A Hands-on Approach to the International Classification of Functioning, Disability and Health (ICF) for Clinicians and Families

 

ICF

 

An exciting new development

From time to time in the field of healthcare an exciting new development appears on the horizon to challenge and potentially transform thinking and behaviour. Changes may involve new approaches to the provision of care; the education of health professionals; how research is conceptualised and conducted; the organisation of services; and sometimes additional ideas not originally envisioned by the people who started the process. Often, in fact, changes in one area beget unexpected changes elsewhere.

The World Health Organization’s (WHO’s) International Classification of Functioning, Disability and Health (ICF) and its Children and Youth Version represents one of those transformative resources that bear closer examination.

 

ICF ideas are useful to whoever you are in the complex world of healthcare

The ICF is increasingly widely used – especially in the field of Child and Youth Developmental healthcare (disability). The ICF has fundamentally changed and enhanced the field of childhood disability, and it has the potential to have similar impacts well beyond this particular area of healthcare. We see opportunities for the ICF framework and concepts to improve interprofessional communication and collaboration across all areas of health services, most particularly, but not limited to, chronic care. The ICF framework is a tool to expand our thinking and actions across all dimensions of the field of healthcare providing rich opportunities to rethink and improve. The biopsychosocial framework for health is an excellent model for all health professionals and should, we believe, be introduced to all health profession students from the outset of their education.

 

Using the ICF as a conceptual framework

The ICF attributes offer a conceptual framework for health. Key ideas that we find compelling include that the ICF provides:

  • a biopsychosocial framework – illustrating the integration and interaction of the biological and social models of health into a unitary framework;
  • a holistic approach to health – applies to the whole person, and to every person;
  • a strength-based model – emphasising functioning;
  • a theoretical premise of universalism (disability as a human trait), thus enforcing Human Rights for everybody including People with Disabilities (UN 2006);
  • neutral language, modelling an approach towards people’s strengths;
  • aetiologic neutrality and parity – which applies to all health issues;
  • an interactional (dynamic) structure (with ‘disability’ as a potential outcome when there is a misfit among elements of people’s lives);
  • multidimensionality and comprehensiveness.

As the ICF is grounded in UN Conventions of the Rights of Children and of People with Disabilities, it provides a framework for considering the ethical dimensions of all health encounters and practices. For example, is impairment alone responsible for disability (stigma, social isolation, poor education or poor housing)?

 

The ICF is a versatile tool

The ICF is a tool with multiple potential applications. These potential applications include:

  • A personalised clinical documentation and organisational tool for patients (and practitioners) to identify strengths, problems/issues, needs and goals, and to help identify windows for management and evaluations of specific management.
  • A tool to explore and explicate issues of people’s vulnerability.
  • Educational tools for all health professions, with respect to thinking about health in a broader context than the biomedical dimensions of health and disease alone.
  • A terminology and communication tool: Classificatory, international and interprofessional.
  • An epidemiological tool to collect and analyse data.
  • An ethical tool (promoting the central values of respect, confidentiality, autonomy, beneficence, benevolence and justice/fairness).
  • A health policy tool.

 

Conceptual issues that provide a context and background to the ICF

  • The evolving concept of health in the current century – how we are moving from thinking about a health condition as a biomedical problem that resides within the anatomy or physiology of the person (often established clinically by ‘ruling out’ competing diagnostic considerations) to a biopsychosocial framework that formally encompassed personal and environmental factors, and actively ‘rules in’ elements of a person’s life that may impact their health and hence provide ‘points of entry’ for interventions.
  • The idea of ‘functioning’ as the central notion in modern ideas about conceptualising ‘health’. ‘Personal factors’ are one of the ‘contextual’ elements of the ICF that are now explicitly meant to be identified and used in the formulation of a person’s story.
  • The idea of ‘participation’ – engagement in life in ways that are meaningful and important to a person. In many ways participation is the pinnacle of health, insofar as one is able to realise one’s personal ‘engagement’ regardless of how those activities are accomplished.
  • The relationship between patient/ person-reported outcomes (PROs) and the ICF. How, at both the clinical and the research level, this essentially personal valuation of one’s life is very important to understand, and complementary to professionals’ evaluations of our interventions based solely on clinicians’ and  researchers’ ideas about how a disease or disorder, and the impact of interventions, should be measured.

 

Ways that people are applying the ICF ideas in their work – be it for clinical, research or administrative purposes

  • Using the ICF in everyday clinical practice.
  • Creating an ICF-informed team for promoting effective health and social care.
  • Using the ICF framework, language and concepts to inform the fundamental education and acculturation of all health professionals – a goal we believe can and must be achieved.
  • Using the ICF concepts to inform the policies, administration and advocacy efforts of clinical and health services programs.

 

Caveats

It is of course important to note what the ICF does not do! First, while the framework provides a structure into which to aggregate the details of an individual’s current health reality across several dimensions, the resulting profile provides only a point-in-time snapshot account of that person’s situation. There is no temporal element to the profile, meaning that as the person’s story evolves it is essential to update the profile.

Second, the profile provides a factual account of the person’s situation, objectively described, measured or perceived, with little or no valuation of the details. Even the contextual elements of personal and environmental factors are meant to provide perspectives on these aspects of people’s lives but not how people value these components. That is done – or in our view should be done – using the fully-populated ICF framework as the ‘raw material’ with which to identify both the issues of importance to a person or their family, and the potential strategies to approach those issues.

A corollary to this idea is that the ICF framework does not provide an account of people’s ‘quality of life’ – at least not what we refer to as the existential perspectives of people’s personal valuation of their life quality. There are other more focused approaches to ‘quality of life’ – ‘health-related’, social determinants and econometric systems – that could potentially use the details in a populated ICF framework to calculate, for example, a health ‘utility’ value based on an individual’s functional profile. Once again, however, such a value would not include how people feel about or self-evaluate their lives. This is important because it has been shown that even when people have what might objectively be assumed to be ‘severe disability’ they may still adapt to a new health situation and self-assess their quality of life to be very good.

Users of the ICF need to be aware of these limitations and always document ICF information collaboratively with the patient and their family (and other professionals involved in the care) to obtain the best possible understanding of what matters to the patient and their family.

 

* Excerpted from the book ICF: A Hands-on Approach for Clinicians and Families edited by Olaf Kraus de Camargo, Liane Simon, Gabriel M. Ronen and Peter L. Rosenbaum.

 

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