Implementation of the ICF Concept in the Making of Problem

Framework based on Comprehensive Geriatric Assessment for

Physical Medicine and Rehabilitation Resident of Medical Faculty

University of Indonesia

Teffy Aulia Merry Dame

, Wanarani Alwin

Melinda Harini

Department of Physical Medicine and Rehabilitation, Dr. Cipto Mangunkusumo Hospital, University of Indonesia,

Jakarta, Indonesia

Keywords: International Classification of Functioning, Disability, and Health (ICF), Comprehensive Geriatric

Assessment (CGA)

Abstract: The Comprehensive Geriatric Assessment (CGA) is a multidisciplinary evaluation which the multiple

problems of elderly are uncovered, described, and explained, which the resources and strengths of the

person are cataloged, assessed and coordinated to make care plan which developed to focus interventions on

the person’s problems. In PMR, the International Classification of Functioning, Disability, and Health (ICF)

framework is fundamental for analysis and problem intervention. PMR residents expected to have a better

guidelines in establishing the CGA program. A Cross-sectional study with a quantitative approach carried at

the Medical Faculty University of Indonesia. The objective is to compare the process of making a problem

framework using the ICF concept based on a comprehensive geriatric examination with the problem-making

process without the use of the ICF concept and to evaluate the effectiveness of the ICF concept uses for

making problem framework based on CGA examination. All of the respondents agree that the ICF concept

makes an improvement in integrating, understanding, and analytical skills in the geriatric problem; defining

rehabilitation target, priority; and simplify communication with other colleagues and patients. On the other

hand, it takes more time (28,5%) and difficulty in writing of framework (35,7%). More respondents (85,7%)

agree that it facilitates in making functional diagnosis and prognosis. The ICF concept can help to make a

better comprehensive assessment of geriatric patients based on CGA.

1 INTRODUCTION

The percentage of the elderly population in

Indonesia continues to increase. In 2015 the number

of elderly people in Indonesia is 8.49% of the total

population of 21.70 million, in 2025 estimated that it

will be 11.83% and in 2035 will continue to increase

to 15.77% of total population (BPS, 2013). Elderly

patients have different characteristics with young

adult patients. Elderly patients often suffer from

various diseases, Mental function, impaired

mobility and independence, experience malnutrition,

and experience a decline in organ function. If in

these conditions elderly patients are stricken with an

illness, the patient may fall into a state of severe

illness. When the patient succeeds through the acute

phase, the recovery phase is still awaiting and will

take a long time. In the geriatric population, the

central point of attention to care is the patient as a

whole person, not just the illness he suffered. The

attention is not limited to individual patients but is

extended to include his family. For this reason, the

best approach is through an integrated approach

involving physical, mental, social, and spiritual

aspects. Geriatric patients who report greater

spirituality, are more likely to appraise their health

as good. Spirituality may be an important

explanatory factor of subjective health status in older

adults as physical, mental and social aspects

(DaelemanTP, 2004). Then a comprehensive

assessment is needed to set patient management

goals.

The CGA is “a multidisciplinary evaluation in

which the multiple problems of older persons are

uncovered, described, and explained, if possible, and

290

Dame, T., Alwin, W. and Harini, M.

Implementation of the ICF Concept in the Making of Problem Framework based on Comprehensive Geriatric Assessment for Physical Medicine and Rehabilitation Resident of Medical Faculty

University of Indonesia.

DOI: 10.5220/0009089602900295

In Proceedings of the 11th National Congress and the 18th Annual Scientiﬁc Meeting of Indonesian Physical Medicine and Rehabilitation Association (KONAS XI and PIT XVIII PERDOSRI

2019), pages 290-295

ISBN: 978-989-758-409-1

in which the resources and strengths of the person

are cataloged, need for services assessed, and a

coordinated care plan developed to focus

interventions on the person’s problems”. Physical

Medicine and Rehabilitation (PMR) Resident is

expected to be able to carry out a comprehensive

assessment of the elderly and can frame the problem

properly so that it can facilitate the problem

identification process for further intervention in the

elderly. The approach using the ICF framework

model when combined to identify problems found in

the elderly who have received a comprehensive

assessment through CGA is expected to facilitate the

process of identifying problems that occur to provide

optimal interventions for the elderly.

In PMR, the International Classification of

Functioning, Disability, and Health (ICF) framework

is fundamental for analysis and problem

intervention.ICF is a framework for describing and

regulating information about functions and

disabilities that can provide standard and conceptual

basic language for definitions and measurements of

health and disability. ICF offers an international

scientific tool for studying disability, in all its

dimensions especially in the geriatric population

which requires comprehensive assessment for

further therapy (World Health Organization, 2001).

The ICF was developed by the World Health

Organization to provide a framework to describe

health and health-related states and to suggest

standardized language to describe these states. (BPS,

2013). Based on the work of Nagi, the ICF model

shifts the focus of disablement from cause to impact,

from disability to health and function, and from a

static process to a dynamic process. As stated

previously, the ICF defines 3 domains of human

function (Figure): body function and structure,

activity, and participation. Body function and

structure refers to the anatomical and physiological

function of the body systems, and these body

functions and body structures are categorized into

the subdomains listed in Figure 2. Deficits in this

domain are called “impairments” (eg, muscle

weakness, restricted joint motion, poor

cardiorespiratory fitness) and often are identified,

measured, and treated. The activity domain

describes the ability of an individual to perform

specific tasks such as sweeping the floor, raking the

yard, or putting away groceries (Nagi, 1965 ).

Decrements in the activity domain are called

“limitations” and describe the difficulty an

individual has performing a particular task.

Rehabilitation goals often are aimed at reversing or

normalizing such activity limitations. The

participation domain describes the ability of a person

to be involved in life situations ( Jette AM, 2006 ).

Participation restrictions describe the reduced ability

of a person to maintain normal role functions and

interact with society. Rehabilitation interventions are

designed, directly or indirectly, to enhance

participation levels for every client at home, school,

or work; on the athletic field; or in any community

setting. In the ICF model, health conditions,

personal factors, and the environment interact

dynamically across the 3 domains of a body function

to help determine whether disordered function

results in disability. For example, if a geriatric

patient had a cancer treatment (eg, chemotherapy)

that causes a patient to develop unresolved

peripheral neuropathy and ankle weakness, this

patient may have a limited ability to walk

(limitation) and may require long-term use of an

ankle brace. Limited ability to walk could result in

an employment restriction for an active elderly.

Participation restrictions occur when activity

limitations cannot be sufficiently overcome to

maintain role functions in a person's normal

environment.

Figure 1: Interactions between the component of ICF

(World Health Organization. 2001).

Figure 2: Problem framework without using ICF concept

in Geriatric patient with Digital Ulcer in Scleroderma,

Community-Acquired Pneumonia, Chronic Heart Failure

Functional Class II, Hypertension, Chest expansion

problem, Low Endurance Cardiorespiration, Visual and

hearing Problems, Frailty, Risk of falls and decrease of

Quality of life.

Decreased

Chest

Expansion

Decreased

Cough Activity

Implementation of the ICF Concept in the Making of Problem Framework based on Comprehensive Geriatric Assessment for Physical

Medicine and Rehabilitation Resident of Medical Faculty University of Indonesia

291

In the PMR learning process, the most important

things are to recognize disability, premorbid factors

and the reciprocal relationship between. PMR

residents expected to make a rehabilitation program

with considering environmental and personal factors

that can be a facilitator or barrier to our programs.

All this time, PMR resident asked to make a

problem framework that including all those factors

without a certain format. Start from 2019, an ICF

concept was proposed to be used to make a problem

framework by problems found from CGA.

As an example of Using an ICF concept in

geriatric patient based on CGA in patient with

Digital Ulcer in Scleroderma, Community-Acquired

Pneumonia, Chronic Heart Failure Functional Class

II, Hypertension, Chest expansion problem, Low

Endurance Cardiorespiration, visual and hearing

Problems , Frailty, Risk of falls and decrease of

Quality of life can be seen in figure 3 and 4. From

the figure below, see that using an ICF concept

makes a more clear vision of what kind of

impairment, disability, and handicap happens in the

geriatric patient. We can classify at what stage

patients meet the disability, impairment and

handicap criteria So that we can take immediate

action to prevent deterioration of function in the

patient.

The purpose and benefit of this research are to

measure and compare the process of making a

problem framework using the ICF concept based on

comprehensive geriatric examination with the

problem-making process without the use of the ICF

concept and to evaluate the effectiveness of ICF

concept uses for making problem framework based

on CGA examination.

Figure 3: Problem framework using ICF concept in Geriatric patient with Digital Ulcer in Scleroderma, Community-

Acquired Pneumonia, Chronic Heart Failure Functional Class II, Hypertension, Chest expansion problem,

Low Endurance Cardiorespiration, Visual and hearing Problems, Frailty, Risk of falls and decrease of Quality of life.

2 METHODS

This is a cross-sectional study and a quantitative

approach. The study was conducted in a PMR

department - Rumah Sakit Cipto Mangunkusumo,

Medical Faculty University of Indonesia located in

Jakarta, Indonesia, between the months of April and

September 2019. PMR resident, Faculty of

Medicine, University of Indonesia who had gone

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

292

through the Geriatric Division and had made a

problem framework based on CGA using the ICF

concept were included. The studied population

comprised of 14 PMR residents.

Data collection was supported by a structured

script to obtain personal and social information. The

data collection instrument was validated by experts

on the subject, concluding that the language and the

presentation of the items were pertinent to the

objective of the study.

Subjects will be asked to fill out a short closed

questionnaire about the method of making a problem

without and using the ICF concept ( Lichstenstein G,

2011). The questionnaire including 3 fields;

framework making process, problem management

and other clinical skills contains questions about the

comparison of time needed to make a framework,

writing process, differences of integrating,

understanding, and analytical skills in geriatric

problems, defining rehabilitation target, priority; and

simplify communication with other colleagues and

patients, facilitates in making functional diagnosis

and prognosis using ICF models in geriatric patients

as seen in table 1.

Table 1: Questionnaire list.

No Questionnaire Yes No

Framework Making

1 Using of ICF concept in

making problem

framework based on CGA

give a faster time than the

usual approach

2 Using of ICF concept can

simplify the writing

process of problem

framework based on CGA

Problem Management

3 Using of ICF concept help

me to integrate problems

found from CGA

4 Using of ICF concept help

me understanding

problems found from

CGA

5 Using of ICF concept

increase my analytical

skill to recognize social

and environmental factors

affect patient problems

6 Using of ICF concept

increase my analytical

skill to recognize

disability problem in the

patient

7 Using of ICF concept

increase my analytical

skill from problems found

from CGA

8 Using of ICF concept can

simplify the

communication of

problems found to another

division

9 Using of ICF concept help

me in presenting a list of

problems found to the

patient and their family

Other Clinical Skills

10 Using of ICF concept

facilitate to make a

functional diagnosis

11 Using of ICF concept

facilitate to make a patient

functional prognosis

12 Using of ICF concept

facilitate to decide

programs needed by the

geriatrician

13 Using of ICF concept

facilitate to set up

rehabilitation target in the

geriatric patient

14 Using of ICF concept help

me to determine problems

priority

3 RESULTS

Among the 14 resident included in the sample

with a mean age of 32,14 (± 3.8) years, a large

majority agree that ICF concept make an

improvement in integrating, understanding, and

analytical skills in geriatric problem; defining

rehabilitation target, priority; and simplify

communication with other colleagues and patients

(100 %). On the other hand, it takes more time

(28,5%) and difficulty in writing of framework

(35,7%). More respondents (85,7%) agree that it

facilitates in making functional diagnosis and

prognosis

Implementation of the ICF Concept in the Making of Problem Framework based on Comprehensive Geriatric Assessment for Physical

Medicine and Rehabilitation Resident of Medical Faculty University of Indonesia

293

Figure 4: Percentage of questionnaire agreement.

4 DISCUSSIONS

A questionnaire including 14 questions revealed the

first use of the ICF concept for making a problem

framework in a geriatric patient by PMR resident.

All of the respondents (100%) agree that the ICF

concept improves integrating, understanding, and

analytical skills in a geriatric problem. Respondent

agrees that using a framework based on the ICF

concept makes them more understanding of how to

analyze the problem found from CGA, so its easier

to defining rehabilitation targets and priority

problems in geriatric patients. The using of ICF

concept in a process to make a problem framework

in geriatric patient simplify communication with

other colleagues and patients, to communicate what

is need to support rehabilitation process to solve a

problem found in a geriatric patient. On the other

hand, 4 respondents (28,5%) reveal the using of the

ICF concept takes more time in the process to make

the framework compare to their usual approach.

However this is their first time implementing an ICF

concept to make a geriatric problem framework, so it

needs habituation in applying the ICF concept to

make a problem framework. We also revealed that 5

respondent showed that using an ICF concept make

a difficulty in writing of framework (35,7%). They

find a difficulty to recognize what problems should

be placed first of the many problems found from

CGA, but due to time, they admit that using the ICF

concept getting easier for them because of the

habituation process.

There is 12 respondent from 14 respondent

(85,7%) agree that it facilitates in making functional

diagnosis and prognosis, only 2 of 14 respondents

said an ICF concept did not support and make no

differences in deciding for diagnosis and prognosis

in geriatric patients compared to their usual

methods. Considering to make a functional diagnosis

and prognosis is important learning material for

PMR residents, this shows that along with the higher

frequency of contact with patients, PMR residents

will be more capable to make a functional diagnosis

and patient prognosis. Unlike the rehabilitation

programs, target and priority, which can find from

more sources, skills to set up prognosis and

functional diagnosis develop as the time they spend

with patient and habituation using the ICF concept.

Studies show that diagnosis alone does not

predict service needs, length of hospitalization, level

of care or functional outcomes. Nor is the presence

of a disease or disorder an accurate predictor of

receipt of disability benefits, work performance,

return to work potential or likelihood of social

integration. This means that if we use a medical

classification of diagnoses alone we will not have

the information we need for health planning and

management purposes. ICF makes it possible to

collect those vital data in a consistent and

internationally comparable manner. For basic public

health purposes, including determining the overall

health of populations, the prevalence, and incidence

of non-fatal health outcomes, and to measure health

care needs and the performance and effectiveness of

health care systems, we need reliable and

comparable data on the health of individuals and

populations. ICF provides the framework and

classification system for these purposes. With using

an ICF concept there is an increased recognition

among social planners and service agencies that

reductions in the incidence and severity of disability

in a population can be brought about both by

enhancing the functional capacity of the person and

by improving performance by modifying features of

the social and physical environment. ICF allows

analyzing the impact of these different interventions,

classifying domains of areas of life as well as the

environmental factors that improve performance

especially in the geriatric population ( WHO, 2002).

ICF is an essential basis for the standardization

of data concerning all aspects of human functioning

and disability around the world to evaluate health

care settings that deal with chronic illness and

disability, such as rehabilitation centers, nursing

homes, psychiatric institutions, and community

services. ICF is useful for persons with all forms of

disabilities, not only for identifying their health care

and rehabilitative needs but also in identifying and

measuring the effect of the physical and social

environment on the disadvantages that they

experience in their lives. From the viewpoint of

health economics, ICF will help monitor and explain

health care and other disability costs. Measuring

functioning and disabilities will make it possible to

KONAS XI and PIT XVIII PERDOSRI 2019 - The 11th National Congress and The 18th Annual Scientiﬁc Meeting of Indonesian Physical

Medicine and Rehabilitation Association

294

quantify the productivity loss and its impact on the

lives of the people in each society. The classification

will also be of great use in the evaluation of

intervention programs (WHO, 2002)

By using an ICF concept in geriatric patients

based on the problem found from CGA, we can

recognize impairment and disability problem, thus

we can prevent more deterioration which can lead to

a handicap. Health Education can be applied earlier

to prevent deterioration of function as a secondary

prevention, aims to reduce the impact of the disease

by detecting and treating disease or injury as soon as

possible to halt or slow its progress, encouraging

personal strategies to prevent re-injury or recurrence,

and implementing programs to return people to their

original health and function to prevent long-term

problems.

5 CONCLUSIONS

ICF concept can help to make a better

comprehensive assessment of geriatric patients

based on CGA and effective ways to improve

problem management and other clinical skills of

PMR residents.

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Medicine and Rehabilitation Resident of Medical Faculty University of Indonesia

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