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 Table of Contents  
Year : 2019  |  Volume : 2  |  Issue : 3  |  Page : 107-109

Implementing international classification of functioning disability and health in rehabilitation medicine: Preliminary considerations from a nation-wide Italian experience in routine clinical practice

1 Istituto di Montescano, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy
2 Istituto di Genova Nervi, Istituti Clinici Scientifici Maugeri IRCCS, Pavia, Italy

Date of Submission26-Mar-2019
Date of Decision14-Jul-2019
Date of Acceptance01-Aug-2019
Date of Web Publication23-Oct-2019

Correspondence Address:
Dr. Caterina Pistarini
Istituti Clinici Scientifici Maugeri, via Maugeri 4, 27100 Pavia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jisprm.jisprm_56_19

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How to cite this article:
Giardini A, Pistarini C. Implementing international classification of functioning disability and health in rehabilitation medicine: Preliminary considerations from a nation-wide Italian experience in routine clinical practice. J Int Soc Phys Rehabil Med 2019;2:107-9

How to cite this URL:
Giardini A, Pistarini C. Implementing international classification of functioning disability and health in rehabilitation medicine: Preliminary considerations from a nation-wide Italian experience in routine clinical practice. J Int Soc Phys Rehabil Med [serial online] 2019 [cited 2023 May 28];2:107-9. Available from: https://www.jisprm.org/text.asp?2019/2/3/107/269819

Is it time to introduce into clinical practice instruments and tools up to now used mainly in research? The WHO International Classification of Functioning Disability and Health (ICF) framework is widely acknowledged as one of the soundest and well-grounded tools to assess and describe disability. The ICF, since its dissemination in 2001, has helped to challenge misconceptions on disability, by identifying the individual's areas of strength, and those areas that instead require treatment and care. It has highlighted the need to escape from the loop of stereotypes related to a now-obsolete concept of handicap and has helped to deal with prejudices and discrimination. Therefore, we can state that its role as a tool for society change is well established and proved. However, what about its use in rehabilitation medicine? Despite widespread interest in the tool itself,[1] it is considered still too complex to be easily implemented in clinical practice. Working groups have been set up to deal with these issues, proposing solutions related to ICF (ICF core sets)[2] and how these can be linked with well-known and internationally validated assessment tools.[3]

Recent statements affirm the need to widely implement the ICF framework – so far applied mainly in research – also in clinical rehabilitation, due to its strengths in providing a holistic patient description based on the biopsychosocial view that guided its development.[4] Despite its undoubted importance in the field of chronicity and disability, few experiences in ICF implementation or dissemination, i.e., large clinical studies, can be found in the literature.[5],[6] Most ICF implementation studies focus on a specific condition or just a few pathological conditions,[7],[8] thus not permitting the generalization of the ICF framework in clinical practice, where the settings, services provided, health-care system organization, and the patient's clinical features are highly diversified. To our knowledge, there are no reports of a systematic adoption of ICF as a tool to evaluate the rehabilitation care process.

There is an urgent need to implement a common operational method in patient care using a common national and international language to create a global e-health network, which will facilitate easier sharing of skills and thus large-scale research. Moreover, it is of paramount importance to favor a scaling up of e-health care, whereby patients undergoing rehabilitation can benefit from a better-organized health-care system. To develop a practical guide for health risk stratification, care pathways and big data management are considered of high priority at the level of international policy; the collection and use of comparable data could provide efficiency indicators and could facilitate the longitudinal assessment and scaling up processes.

Given these premises, in December 2016, the Clinical Scientific Institutes Salvatore Maugeri in Italy set out on the long journey toward digitalization of the clinical care pathways, in which pharmacological, surgical, physical, and cognitive disability treatments will coexist in a holistic and interdisciplinary synergy.[9] We started with some key clinical conditions managed by rehabilitation medicine, integrating them with the International Classification of Diseases (ICD) and ICF models as recommended by the WHO framework.[10] Due to the complexity of the process, the project management has been organized step by step, starting with goals definition, then moving to the interdisciplinary working groups, to provide a final digital tool able to describe the clinical care pathways using ICF and ICD language. The ICF framework is the keystone able to describe the conceptual link, within the clinical process, between the ICD classification of diseases and the rehabilitation programs and procedures. In the Clinical Scientific Institutes Salvatore Maugeri, an ICF-based program has been implemented in clinical practice to allow the description of patients' individual health problem starting from their ICD diagnoses. Although today the ICD system is established worldwide in routine clinical practice, it still fails to provide an accurate description of functioning and capacities and of the problems (rehabilitation aims) of inpatients admitted for rehabilitation treatment. The integration with ICF will be able to tailor the rehabilitation project better to each patient's characteristics based on their disability severity.

Transforming theory into practice is a complex task, involving a reorganization of the whole system. On March 15, 2018, the official kickoff meeting took place to initiate the process of ICF implementation in the Maugeri institutes nationwide. The first step was to gain a general consensus on the linking among ICF codes and clinical assessments, in accordance with the international literature.[3] The second was to describe the inpatient clinical workflow and the care process in different rehabilitation settings (neurological, respiratory, cardiac, and orthopedic) based on an individually tailored approach (individual rehabilitation project) and delivered by a multiprofessional team. Linking of the ICD diagnoses to the ICF disability description and related rehabilitation objectives and ICD procedures was accomplished through consensus using the Delphi procedure. Given the holistic nature of the ICF framework, based on the biopsychosocial model of disability, all health-care professionals (physician, nurse, physiotherapist, vocational therapist, speech therapist, psychologist, neuropsychologist, and social worker) involved in the inpatient rehabilitation process were involved in linking the ICD disease diagnosis and procedures and ICF assessment. We decided to identify two main objectives and to proceed sequentially, not in parallel. As to ICF codes selection, the ones belonging to body function and activity and participation area were chosen to describe the patient's impairment and performance at admission to the rehabilitation setting (codes were identified by interdisciplinary working teams over the course of a year).[11],[12] To date, the pilot program is structured as follows: the care pathways and related rehabilitation aims are described by the ICF framework and linked with the ICD procedures; at discharge, in order to identify the patient's needs and the rehabilitation outcome, the patient is reassessed on the ICF basis through the e-health information system.

This methodological framework was based on our goal which was to facilitate the description of the patient's disability profile, the related rehabilitation aims, and the patient's consequent global outcome on which to set up their reinsertion into the family and social environment. The project is still ongoing, in terms of digital transformation and innovative tools refinement and conceptual scaling up. Further conferences will be organized and scientific papers written to disseminate the results. Our current objective is to aid clinical practice and to respect the Italian laws, which require that both the WHO ICD classification system and the WHO ICF model of disability and health be integrated in rehabilitation. Nevertheless, another possible area of impact is envisaged; by collecting real-life information on inpatient rehabilitation, we may in future be able to contribute to the international debate on rehabilitation policies.

When this process of organizational change began, only a few “dreamers” thought it could be achieved in reality. While some complained of the complexity of the WHO biopsychosocial model, most nevertheless worked hard in order to achieve the goal. Many barriers still exist and some issues remain to be resolved. Is this product a time-consuming way to describe processes and procedures which could be better described by other means? At present, the principal challenges are to deal with change management and with the need to provide a well-organized dissemination of information on the ICF framework, a big issue previously highlighted in the literature.[6] Nevertheless, we foresee many benefits. First, this large-scale implementation gives space and voice to all the rehabilitation professionals involved in the rehabilitation process, linking their work to defined objectives with a common consensus as regards the language and content. Second, by linking the ICD classification and ICF, it provides a holistic description of the patient. Finally, it gives us the opportunity to collect big volumes of data on rehabilitation medicine processes for sharing at scientific and policy level, providing information of interest in order to advocate for the best possible patient treatment and care.

Our initial question remains open, but we believe that our proposal will pave the way for the use of ICF functioning assessment and capacities description as essential components in routine rehabilitation clinical practice, enabling us to understand better the improvements and outcomes after the rehabilitation treatments. We believe that the Maugeri experience, based on an attempt to reconcile the ICD classification, now used worldwide, and the ICF, can provide a better characterization of the rehabilitation pathways of care and will be a valuable support for the implementation of the ICF as a clinical aid in different rehabilitation settings.

  References Top

Stucki G, Ewert T, Cieza A. Value and application of the ICF in rehabilitation medicine. Disabil Rehabil 2002;24:932-8.  Back to cited text no. 1
Yen TH, Liou TH, Chang KH, Wu NN, Chou LC, Chen HC. Systematic review of ICF core set from 2001 to 2012. Disabil Rehabil 2014;36:177-84.  Back to cited text no. 2
Cieza A, Fayed N, Bickenbach J, Prodinger B. Refinements of the ICF linking rules to strengthen their potential for establishing comparability of health information. Disabil Rehabil 2019;41:574-83.  Back to cited text no. 3
Wiegand NM, Belting J, Fekete C, Gutenbrunner C, Reinhardt JD. All talk, no action?: The global diffusion and clinical implementation of the international classification of functioning, disability, and health. Am J Phys Med Rehabil 2012;91:550-60.  Back to cited text no. 4
Maini M, Nocentini U, Prevedini A, Giardini A, Muscolo E. An Italian experience in the ICF implementation in rehabilitation: Preliminary theoretical and practical considerations. Disabil Rehabil 2008;30:1146-52.  Back to cited text no. 5
Reinhardt JD, Zhang X, Prodinger B, Ehrmann-Bostan C, Selb M, Stucki G, et al. Towards the system-wide implementation of the international classification of functioning, disability, and health in routine clinical practice: Empirical findings of a pilot study from Mainland China. J Rehabil Med 2016;48:515-21.  Back to cited text no. 6
Pistarini C, Aiachini B, Coenen M, Pisoni C; Italian Network. Functioning and disability in traumatic brain injury: The Italian patient perspective in developing ICF core sets. Disabil Rehabil 2011;33:2333-45.  Back to cited text no. 7
Aiachini B, Cremascoli S, Escorpizo R, Pistarini C. Validation of the ICF core set for vocational rehabilitation from the perspective of patients with spinal cord injury using focus groups. Disabil Rehabil 2016;38:337-45.  Back to cited text no. 8
Giorgi G. Chronic patient and a circular care-related prevention-treatment-rehabilitation model. G Ital Med Lav Ergon 2018;40:6-21.  Back to cited text no. 9
Escorpizo R, Kostanjsek N, Kennedy C, Nicol MM, Stucki G, Ustün TB, et al. Harmonizing WHO's International Classification of Diseases (ICD) and International Classification of Functioning, Disability and Health (ICF): Importance and methods to link disease and functioning. BMC Public Health 2013;13:742.  Back to cited text no. 10
Giardini A, Traversoni S, Garbelli C, Lodigiani A. Digitalisation and clinical care pathways in rehabilitation medicine: A possible integration from the goal-planning and the rehabilitation programme design to the evaluation of clinical outcomes. G Ital Med Lav Ergon 2018;40:22-9.  Back to cited text no. 11
Lodigiani A, La Manna A, Traversoni S, Giardini A. Organizational, digital and theconological innovation in support of clinical practice and of the “Comprehensive digital rehabilitation” model. G Ital Med Lav Ergon 2018;40:76-82.  Back to cited text no. 12

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