ICF-Based Rehabilitation Programme for Community- Dwelling Survivors with Chronic Conditions: Insights from a Hong Kong Initiative

Goh LY, Law JYM, Rebecca S and Jyoti R

Published on: 2025-06-17

Abstract

A two-year pilot centre was established in Hong Kong to support community-dwelling survivors with moderate to severe disabilities. The Centre provides integrated day and home care services by implementing an ICF-based rehabilitation programme tailored to local resources and needs. The multi-disciplinary team members utilise a unified set of tools to plan interventions, evaluate changes, and coordinate care. A centre-specific ICF core set was developed to address the rehabilitation needs of target users, aligning with the Centre’s service scope. This core set serves as a common reference for the multidisciplinary team to evaluate clients’ functioning and established client-centred rehabilitation goals across disciplines. Collaborative care involving professionals, support staff, and family caregivers, along with client engagement in goal setting, enhances participation in daily routines, and facilitates the transition from supervised centre-based training to self-administered home practice. A simplified Goal Attainment Scale (GAS-Light) was used to evaluate intervention outcomes by comparing composite GAS-Light T-scores before and after intervention using paired t-test. Over 18 months, 50 clients were recruited, with 30 completed a second 6-month review. Each client typically had 2-4 GAS-Light goals, yielding a single overall GAS score. Significant improvements were observed across both review periods (t(49) = -13.2; t(29) = -12.8, p<0.05, paired t-test). ICF category assignments to individual disciplines were integrated into the centre’s workflow, systematically distributing responsibilities and follow-up duties among professionals, support staff, and caregivers. The distribution of duties for each selected ICF category was also evaluated. The follow-up roles were not limited to support staff and caregivers, professionals were also designated to follow-up on specific ICF categories assigned to other disciplines, reflecting trans disciplinary process in the collaborative care for individual clients. This pilot initiative demonstrates the flexibility and continuity of rehabilitation training and support throughout the client’s entire day, via both centre-based and home-based services, promoting sustainable community reintegration and preventing unnecessary institutionalisation.