Rehabilitation has a role at all levels and in all domains of the ICF.
The ICF model (figure 6) shows that the relationship between the domains is reciprocal and they interact by mutually influencing one another. Personal and environmental factors are foundational to person-centred care.
While the ultimate goal of recovery is to maximise participation, rehabilitation will generally break this down into smaller steps. Interventions often focus on mitigating disability in body structures and function and maximise activity capability. Working closely with the person and their family will ensure contextual factors which are facilitators to rehabilitation, are identified and used; and factors which are barriers are managed.
Working with complexity in rehabilitation is seldom just about the severity of the health condition. Complexity is equally influenced by contextual factors.
Participation focus
Goals are most helpful when they address priorities that are important to the person.4 People may identify participation, activity or impairment level intentions or priorities, but extending the conversation will identify how this will impact on their life. Participation level goals work towards improving the real life impact of their illness or disability.
The ICF defines participation level outcomes.12 Understanding the ICF helps to develop valued outcomes at the participation level. A participation focus means that the goals have meaning to a person’s life roles and will help them return to these roles throughout their recovery.
Identifying participation level goals
In early days of their rehabilitation, a person may need to be guided by therapy staff before they understand the progress of their illness or disability. Relating therapy steps to their real life or participation level helps the person visualise the difference that can be achieved.
If the person is focused on body or activity levels, you can prompt them to identify participation level outcomes by asking: ‘What difference will it make to your life if you can?’
Sometimes it’s the justification that needs to be sold simply and positively, for example: ‘We’re working on [this activity] so that it will help you [reach your goal].’
Examples of different levels of goals
- Body function and structure level goal: Jane’s active knee flexion will reach 70 degrees by 3 November.
- Activity level goal: Jane can get up and down from the floor.
- Participation level goal: Jane will be able to play on the floor with her toddler.
Planning discharge from service
Achieving goals is a factor in determining when the person is ready to be discharged from NSW Health rehabilitation services.
Reaching participation level goals often takes time and may occur well after the person has been discharged. Frequently, the ability to return home is determined by independence (or safety) at the activity level, or plateau at the body structures and functions level. A person will continue to work towards their participation goals by themselves, through outpatient or community rehabilitation services or other support schemes.
Section 7 has more detail about using outcome measures to determine progress and when someone is ready to move on from their health program.