The Evolution of Disability Models: Understanding ICF Framework in TR Practice

1. The Role of the International Classification of Functioning, Disability, and Health (ICF) in TR Practice, Research, and Education Chapter 4 HPR 453

2. Earlier Models of Disability, Health and Functioning • Original Disability Model (Linear) Nagi (1965) • If active pathology was present, impairment, functional limitation, disability would follow • ICIDH for trial purposes WHO (1980) – no support due to lack of cross-cultural applicability – no international support • Described 3 concepts of disease and health: Impairments, Disabilities, Handicaps • NCMRR (1993)To guide outcome measurement and research • Linear to show course of disease or pathology but acknowledged that social policies and barriers limited participation in society = Society could impose disability

3. ICIDH revised from 1997-1999 and renamed International Classification of Functioning, Disability, and Health (ICF) • Overall aim…to provide a unified and standardized language and framework for the description of health and health-related states. • WHO endorsed as international standard in 2001

4. Shift from Medical Model  Social Model • From medical model that focused on disability  holistic model of health and well-being • From disability needing an intervention to “fix the problem”  a more complete picture of health status by describing behavioral aspects of chronic diseases • Social Model – Individuals experience disability as a result of their interaction with barriers in their environment (i.e. stairs) ICF is biopsychosocial model

5. Endorsed by ATRA and NTRS • ICF provides a model for clinical practice, professional education and research • Endorsed by ATRA in 2005 and NTRS in 2008 – ATRA has an ICF Team • Comparable with recreational therapy practice and should be used in Practice Guidelines, Standards of Practice, Curriculum Development, Public policy, International Relations, and Research

6. ICF ModelWHO (2001) • 4 primary purposes • Provide scientific basis for understanding and studying health and health-related states, outcomes, and determinants • Common language to improve communication between users (h.c. workers, researchers, policy-makers, the public, including people with disabilities • Permit comparison of data across countries, healthcare disciplines and time • Provide systematic coding system for health information systems

7. ICF Model

8. ICF has 2 PartsEach Part has 2 components WHO (2001) • Functioning and Disability • Body Functions and Structures • Activity and Participation • Contextual Factors and Components • Environmental Factors • Personal Factors • Not linear – Arrows indicate interaction after a change in health condition to improve well-being (Important for TR – we restore well-being)

9. Coding the ICF • Will be used soon by healthcare professionals to collect functional data • Classification system and not assessment • Data will pertain to a particular session • Contextual factors will result in variability because each session is a snapshot in the big picture (i.e. more alert in morning than afternoon – contextual factors play a role)

10. Definitions of key concepts and terms • Body Function – physiological and psychological functions of body systems • Body Structures – anatomical – organs, limbs and their components • Impairments – problems in function or structure (i.e. significant deviation or loss) • Activity – Execution of a task or action • Participation – involvement in a life situation

11. Activity Limitations – difficulties an individual may have in executing activities • Participation Restrictions – problems experienced in involvement in life activities • Environmental Factors – physical, social, and attitudinal components in which live and conduct their lives

12. CODING • BS – “s” (anatomical) • structure of brain, structure of heart, etc • 3 qualifiers to describe extent of impairment, nature of the change and location of the impairment • CTRS won’t code much in BS but must understand codes • BF – “b” • Physiological and psychological functions • 1 qualifier to describe level of impairment with b.f. • CTRS will code (i.e. temperament and personality, attention, exercise tolerance, etc)

13. A&P – “d” • Activities commonly performed in life (daily routine, conversation, climbing, managing diet and meals, forming relationships, play, taking care of animals, crafts, etc) Meaningful activity • 4 qualifiers (2 capacity and 2 performance) • Capacity = Ability in standard environment • Performance = inreal life situations • Coding more complex than previous categories

14. EF – “e” • Things in environment which facilitate or hinder health and functioning • Equipment, attitudes, social policies • Codes attached to A&P to reflect effect on a specific activity or participation • PF – recognized but not currently included due to large cultural and social variance (i.e. gender, coping styles)

15. Why you need to know this…. • Will soon be used by clinicians for payers because functional status is much better predictor of health system usage than diagnostic information • ICF includes a chapter related to social, civic, and community functioning that recognizes recreation and leisure as an important aspect of functioning

16. Related to TR Practice • Functional status and holistic approach to individual and his/her environment • Inter-professional communication • CTRSs will use same language as other disciplines (i.e. cognitive domain) • Core sets related to health conditions – 12 developed – more being developed – Table 4.2 • See case study on pgs 53-55