Use of the ICF to Achieve Transdisciplinary Thought and Action in Rehabilitation

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Use of the ICF to Achieve Transdisciplinary
Thought and Action in Rehabilitation

• ICDR State-of-the-Art Conference
• New Federal Applications of the ICF
• Arlington, Virginia
• July 10, 2007

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Travis T. Threats, Ph.D.

• Chair, Associate Professor
• Department of Communication Sciences and
  Disorders
• Saint Louis University

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Multidisciplinary rehabilitation- Traditional
framework

• Multidisciplinary- Each health profession
  evaluates patient independently and sets goals on
  their specific areas, while informing each other
  the progress being made and seeking if any common
  difficulties arising during intervention.

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Definition of Transdisciplinary approach

• . . .The primary purpose of this approach is to
  pool and integrate the expertise of team members
  so that more efficient and comprehensive
  assessment and intervention services may be
  provided. The communication style in this type
  of team involves continuous give and take between
  all members (especially with the parents) on a
  regular, planned bases. Professionals from
  different disciplines teach, learn, and work
  together to accomplish a common set of
  intervention goals for a child and her family.
• Bruder, M.B. (1994) Working with members of other
  disciplines Collaboration for success. In M.
  Wolery and J.S. Wilbers (Eds.) Including children
  with special needs in early childhood programs
  (pp. 45-70). Washington D.C. National
  Association for the Education of Young Children

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Transdisciplinary framework

• Patient and family considered center of the team
• Group decides goals, with patient input, and then
  each profession works to contribute to these goals

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Barriers to Transdisciplinary

• Language
• Fear of giving up autonomy job security
• What if patient has unrealistic desires?
• Secret plot by government to eliminate
  professions

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ICF role in decreasing barriers to
transdisciplinary framework

• Common language- Ability to step from
  professional jargon
• Realization that whole is more than the sum of
  the parts- more satisfying to clinicians.
• Interaction with patients and families
  facilitates realistic goal setting on both sides
  
• Without evidence based practice linked to real
  life functioning and quality of life
  improvements, rehabilitation professions at risk

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Is just pie in the sky OR can real clinicians do
in real time ?
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What needed to implement ICF

• High initial start up in time and training
• Clinical guidance on use of the codes provided by
  American Psychological Association/WHO joint
  publication Procedural Manual and Guide for the
  Standardized Application of the ICF A Manual
  for Health Professionals
• Commitment by team members to fundamentally alter
  approach to rehabilitation

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Example of use of ICF in Rehabilitation Setting
Rehab_at_Weiss

• Description of facility
• Weiss Memorial Hospital in Chicago inpatient 26
  bed acute rehabilitation unit
• Most patients over 65 years old
• Program called Living Well with emphasis on
  what their life will be like after they are
  discharged from rehabilitation unit

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Weiss_at_Rehab Person-centered care using the ICF
framework

• Patient and caregiver goals set at the
  Activity/Participation level function
• Patient/caregiver education to connect inpatient
  care to post-discharge life, specifically the
  relationship between Body Structure/Function to
  performance level of Activity/Participation
  goals
• Understanding the Environmental Factors and
  Personal Factors for individual patients

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Living Well program outcomes- Patients

• 10-month pilot data collection with 240 group
  participants using questionnaire and interviews
• Increased reporting of understanding of goals of
  therapy and relationship between therapy and life
  participation
• Patients and families more active, less passive,
  in intervention process
• Consideration of possible physical and
  psychosocial benefits of resuming involvement in
  as many activities as possible.
• Specifically tertiary prevention defined by the
  American Geriatrics Society as The aim of
  tertiary prevention in older people is to
  identify and alleviate established disease at an
  early stage, in order to improve or maintain
  functional status. The rationale depends on the
  ability to prevent disability and handicap, but
  not necessarily the impairment itself, which may
  not be amenable to a specific treatment

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Living Well Outcomes- Clinicians

• Clinician views
• Increased understanding of relationship of Body
  Function to Activity/Participation promotes a
  broader view of rehabilitation
• Appreciation of benefits of having
  patient/caregiver at center of efforts
• Evolution of clinician from expert to
  facilitator/coach
• Moved to single rehabilitation report with
  Activity/Participation goals at the top, with how
  each specific discipline worked to achieve in
  text, with resultant better understanding global
  functioning of patients

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Example of ICF framework intervention - Case
presentation

• 65 year old woman who has had a stroke, resulting
  in mild aphasia and dysarthria, mild oral stage
  dysphagia (swallowing disorder), moderate left
  side paresis in arm and mild left side paresis of
  the leg. Patient has relatively intact cognitive
  abilities. The patient also has a hearing aid
  that she rarely uses.

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ICF framework example - Intervention Goal

• Beginning at the end
• Important life activity for this devout Catholic
  woman is going to Mass
• Activity/Participation code d9300 Organized
  religion- Engaging in organized religious
  ceremonies, activities, and events

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ICF framework example Intervention of Body
Function

• Sampling of Body Function abilities to meet
  patients life participation goal
• b 16701 Reception of written language
• b 16710 Expression of spoken language
• b 340 Articulation functions
• b 5105 Swallowing
• b 770 Gait pattern functions
• b 7601 Control of complex voluntary movements

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ICF framework example Intervention of
Activity/Participation

• Associated Activity/Participation areas
• d 310 Communicating with-receiving messages
• d 350 Conversation
• d 4102 Kneeling
• d 440 Fine hand use
• d 450 Walking
• d 7502 Informal relationships with acquaintances

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ICF framework example Environmental Factors

• e 1251 Assistive products and technology for
  communication
• e 145 Products and technology for the practice of
  religion and spirituality
• e 2501 Sound quality
• e 310 Immediate family
• e 330 People in positions of authority
• e 445 Individual attitudes of strangers

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ICF framework example Personal Factors

• Age
• Individual psychological assets
• Upbringing
• Coping Styles
• Social Background
• Other health conditions

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Transdisciplinary intervention with this patient

• Each profession approaches individualized
  treatment plan with end goal in mind
• What fine motor skills needed in Mass, such as
  holding book, turning pages of book
• What communication skills needed in Mass, such as
  types of verbal interaction, what needs to be
  said during service
• What gross motor skills needed, such as being
  able to get in church, stand, kneel, walk
• Other skills needed such as taking in food and
  drink during Holy Communion

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Transdisciplinary intervention with this patient

• After working on specific goals, then clinician
  can work to see if they can all be coordinated
  and produced with acceptable approximation
  together. For example, can she stand up from
  kneeling with a book in her hand.

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ICF support of patient centered rehabilitation-
Ethical guidelines

• In clinical settings, ICF should always be used
  with the full knowledge, cooperation, and consent
  of the persons whose levels of functioning are
  being classified. If limitations of an
  individuals cognitive capacity preclude this
  involvement, the individuals advocate should be
  an active participant

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ICF support of patient centered rehabilitation-
Ethical guidelines- 2

• Because the deficit being classified is a result
  of both a persons health condition and the
  physical and social context in which the person
  lives, ICF should be used holistically

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ICF and Evidence based Practice

• Evidence based medicine is not cookbook
  medicine. Because it requires a bottom up
  approach that integrates the best external
  evidence with individual clinical expertise and
  patients choice, it cannot result in slavish,
  cookbook approaches to individual clinical
  expertise. External clinical evidence can inform,
  but can never replace, individual clinical
  expertise, and it is this expertise that decides
  whether the external evidence applies to the
  individual patient at all, and, if so, how it
  should be integrated into a clinical decision.
  (p. 72)
• Sackett, D., Rosenberg, W., Gray, J., Haynes, R.,
  Richardson, W. (1996). Evidence based medicine
  What it is and what it isnt. British Medical
  Journal, 312, 7172.