The International Classification of Functioning, Disability and Health (ICF)

1. The International Classification of Functioning, Disability and Health (ICF) A tool for self-learning German WHO-FIC Collaborating Centre ICF Research Branch

2. The International Classification of Functioning, Disability and Health (ICF) • Welcome to this ICF self-learning tool • The purpose of this self-learning tool is to provide users with basic knowledge of the ICF and its uses. • The course is composed of seven sections. Each section has one or more units. At the end of each unit you will find a • Keep in mind slide that summarizes the most important facts about the unit. At the end of each section you will find the hint for the • Exercises (questions and tasks)

3. Learning ICF • Contents: • Introduction - Need for the ICF • Aims of the ICF • Uses of the ICF • The ICF Integrative Bio-Psycho-Social model of functioning and disability • The structure and codes of the classification • Coding with the ICF • WHO Family of International Classifications (FIC)

4. Learning ICF 1. Introduction – Need for the ICF

5. 1. Introduction –Need for the ICF • In the following section you will: • learn why the description of functioning and disability is important for people with different health conditions • understand why information about functioning is essential for many uses

6. 1. Introduction – Need for the ICF Grandma Smith loves to spend time with her granddaughter. In recent years, her worsening rheumatoid arthritis has made this increasingly difficult. Both her hands and knees are affected, but her finger joints are what cause the most problems; especially with respect to finger movement. She can hardly perform simple tasks such as helping her granddaughter button her coat. Functioning & Disability

7. 1. Introduction – Need for the ICF • Functioning is an • umbrella term for • Participation • Taking care of others • Activities • Manipulating objects • Body Functions • Mobility and stability of joints • Body structures • Joints

8. 1. Introduction – Need for the ICF • Disability is an • umbrella term for • Restrictions • Participation • Limitations • Activities • Impairments Disability is an umbrella term for impairments, activity limitations and participation restrictions. It denotes the negative aspects of the interaction between an individual (with a health condition) and contextual factors (environmental and personal factors) that individual. • Body Functions • Body structures

9. Introduction – Need for the ICF Functioning & Disability are multidimensional • they encompass the • human experience at the level of • body functions and structures, • activities • and participation • in interaction with the environment.

10. Mild-Moderate vision impairment: Needs eye glasses, contact lenses… 10/20 Severe vision impairment: Needs operation 2/20 Complete vision impairment (blind): Needs assistance – pension, device, assistant environmental modifications 1/20 Introduction – Need for the ICF Functioning & Disability are also a continuum for example in Seeing Functions

11. 1. Introduction – Need for the ICF Functioning & Disability • are related to a variety of factors: • to the person’s health condition

12. 1. Introduction –Need for the ICF Functioning & Disability • are related to a variety of factors: • to the person’s health condition • to the person’s resources (both personal abilities and economic resources).

13. 1. Introduction –Need for the ICF Functioning & Disability • are related to a variety of factors: • the person’s health condition • the person’s resources • the environment in which the person lives

14. 1. Introduction –Need for the ICF • So, the level and nature of functioning and disability may differ: • between people with the same health condition People with the same disorder may experience functioning differently and at different levels in relation to their disease.

15. 1. Introduction –Need for the ICF • So, the level and nature of functioning and disability may be similar: • between people with different health conditions For example people with sensory disorders may experience functioning differently than people with motor or mental disorders.

16. 1. Introduction –Need for the ICF • So, the level and nature of functioning and disability may change • for the same person over time even though the health condition does not change A person‘s experience of functioning and level of functioning may change over the course of the disease.

17. Joseph and his mother, 2003 Joseph and his mother, 2004 1. Introduction – Need for the ICF Medical diagnosis may remain the same, but the experience of functioning changes. • Joseph Jeune from Zambia was diagnosed with „unspecified human immunodeficiency virus (HIV) disease“ in 2002. He had severe limitations in daily activities like moving around or washing himself. He couldn‘t work at all. • In 2003 he was one of the 3 million beneficiaries of the „3by5“ WHO Program for inter-viral treatment in Africa. • One year after treatment, he was still HIV positive, but his level of functioning had increased remarkably. His participation restictions in remunerative employment were only moderate.

18. 1. Introduction – Need for the ICF A description of functioning complements information on disease. This information is needed to support decisions about resource allocation, services required, level of care or length of hospitalization. • Mr. Sneider has had progressive-relapsing multiple sclerosis (ICD-10 G.35) for 14 years. From that time on, he‘s had a steady neurologic decline and also experiences clear superimposed attacks.His cognitive and orientation functions are severely impaired and he currently requires care 24 hours a day. • Carol Bauer was diagnosed with relapsing-remitting multiple sclerosis (ICD-10 G.35) three years ago. She had her second relapse two months ago, her seeing functions were impaired and she lost a portion of her field of vision. She needed to take sick leave for three weeks, after that she returned to her regular routine. Currently she has follow up visits with her doctor every six months.

19. 1. Introduction –Need for the ICF A description of functioning is fundamental to identify the health problems and needs of individuals and populations. It is the starting point for any approach to achieve or maintain optimal levels of functioning in individuals and populations.

20. 1. Introduction –Need for the ICF Hence, the description of functioning of individuals and populations give us the evidence for policies, systems and service provision.

21. Health condition Body functions/ Body structures Activities Participation Environmental factors Personal factors 1. Introduction – Need for the ICF • The International Classification of Functioning, Disability and Health (WHO, 2001) provides a comprehensive, universal and globally accepted model and taxonomy to describe functioning.

22. Keep in mind: 1. Introduction – Need for the ICF? 1. Functioning & disability encompass the human experience at the level of body functions and structuresactivities and participation in the context of environmental and personal factors 2. Functioning & disability are multi-dimensional and represent a continuum 3. Functioning may differ between people with the same health condition, may be similar in persons with different health condition 4. The description of functioning is the starting point for any approach to achieve or maintain optimal levels of functioning in individuals and populations

23. Handout Page 2  Now go to 1. Introduction –Need for the ICF Exercises To check your knowledge of the content of information from different measures To check your understanding of the differences in functioning status To check your understanding of the need for the description of functioning

24. Learning ICF 2. Aims of the ICF

25. 2. Aims of the ICF • In the following section you will: • learnthe aims of the ICF • understand the importance of the application of the ICF

26. 2. Aims of the ICF • The aims of the ICF are: • to provide a scientific basis for understanding health and health-related states, outcomes and determinants; • to establish a common language to improve communication between disciplines and sectors; • to enable data comparison between different countries and health care systems and services;to provide a systematic coding scheme for health care information systems; • to stimulate the development of services to increase levels of social participation among people with disabilities. • (WHO 2001:5)

27. 2. Aims of the ICF • to establish a common language to improve communication between disciplines and sectors ICF is used not just by people in the disability or medical sectors. People do use it across other broad sectors including insurance, social security, employment, education, economics, social policy, and environmental modification.

28. b1 • b130 • b134 • b1801 • s299 • s710 • s730 • s7301 EQ-5D Joint mobility Mobility (general) Muscle power / Strength Pain Stability of joints Emotional function Engergy & Drive functions Gait / Ambulation Stiffness Muscle endurance Sexual functions Sleep NHP Joint mobility Mobility (general) Muscle power / Strength Pain Stability of joints Emotional function Engergy & Drive functions Gait / Ambulation Stiffness Muscle endurance Sexual functions Sleep WHODAS INSTRUCTIONS: This survey asks foryour views about your health. Thisinformation will help keep track of howyou feel and how well you are able to do your usual activities. Answer every question by markingthe answer as indicated. If you ar unsure about how to answer aquestion, please give the best answer you can. • d170 • d230 • d410 • d415 e110 e115 e125 e150 Ql-I Spitzer Joint mobility Mobility (general) Muscle power / Strength Pain Stability of joints Emotional function Engergy & Drive functions Gait / Ambulation Stiffness Muscle endurance Sexual functions Sleep SF-36 INSTRUCTIONS: This survey asks foryour views about your health. Thisinformation will help keep track of howyou feel and how well you are able to do your usual activities. Answer every question by markingthe answer as indicated. If you ar unsure about how to answer aquestion, please give the best answer you can. WHOQoL Joint mobility Mobility (general) Muscle power / Strength Pain Stability of joints Emotional function Engergy & Drive functions Gait / Ambulation Stiffness Muscle endurance Sexual functions Sleep 2. Aims of the ICF • to provide a systematic coding scheme for health care information systems

29. b1 • b130 • b134 • b1801 • s299 • s710 • s730 • s7301 For example, ICF provides the framework for the development of research questions and outcome measurements in relation to functioning. • d170 • d230 • d410 • d415 e110 e115 e125 e150 e460 Outcome measures 2. Aims of the ICF • to provide a scientific basis for understanding health and health-related states, outcomes and determinants

30. 2. Aims of the ICF • to enable data comparison between different countries, health care systems and services. Universality

31. 2. Aims of the ICF ICF enables data comparison

32. Functioning data is essential for identifying the needs of a population. 2. Aims of the ICF • to stimulate the development of services to increase levels of participation among people with disabilities.

33. Keep in mind: 2. Aims of the ICF ICF 1. Establishes a common language 2.Provides a systematic coding scheme 3. Provides a scientific basis for understanding health 4. Enables data comparison 5. Stimulates the development of services

34. Handout Page 8  Now go to 2. Aims of the ICF Exercises To check your knowledge To check your understanding To check your understanding

35. Learning ICF 3. Uses of the ICF

36. 3. Uses of the ICF • In the following section you will • learnthe uses of the ICF • understand the benefits of using the ICF for different purposes • be able tojustify the use of ICF for a specific purpose

37. 3. Uses of the ICF ICF can be used in the areas of: Policies (Macro level) Systems and Organizations (Meso level) Service provision (Micro level)

38. Research Statistics A common language to exchange information is required in different levels and fields like research and statistics; the ICF provides the framework and definitions. 3. Uses of the ICF Policies (Macro level) Systems and Orgnizations (Meso level) Service provision (Micro level) ICF facilitates the information flow

39. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF The ICF is being used in policy for: • Assessment of population health • Impact of disability • Economic • Social • Personal • Policy decision making • Provision of services • Eligibility • Equity and human rights

40. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF • ICF has been accepted as one of the United Nations social classifications. • The Convention on the Rights of Persons with Disabilitiesrefers to and incorporates the ICF. • ICF provides an appropriate instrument for monitoring the implementation of international human rights mandates as well as national legislation

41. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF Assessment of population health • ICF based disability surveys can be used to estimate the number of people with disabilities in a population and the sorts of disabilities they experience. The sorts of services needed can thence be based on the population picture of functioning. ICF as the basis for decision making

42. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF • Let us take a look at an example of using ICF in social policy… • Specifically • ‘participation gap’ policy analysis • ‘participation gap’ policy analysis • ICF facilitates description of levels of participation in non-disabled population in employment, education, community life, etc. • ICF facilitates description of levels of participation for persons with disability (stratified by type) • The difference between these two descriptions is a ‘participation gap’, the use of ICF enables: • Needs assessment • Policy planning • Outcomes research • Cost-effectiveness

43. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) Health & Disability Statistics may be used at the Macro and Meso levels: 3. Uses of the ICF Differences between health and disability surveys… While both health and disability surveys collect information on an individual's and population's overall health, the focus of each differs. Health surveys focus largely on the health condition (e.g. a stroke, classified with ICD), health determinants (e.g. smoking, high blood pressure), prognosis (e.g. permanent damage, possible recovery, recurrence), health interventions (e.g. hospitalization, medication) and satisfaction (e.g. with health care received). ICF based Disability surveys focus on level of functioning at body, person and societal levels (ICF domains), services received and required (e.g. services such as walking frames or personal assistance), and satisfaction (e.g. with services received) the health condition (e.g. stroke) may or may not be collected.

44. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF ICF provides a common conceptual framework that links health and disability statistics

45. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF • Functional status data is essential for equitable eligibility criteria for state entitlements such as social security benefits, disability pensions, workers’ compensation and insurance.

46. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF - Education • The development of eligibility criteria for educational services for children and youth requires a comprehensive approach and a common language in order: • to provide support in schools for students with disabilities; and • to follow people across settings and monitor quality and outcomes.

47. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF - Education • Linking process of education to levels of education system Process of Education Levels of EducationSystem

48. Keep in mind: 1. By enhancing person-centered services and programs e.g. school programs 2. By modifying features of the social and physical environment. e.g. accessible communication, building ramps 3. Uses of the ICF • Policy decisions can bring reductions in the incidence and severity of disability in a population:

49. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) 3. Uses of the ICF - Service management • Working in health management we may ask ourselves some of the following questions: • What health care and other services will be needed? • How well do we serve our clients? • What basic indicators for quality assurance are valid and reliable? • How useful are the services we are providing? • How cost-effective are the services we provide? • How can the service be improved for better outcomes at a lower cost?

50. Policies (Macro level ) Systems and Organizations (Meso level) Service provision (Micro level) Functioning status Environment 3. Uses of the ICF - Service management In order to answer those questions, the measurement of health care needs and the performance and effectiveness of health care systems are essential. For these purposes, we necessarily require reliable and comprehensive information. Information required Evidence based treatment Resources See section 7