersage des Inanspruchnahmeverhaltens & Länge der Hospitalisierung)
70 Characteristics of a ‘Good’ Assessment of Need (AON) The ICF provides a useful framework to support AONs that are:Person centredNeeds DrivenBiopsychosocialAge appropriateMulti-disciplinaryPSI LDSIG 16/04/201070
71 Suggested Framework for Assistive Technology Assessment Identify Functional LimitationIdentify Impairments that cause functional limitationWork with rehabilitation specialists to address impairment level issues.Maximize function by collaborating with rehabilitation specialist to create assistive technology solutions which take into account individual impairments.
72 Joseph Pre-assessment Example (including ICF components and International Standards Organisation (ISO) 9999 (AT) products)Joseph is a 22-year-old male who received a T-12 incomplete spinal cord injury [body functions and structures (b)] from a diving accident 4 years agoAfter rehabilitation, he returned to his parents’ home and both his mother and father worked hard to meet his physical needs. During the past 3 years, however, he has had a difficult time recognising and acceptingthe changes in his lifestyle he must make [emotional functions (b1) and personal factors, identity]. As a result, Joseph frequently feels angry and depressed (b1, temperament and personality) and often prefers to be alone (d7, interpersonal interactions).At first family and friends would stop by to visit, but his withdrawal, anger and depression led to strained interactions and eventually the visits became rare occurrences (d7, e3 and e4).
73 Joseph AssessmentAt Time Point 2, 3 years post-injury, Joseph learned about the existence of a wheelchair basketball team in his city that was looking for an additional player.Joseph is fortunate that he lives in a large enough city that has the facilities and resources to foster a wheelchair basketball team [e5]Joseph uses a lightweight manual wheelchair (e1,ISO 9999 class , bimanual wheel driven wheelchairs), but to play on the team required thatJoseph have an additional specialised wheelchair, that is a sport wheelchair (e1, ISO 9999 class ).His physician recommended an assessment at a local AT centre that focussed on his preferences as well as needs (b7, d4, d7, d9, personal factors), thepurpose and environments of wheelchair use (d9, e2) and desirable product features and add-ons such as special tires and a means for transporting himself and his wheelchair (ISO 9999 class 12).
74 Joseph post assessment The outcome of the comprehensive assessment was the selection of a wheelchair among multiple choices that Joseph could afford, was a good match with his needs and preferences, and that performed well for him as a wheelchair basketball player [28–30].Joseph enjoyed playing on the team, and the team valued Joseph’s contribution (e3 and e4). Joseph interacted with other individuals, some who become closer friends than others (d7).The addition of Joseph affected the group identity as a whole as well as each individual (e3 and e4,personal factors). As a group they performed very well and won a regional championship.Now,almost 4 years post-injury, Joseph is finding he is less depressed and angry (b1) and greatly looks forward to being with his teammates not only on the basketball court but socially as well [d7].He is now thinking of returning to university and wants to explore additional ATs to save time and energy.
75 In Summary : ICFICF describes all aspects of health in terms of health domainsICF is integration of the medical and social models – biopsychosocial approachICF is designed in a hierarchical scheme based on commonly understood principles and languageThe ICF facilitates collaboration and communication amongst system supportsICF describes situations for functioning and its restrictions and provides a framework to organise this information75
76 In Summary The New Approach: ICF The ICF is an active system, it is constantly changingThe ICF understands that disability is the interaction between a person and their environmentThe ICF provides an assessment tool and a means to classify data collection using simple, common language and forms76
78 John’s Profile Intellectual Functioning:: Average Age 12 .5 years Gender MaleAddress Dublin 11Medical Diagnosis ADHD(ICD 10 Code F90.0/ DSM IV 314.1)Family Status Father: Information TechnologistMother: Dental SecretaryEducational Status First Year SecondaryReason for ReferralAssessment of Need as a result of class disruption and aggressive behaviour during recreation. Bedwetting is also reported by his parents as an issue. GP has identified ADHD as the most likely cause.PSI LDSIG 16/04/201078
79 John’s Behaviour Profile John has difficulty:Paying attention to detailsSustaining attentionListening to stories and instructionFinishing tasksOrganising himselfKeeping track of his belongingsJohnBlurts out answers before a question is finishedDoesn’t wait his turnInterrupts and intrudes upon othersFidgetsIs unable to stay seatedHas difficulty engaging in leisure activities quietlyPSI LDSIG 16/04/201079
80 John Learning Strengths ArticulateArtisticPopular with school friendsInterested in sportsSupports in place for him already e.g. OT and TuitionWilling to participateGood relationship with his motherSupport and interest from homeReflective abilityGood Auditory DiscriminationGood Expressive languageAbility to understand directions when presented clearlyCan interpret body language80
81 John’s Activity and Participation Profile Has difficulty in settling down to listen to stories or instructionsHas yet to acquire introductory word decoding skillsHis formation of letter shapes is very immatureHas not exhibited the ability solve simple problems when presented orallyHas moderate difficulty in organising himself to carry out anything other than simple taskHas no difficulty in communicating through speech and gestureIs constantly in motion, fidgeting and moving aroundPSI LDSIG 16/04/201081
82 John’s Activity and Participation Profile Has difficulty relating to his father without getting angry.The relationship with his mother is close but dependentCan react aggressively even to friendly approaches from other childrenFinds it very difficult to respond appropriately to correction or control from teachersIn the school yard he often gets into fights and has no close friendsHas been unable to adapt to formal education and is failing in school workIs not very good at physical activities and has developed no interests sports or other pursuits82
83 An analysis of John’s Environment His father has given him a number electronic toys and gadgets including a electronic spelling tutor all of which he refuses to useHis mother works flexi-time in order to be available to him when problems arise.His father is well meaning but often absent from the home on business tripsHis parent have recently identified an OT who has begun to work with him using Sensory Integration techniquesHis teacher is frustrated and has yet to find a way to manage his behaviour in class. He is on The waiting list for the Learning Support Teacher but is unlikely to receive help in the current school year83
84 An analysis of John’s Environment His mother is frustrated and fears that she may have to give up work in order to cope with his problemsHis father is distant emotionally and tends to underplay the problems as something ‘he will grow out of’He has no close friendsIs currently receiving no SEN supportApart from the GP and the occasional visits to the OT his parents are paying for privately he is receiving no health or social care intervention84
85 John’s Learning NeedsNeeds support to organise and manage personal possessionsNeeds to deal with authority betterNeeds a review of what he has been doing in learning support to identify what works and what needs to changeNeeds to get agreement on using alternative format for presenting his academic workExtend his ability to communicate emotionallyNeeds to be encouraged to attend and stay in schoolNeed to feel better about himself and be more confident about communicating with others85
86 John’s Learning Needs Needs to related better to his father He needs to start using assistive technologyNeeds to work cooperatively with his class matesEyes and ears need to be checkedFamily may need to work to improve relationshipsAppropriate programme to facilitate transfer to secondary school
87 John’s ICF Profile ICF Rating Description of Need Area of FunctioningICF CodeICF RatingDescription of NeedIntellectualb117Intelligence assessed within average rangeRegulation of behaviorb127.43Has great difficulty adapting behaviour appropriately to classroom contextImpulse controlb1304.32Has difficulty resisting sudden urges to do thingsShort term memoryb1440Moderate impairment in tests of STMAttentionb1460Both parents and teachers report moderate difficulties in maintaining attentionOrientationb1141/b1148Has difficulties with temporal and spatial orientationEmotionalb152Emotional responses are inappropriate and he has difficulty regulating themVisual Perceptionb1561Had difficulty with all tests involving visual perceptionMotor coordinationb760/b7601 &2Fine motor coordination and finger dexterity difficulties have been identified87
88 Activity /Participation ICF Code Capacity Performance Listening d115 2 Has difficulty in settling down to listen to stories or instructionsLearning to readd1403Has yet to acquire introductory word decoding skillsLearning to writed145His formation of letter shapes is very immatureSolving problemsd175Has not exhibited the ability solve simple problems when presented orallyMultiple Tasksd220Has moderate difficulty in organising himself to carry out anything other than simple taskCommunicationd310-d349Has no difficulty in communicating through speech and gestureMaintaining a sitting positiond4153.3Is constantly in motion, fidgeting and moving aroundFamily Relationshipsd720Has difficulty relating to his father without getting angry.The relationship with his mother is close but dependentRegulating behaviors within interactionsd7202.2Can react aggressively even to friendly approaches from other childrenAuthorityd740Finds it very difficult to respond appropriately to correction or control from teachersPeersd7600In the school yard he often gets into fights and has no close friendsSchoold820Has been unable to adapt to formal education and is failing in school workRecreation & Leisured92011Is not very good at physical activities and has developed no interests sports or other pursuits88
89 Environmental Analysis ICF Code ICF Rating Products & Technologye1Products for personal use in educatione130His father has given him a number electronic toys and gadgets including a electronic spelling tutor all of which he refuses to useSupportse3Immediate Familye310+2His mother works flexi-time in order to be available to him when problems arise.His father is well meaning but often absent from the home on business tripsHealth professionalse355His parent have recently identified an OT who has begun to work with him using Sensory Integration techniquesOther professionals (Teachers)e360His teacher is frustrated and has yet to find a way to manage his behaviour in class. He is on the waiting list for the Learning Support Teacher but is unlikely to receive help in the current school yearAttitudese4e410-2His mother is frustrated and fears that she may have to give up work in order to cope with his problemsHis father is distant emotionally and tends to underplay the problems as something ‘he will grow out of’Friendse420He has no close friendsServices & Systemse5SEN Supporte5860Is currently receiving no SEN supportHealth Servicese5800Apart from the GP and the occasional visits to the OT his parents are paying for privately he is receiving no health or social care intervention89