The International Classification of Functioning, Disability and Health: They’re talking our language

The International Classification of Functioning, Disability and Health (ICF) (2001), aims to provide a common interdisciplinary and consumer language with which to communicate and understand health, health-related outcomes and health determinants. It is also a classification tool used to describe and measure functioning. One of the significant opportunities afforded by the ICF is the development of a model that articulates the complex and dynamic relationships between the multiple elements of an individual's life in determining health and health outcomes. Occupational therapists easily relate to the ICF because of obvious similarities between occupational theory and the ICF model and language (for example, Stamm, Cieza, Machold, Smolen & Stucki, 2006; Darzins, Darzins & Fone, 2006, in this issue). Indeed, we could be forgiven for thinking it was about time the rest of the world caught up with us. The ICF was designed to be used (i) as a conceptual framework in advocacy, teaching, planning or education; (ii) as a classification system to capture national data on disability or services; (iii) to provide detailed codes in specific service, clinical or therapeutic settings; or (iv) as a classification framework for designing new outcome measures or relating measures to each other (Australian Institute of Health and Welfare (AIHW), 2003). As a model, the ICF has been readily taken up by educators, researchers and practitioners around the world and this is a testament to the accessibility of the language and concepts. By endorsing the ICF, the World Health Organization has given a clear mandate to consider more than impairment in the delivery of services for people with disabilities. For occupational therapists focusing on more than the impairment is not a challenge conceptually, but ensuring that the rhetoric translates to service delivery perhaps remains challenging in some settings. Health-care systems at national and local levels require statistics in order to make decisions to plan for and mandate service delivery, to determine costs and outcomes. Collecting workload data for the ‘black hole’ of service statistics may feel irritating and inconvenient to clinicians; however, without data there is no possibility of achieving adequate health services or of determining need. The ICF works in tandem with the ICD-10 (The International Classification of Disease). The ICD-10 is used to classify disease at the level of the health condition in the ICF model. Classification and identification of service needs using the ICD disease or disorder codes are not particularly useful in occupational therapy as two people with the exactly the same disorder may require entirely different types and levels of service. However, the ICF contains a set of specific codes to classify functioning. Use of the ICF codes related to impairment, activity, participation or environment is more likely to result in meaningful data collection, thus providing the allied health professions with a better opportunity to clearly identify where and why they provide services. Using the ICF coding system is however currently cumbersome. Multiple levels and lists of numbers that convey whether the focus of intervention is at body function or activity levels and whether environmental factors act as a facilitator or barrier, do not appear to have been taken up by many practitioners at this stage. Work in streamlining this process is underway with the National Allied Health Classification Committee using the ICF codes in the development of the Indicators for Intervention. The Indicators for Intervention aim to be a more complete and useful mechanism for reporting on allied health involvement and benefits (Stokes, 2006). Despite difficulties with coding, there is an opportunity to use the ICF system to explicitly identify occupational therapy domains of practice, using language that is understood at a consumer as well as national and international policy level. Managers and practitioners can use the ICF descriptors to carefully select core domains in their practice areas. In addition to identifying the focus of practice using the ICF, selection of outcome measures that have been developed using the ICF (The PC Part is one example (Darzins, 2004)) or that have an explicit relationship to the domains of the ICF will clearly articulate occupational therapy's place and worth in health and social services. Researchers’ uptake of the ICF has become apparent with reporting of studies that consider intervention or outcomes according to the ICF model. At the recent AIHW conference on Improving Information on Disability and Functioning (AIHW, 2006), a body of research was presented by a group of Queensland University speech pathologists led by Professor Linda Worrall. The theme in common among these researchers was the explicit use of the ICF not only in the planning of the research but also in interpreting and communicating the findings. This work exemplifies the utility of the ICF in promoting understanding of disability and its relationship to health and well-being. This is a strong answer to the call for research that makes known how the domains of the ICF relate to each other. Occupational therapy research can also contribute in this area by going beyond considering the ICF model in framing research to explicitly examine the relationship between domains and how occupational therapy intervention applied at the body function, activity, participation or environment levels contributes to positive health and well-being outcomes. Some of this research already exists, embedded in discipline-based theoretical models such as the Canadian Model of Occupational Performance (CAOT, 2002). Discipline-based research is critical to our professional identity and growth and we should not only consider the ICF in research or in practice. But, we do need to interpret our research to policy makers to make explicit what we already know about the relationships between domains identified by the ICF so we can stand up and be counted using language that is understood. In addition, the ICF provides an extremely useful model in which to embed collaborative interdisciplinary research. One purpose of the previously mentioned conference was to reflect on the current status of the ICF in Australia and to plan for future developments including integrating the new ICF for children and youth (ICF-CY, Lollar & Simeonsson, 2005), mapping current outcome measures to the ICF domains (for example, Cameron, 2006) and ICF codes to Australian Bureau of Statistics (ABS) data (Goodspeed, 2006). The need to understand further how the domains of activity and participation relate to one another and how to code capacity and/or performance were also discussed. Occupational therapists’ in-depth understanding of activity and participation places us in a unique position to advance the development of these elements of the ICF. The ICF offers an opportunity to capture health statistics in a far more meaningful way than has been possible previously, and the AIHW Health and Welfare and the ABS are working together to facilitate improved gathering of disability statistics. The capturing of population-based statistics using core terminology will allow for far more powerful and meaningful comparisons across systems and for better health planning as well as measurement of change over time. Occupational therapists need to use the ICF to build and communicate knowledge of practice that counts at policy level. We have embraced the model, we need to also explicitly identify our professional domains of practice and effect as well as contribute to the ongoing development of the ICF system.