SAHK, an NGO specialised in community rehabilitation, was awarded the operation of the 2-year pilot project for the Integrated Community Rehabilitation Centre in the New Territories West Region (NTWICRC) in 2023. The pilot project offers an integrated service that combines day care centre and home care service in a flexible manner. It utilises the International Classification of Functioning, Disability, and Health (ICF) framework in rehabilitation service at the community level. The project aims to provide a continuum of coherent and interconnected services for individuals with disabilities who have intensive care needs and live at home. The target service users are individuals aged 15 or above with moderate to severe intellectual and/or physical disabilities living in the community.

Successful use of the ICF in clinical practice relies heavily on the adoption of suitable ICF tools and their seamless integration into the existing rehabilitation process. NTWICRC of SAHK has implemented an ICF-based rehabilitation service that has been locally adapted to meet local resources and needs. The Centre employs Rehab-Cycle®, ICF core sets, the WHO Disability Assessment Schedule (WHODAS 2.0), and a simplified version of the Goal Attainment Scale (GAS-Light) in its rehabilitation management. Staff members from multiple disciplines use a single set of tools to guide planning, evaluate changes, and coordinate actions in their clients’ rehabilitation.

A Localised ICF-Based Community Rehabilitation Programme

The ICF employs a ‘universal language (alpha-numeric code)’ to describe health in terms of functioning. Since the aim of rehabilitation is to optimise function, the ICF model can be effectively applied in this context. The clinical application of ICF is best illustrated in Figure 1 (modified from its typical graphical representation), highlighting ‘Activities (what Can-Do at centre)’ and ‘Participation (what Do-Do at home)’ as the client’s ultimate rehabilitation goals. These goals can be achieved through a 3-pronged approach: improving ‘Functions & Structures’ (Bio-), optimising external ‘Environmental’ (Social-), and/or strengthening internal ‘Personal’ (Psycho-) factors. Thus, the ICF is also known as a bio-psycho-social model, framing goal setting and intervention planning.

There are differences between the ICF classification coding system and the ICF model. The latter depicts ‘Activities’ and ‘Participation’ as distinct components, while the former treats ‘Activities & Participation’ as a single entity. Conversely, ‘Functions & Structures’ is a single component in the model, whereas the system considers them as separate entities. Each entity is coded with a letter prefix: body functions (b), structures (s), activity & participation (d), and environmental factors (e), while personal factors have not been classified. Within each entity, there is an exhaustive list of functions (categories), each denoted by a numeric code of up to 5 digits that are hierarchically organised into 4 levels [1]. In total, there are over 1,400 ICF categories.

Figure 1: The ICF Model Tailored for Clinical Practice.

Centre-Specific ICF Core Set

The ICF core set is a list of essential ICF categories tailored to the needs of individuals with specific health condition. To date, core sets have been developed for a range of adult-onset conditions at different stages of recovery, as well as for childhood- onset conditions at various life stages [2]. They have been reported to cover the majority of problems treated by therapists for the respective conditions [3-6] and are primarily used for goal setting [7]. The NTWICRC developed a centre-specific ICF core set, adapted from various relevant core sets to align with its target users to address their rehabilitation needs, and tailored to the scope of its services. The customised core set serves as a common reference tool for the multidisciplinary team to consider relevant aspects of their clients’ functioning in areas both within and outside of their respective disciplines.

Client-Centred and Structured Goal Setting

Rehabilitation management at NTWICRC is adapted from the Rehab-Cycle® (Figure 2), an ICF-based rehabilitation cycle that facilitates inter professional collaboration by structuring the entire process with a standardised workflow and shared documentation [8].

Figure 2: Rehabilitation Management in NTWICRC, Modified from the Rehab-Cycle®.

The Rehab-Cycle® establishes an operational definition of client-centred clinical practice by setting client-chosen common goals that are shared by the entire team. The ICF-based holistic clinical reasoning can be conceptualised as the process of identifying and addressing underlying bio-psycho-social issues that may affect the attainment of these common goals, with professional-driven discipline-specific sub goals all directed toward the common goals centred round the ‘Activities’ and ‘Participation’ components (Figure 1).

An Integrated Centre- and Home-Based Service

The NTWICRC offers flexibility in bridging centre-based training and support services to users’ homes, accommodating their evolving needs over time while ensuring sustainable community reintegration and preventing unnecessary or premature institutionalisation.

A Model-Driven Approach

In community rehabilitation, all 5 components of the ICF model should be carefully considered and addressed. As biological functioning may have plateaued during the chronic stage of recovery, the focus should shift to mobilising social resources and strengthening personal factors. This model aims to translate the capacities developed by clients in the Centre into real-life participation at home or in the community.

To address the complex needs of community-dwelling survivors with neurological impairments, an integrated approach that combines centre-based and home-based services, along with collaborative care involving both professional and support teams, is essential. Neuroplasticity is the process by which brain relearns lost functions through rehabilitation. We strive not only to maximise our clients’ biological functioning in clinical settings, but also to enrich their home environment and provide support for their caregivers to promote the generalisation of skills in real life. This whole-team approach enhances client engagement in daily routines, social interactions, and recreational activities, facilitating a smooth transition from centre-based supervised training to randomised self-administered repetitive practice at home. This transition is crucial for promoting neuroplasticity, progressing from the neuro-network level to the structural-functional level.

DAS-Guided Structured Interview

Patient empowerment for self-management is essential in neuro rehabilitation at the community level, starting with enabling clients to recognise their responsibility in maintaining their own health. Patients in Hong Kong are accustomed to taking a passive role in the medical model and may be unaware of this responsibility. The Chinese-translated WHODAS 2.0 questionnaire was implemented at the NTWICRC to enhance clients’ awareness of their activity limitations and participation restrictions through structured interviews conducted primarily by trained social workers. A role-play practicum for administering the WHODAS 2.0 questionnaire, along with an interviewer’s guideline, have been developed to help interviewers navigate the differences between spoken Cantonese and written Chinese, assisting clients in responding to the questions. By partnering with clients and their caregivers in creating their care plans, they are equipped with specific skills, relevant resources, and the best available evidence. This empowerment helps them to accept their current limitations and cultivate positive psychosocial skills (personal factors) to manage the bio psychosocial and economic consequences of living with neurological impairments.

Use of Advanced Technology from the ICF Perspective

Traditionally, rehabilitation technologies have been viewed as devices used in clinical settings. However, advancements in cloud-based, AI-assisted, sensor-based, wearable, and extended reality technologies have brought about a revolutionary shift in rehabilitation service delivery. Bridging the gap between ‘Can-Do’ and ‘Do-Do’ is essential for effectively applying the ICF in clinical practice (Figure 1). Tele rehabilitation plays a critical role in the successful implementation of the ICF. At the NTWICRC, suitable tele rehabilitation systems have been introduced to facilitate the transition from centre-based supervised training to self-administered, unsupervised repetitive practice in clients’ homes, with remote monitoring of their adherence and performance by professionals at the Centre.

Fifty clients were recruited over a period of 18 months, with mutually agreed individualised care plans developed collaboratively between the Centre and the clients. The care plans were reviewed on a half-year basis.

NTWICRC adopted the 36-item version of WHODAS 2.0, where each item is rated on a 5-point scale (0 = none; 1 - mild; 2 = moderate; 3 = severe; and 4 = extreme difficulty experienced by clients in participating in the respective activity over the past 30 days). This tool is well established for non-condition-specific assessments of an individuals’ global health status; however, it may not be sensitive enough for evaluating short-term goals within the 6-month review period.

Goal Attainment Scaling (GAS) is a client-centered, collaborative approach used to evaluate the effectiveness of interventions on personally relevant goals, with mutually satisfying outcomes established between clients/caregivers and professionals prior to the intervention [9]. GAS is rated on a 5-point scale (0 = client achieves the expected level; +1 = somewhat more than expected; +2 = much more than expected; -1 = somewhat less than expected; -2 = much less than expected).  The ICF provides a framework that enables these 3 parties to identify areas of clients' needs, while GAS facilitates their collaboration in translating these identified areas into clear, distinct goals [10]. To assess short-term goals during each review period, a simplified version of GAS (GAS-Light) was adopted, and the pre- and post-intervention GAS-Light composite T-scores for individual clients were pooled for quantitative analysis of the effectiveness of the ICF-based rehabilitation management [10-12].

Since the essence of using the ICF in clinical practice is to transform the fragmented multidisciplinary rehabilitation process into a client-centred, holistic, and trans disciplinary journey (Figure 2), the evaluation also focused on these 3 aspects. Among the 277 level-2 ICF categories from the ICF core set customised for NTWICRC, the top 5 most commonly used categories from each component were identified to understand the common rehabilitation needs of the Centre’s target clients. Additionally, the utilisation of ICF categories from different components for individual clients reflects the service team’s ability to take a holistic approach to the rehabilitation needs of their clients.

Finally, the discipline assignment for individual ICF categories serves as a measure of the extent of interprofessional collaboration and the continuity of follow-up training outside therapy sessions.

Among the 50 clients included in this pilot study, 30 completed the second six-month review. Approximately 80% of clients received dual mode service, while 20% received either centre-based or home-based services.

Pre- and Post-Intervention GAS-Light Composite T-Scores

We adopted the GAS-Light, focusing specifically on precisely defining the expected “level 0” outcome. Typically, 2-4 GAS- Light goals are identified for each client, which are then incorporated into a single overall GAS-Light Composite T-score as calculated by the formula below [11]:

where,

wi = the weight assigned to the i^th goal (if equal weights, wi = 1)

xi = the numerical values achieved for the i^th goal (between -2 & +2)

Significant improvements of the GAS T-score were observed during both the first (Figure 3) and second (Figure 4) 6-month review periods (t (49) = -13.2; t (29) = -12.8, p<0.05, paired t-test).

Figure 3: Significant Improvement in the Overall GAS-Light Score among 50 Clients during the First 6-Month Review Period.

Figure 4: Significant Improvement in the Overall GAS-Light Score among 30 Clients during the Second 6-Month Review Period.

Commonly Used ICF Categories

The client-chosen common goals are mapped to ICF categories from the ‘Activity and Participation’ (d-) component, while the professional-driven sub goals are mapped to the categories from the ‘Body Function’ (b-) and ‘Environmental’ (e-) components. All ICF categories are selected from the ICF core set customised for NTWICRC. Since little intervention on the ‘Structure’ (s-) component can be expected at NTWICRC, no ICF categories from the s-component are included in the Centre’s ICF core set. The utilisation of ICF categories in goal establishment among the 50 clients is summarised in Table 1.

Ninety client-chosen common goals were established among the 50 clients since their admission. Including the professional- driven sub goals set by individual disciplines, a total of 441 ICF categories were selected from the ICF core set of NTWICRC. During each 6-month review period, the average number of ICF categories selected for each client was 4.9. The ICF core set enables professional staff to shift from focusing on biological impairments (b-categories) to considering activity limitations and participation restrictions (d-categories), as well as environmental barriers (e-categories) encountered by their clients. Currently, approximately 40% of individual clients’ established goals and sub goals included ICF categories from all three components of the Centre’s ICF core set. A higher percentage is anticipated as the Centre’s staff becomes more accustomed to the holistic consideration of their clients’ needs beyond their professional boundaries.

Table 1: Number of Goals Established and Utilisation of ICF Categories among the 50 Clients.

NTWICRC primarily targets clients with severe disabilities. Among the client-chosen common goals established for the 50 clients, the top 5 commonly selected ICF categories from the d-component (d-categories) are, in order: ‘Maintaining body position’ (d415), ‘Moving around different locations (d460), ‘Transferring oneself’ (d420), ‘Speaking’ (d330), and ‘Recreation and leisure’ (d920) (Figure 5).

Figure 5: Frequency of d-Categories used for Establishing Client-Chosen Common Goals.

Among the professional-driven sub goals set by individual disciplines, the top 5 b-categories are ‘Muscle power’ (b730), ‘Joint mobility’ (b710), ‘Muscle endurance (b740), ‘Swallowing’ (b510), and ‘Pain’ (b280) (Figure 6). The top 5 e-categories are ‘Immediate family’ (e310), ‘Technology for daily living’ (e115), ‘Personal care providers’ (e340), ‘Technology for mobility’ (e120), and ‘Technology for communication’ (e125) (Figure 7). The expected empowerment and engagement of caregivers (e310) and support staff (e340) in the intervention was successfully achieved at NTWICRC.

Figure 7: Frequency of e-categories used for Establishing Professional-driven Sub goals that could Impact Common Goal Attainment.

Responsible and Follow-up Duty Assignment for Individual ICF Categories

The use of the ICF framework in clinical practice at NTWICRC facilitates a shift from a multidisciplinary team to a trans disciplinary interprofessional collaboration. This trans disciplinary model is characterised by horizontal delegation of knowledge and skills across professional disciplines and downward empowerment to support staff at the centre and caregivers at home. Each ICF category mapped to the established goals and sub goals is assigned to a specific discipline as the responsible personnel, and if necessary, to another discipline as the follow-up personnel.

This role assignment process is embedded within the Centre’s rehabilitation management workflow, ensuring structured and coordinated efforts in care delivery. Figure 8 illustrates how responsibilities and follow-up duties for the selected d-categories are distributed among professionals [physiotherapists (PT), occupational therapists (OT), speech therapists (ST), nurses (N), social workers (SW)), support staff [personal care workers (PCW), therapy assistants (TA), welfare workers (WW)], and family caregivers. Importantly, follow-up roles are not necessarily limited to support staff and caregivers; professionals may also take on follow-up duties of ICF categories responsible by another discipline. For instance, OT and SW were designated as follow-up personnel for d325 (Receiving written messages) and d330 (Speaking) respectively, both of which were led by ST (Figure 8).

Figure 8: Assign multiple disciplines as the responsible and follow-up parties for specific d-categories in the common goals.

The uneven intervals of the 5-point qualifier scale (with a significantly larger interval for qualifier 3) make it less sensitive for pre- and post-intervention evaluation. In clinical application, the qualifier rating is primarily used for clinical reasoning, particularly in conducting a discrepancy analysis of the first and second qualifiers of the d-categories mapped for the client-chosen common goals. This discrepancy analysis provides valuable information on the underlying problems affecting the client’s levels of participation in real life, which are not captured by other measurement tools. The discrepancy between the client’s ‘Performance (Do-Do)’ in real life (first qualifier) and his/her ‘Capacity (Can-Do)’ in a standardised setting (second qualifier) for the same d-category highlights ways to address the client’s activity and participation problems by improving biological impairments, optimising the physical environment, and/or mobilising available social resources.

Interprofessional Communication

Social workers, as case managers, are responsible for initial client contact and engagement, as well as needs and risk assessment, including administering the DAS-guided structured interview with clients. They collaborate with healthcare professional and support teams to arrange home-based and/or centre-based services for clients and their families. The case manager organised ICF- based programmes, helping clients bridge the gap between ‘Activities (what they Can-Do at the centre)’ to ‘Participation (what they Do-Do at home or in the community)’. Inherent in the use of ICF categories and their qualifier ratings is the ability to document goals and outcomes clearly and concisely. This serves as a central source of information for all disciplines and aids in the formulation of intervention targets aligned with shared goals.

An individualised rehabilitation plan establishes well-defined and functionally meaningful common goals through shared decision-making with clients and their family caregivers, fostering their sense of responsibility in the rehabilitation process. The ICF codes provide a common language for goal setting, followed by the assignment of interconnected (sub) goals to specific disciplines to ensure consistency and build continuity between centre and home care. This necessitates planning and coordination of the client’s therapeutic interventions with his/her daily routines, transforming multidisciplinary practice into trans disciplinary interprofessional collaboration.

By aggregating the selected ICF categories and their qualifiers, a categorical profile is created to provide a snapshot of the client’s functioning status at a given time. This can serve as a standard repository of information for inter-organisational data transfer, ensuring a smooth transition with consistency and continuity during inter-center referrals.

A Computer System for ICF-Based Goal Setting and Programming

Mapping (sub) goals to ICF categories and WHODAS 2.0 findings can be tedious. Therefore, computerisation is essential, and we have developed a basic system at NTWICRC for this purpose. It is recommended that the government should take the lead in developing a user-friendly, mobile-compatible, universal, and generic web-based common platform for shared use among community rehabilitation service providers. The common platform should include a customisable centre-specific ICF core set for goal setting, discipline assignment, and intervention planning. Additionally, it should feature documentation and processing functions for the WHODAS 2.0 questionnaire, GAS-Light scoring, and qualifier ratings.

Cross-Sector Collaboration

The common framework offered by the ICF model and the universal language provided by the ICF classification coding system promote effective communication not only among different professional disciplines, but also between the healthcare and technology sectors. NTWCRDC has collaborated with local technology developers and incubators from the Science Park to develop and refine rehabilitation products that address the clinical needs of our clients from the ICF perspective.

The adoption of the ICF model in NTWICRC provides a standard workflow for goal setting, programme planning and delivery, realising a client-centred approach through the establishment of client-chosen common goals shared by the entire team. To address the complex rehabilitation and care needs of individuals with disabilities living in the community at different stages of recovery, the five components of the ICF model should be duly considered. The integrated centre- and home-based service of NTWICRC offers an infrastructure to ensure consistency and continuity of training both at the centre and in the home through trans disciplinary interprofessional collaboration. It would be beneficial if the government could coordinate a shared computer platform across service providers, facilitating data transfer and experience sharing among organisations.

Abbreviations

GAS: Goal Attainment Scaling

GAS-Light: simplified version of the Goal Attainment Scaling

ICF: International Classification of Functioning, Disability, and Health

N: Nurse

NTWICRC: New Territories West Integrated Community Rehabilitation Centre

OT: Occupational therapist

PCW: Personal care worker

PT: Physiotherapist

ST: Speech therapist

SW: Social worker

TA: Therapist assistant

WHODAS2.0: World Health Organization Disability Assessment Schedule Version 2.0

WW: Welfare worker

Author Contributions

Rebecca S : Data curation, Investigation, Writing (review & editing)

Law JYM: Funding acquisition, Project administration, Resources, Supervision, Writing (review & editing)

Jyoti R: Conceptualisation, Formal Analysis, Methodology, Software, Writing (original draft)

Acknowledgments

The authors would like to thank SAHK for its support in the preparation of this article and all team members of NTWICRC for their contributions to project implementation.

Funding

This work is supported by the Lotteries Fund (Grant Code: 35141-837-5350-Z453) for the operation of the NTWICRC.

Data Availability Statement

The data is available from the corresponding author upon reasonable request.

Conflicts of Interest

The authors declare no conflicts of interest.

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