Experiences of ICF/ICF -CY Implementation in...

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Experiences of ICF/ICF-CY Implementation in Taiwan Hua-Fang (Lily) Liao 1,2 , Tsan-Hon Liou 2,3 , Chia-Feng Yen 2 , Ai-Wen Hwang 2,4 , Wen-Chou Chi 2 , Tien-Fang Wu 2 , Yi-Ling Pan 5 1 School and Graduate Institue of Physical Therapy, College of Medicine, National Taiwan University, Taipeiu, Taiwan 2 Taiwan ICF Reasearch Team 3 Institute of Injury Prevention & Control, Taipei medical University, Taipeiu, Taiwan 4 Graduate Institute of Early Intervention, Chang-Gung University, Kweishan, Taoyuan, Taiwan 5 Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, NTU, Taipei CBR: practice and evidence-building in diverse locations, University of Sydney, Oct 5-6 2011 1

Transcript of Experiences of ICF/ICF -CY Implementation in...

Page 1: Experiences of ICF/ICF -CY Implementation in Taiwansydney.edu.au/health-sciences/ncch/docs/icf/hfliaoOct2011.pdf · Experiences of ICF/ICF -CY Implementation in Taiwan Hua-Fang (Lily)

Experiences of ICF/ICF-CY Implementation in Taiwan

Hua-Fang (Lily) Liao1,2, Tsan-Hon Liou2,3, Chia-Feng Yen2, Ai-Wen Hwang2,4, Wen-Chou Chi2, Tien-Fang Wu2, Yi-Ling Pan5

1School and Graduate Institue of Physical Therapy, College of Medicine, National Taiwan University, Taipeiu, Taiwan 2Taiwan ICF Reasearch Team 3Institute of Injury Prevention & Control, Taipei medical University, Taipeiu, Taiwan 4Graduate Institute of Early Intervention, Chang-Gung University, Kweishan, Taoyuan, Taiwan 5Department of Physical Medicine and Rehabilitation, National Taiwan University Hospital, NTU, Taipei

CBR: practice and evidence-building in diverse locations, University of Sydney, Oct 5-6 2011

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Implementation of ICF/ICF-CY in Taiwan since 2002

• Policy design The People with Disabilities Rights Protection Act (2007) Changes in the disability eligibility system and services (2012-)

• Clinical practice and education Professionals

Assessment, documentation, and service delivery (2004 -) Education in different disciplines (2002 -)

Participation of the public, especially people with disabilities Attending and organizing workshops (2008 -) Implementation of ICF in the eligibility system (2012-)

Taiwan Society of International Classification of Functioning, Disability and Health (TSICF) (2009-)

• Research and publication Understanding of ICF/ICF-CY, classification, clinical application,

etc.. (2002-)

Health Condition

Body Functions & Structures

Activities Participation

Environmental Factors

Personal Factors

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Application of ICF/ICF-CY in the disability eligibility system in Taiwan, July 2012

• The health authority Evaluation reports after the medical

examination (b,s) and functional assessment (d,e)

• The social welfare system Needs Assessment (e)

• The county (city) authorities Issue the disability

identifications Provide the mandatorily related

welfare and services

Medical Examination

Functional Assessment

Needs Assessment

Disability Identifications & Providing Services 3

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Task force on functioning assessment of disability eligibility system, Taiwan ICF research team Article 6: Qualification of the disability assessment professionals, the

categories and grades of disability, assessment items and standards, assessment methods, instruments, operation and others are prescribed by the central competent authorities in charge of health (Department of Health) to design content of eligibility assessment to conduct pilot studies to examine its

reliability and validity Article 6: Local health authorities shall assemble assessment

teams to render the assessment services and complete appraising and ascertaining/verification reports on the disability. to design and provide training courses for

assessment teams 4

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Need Assessment

(Social welfare system)

Change assessment content, Assessing 13000 persons with disabilities in 25 cities and counties

Training testers, Assessing 500 persons in 4 cities

Task force for developing the eligibility system based on ICF in Taiwan

Part 1: Functioning and Disability

Part 2: Contextual Factors

Personal Factors

Measuring tool

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Measuring tool Year2008

2009

2010 2011

ICF

Body Functions and Structures

(b, s codes)

Activities and Participation

(d codes)

Environmental Factors

(e codes)

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Comparisons between old and new eligibility systems

Assessed by physician (hc,bs)

Old system New system

Social Bureau issue Identification

Hospital

Professionals (de)

Physician (hc, bs codes)

Social Bureau (Needs Assessment)

Health Bureau

Health Bureau

Social Bureau issue manual

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Category Administration Items Qualifiers Tester qualification

d 410 Changing basic body position

1st qualifier : (Performance) In natural setting, may use devices in the past 1 mo, Interview and observation, direct testing if necessary

2nd qualifier: (Capacity) Without devices Direct testing and observation, interview if necessary

(1) supine to sidelying

(2) supine to sitting

(3) sitting to standing

(4) standing to sitting

(5) standing, pick up things from floor

One point for one failure item. Convert disability score to qualifier

0:(0 point) 1:(1 point) 2:(2-3 points) 3:(4 points) 4:(5 points)

Health-related professionals after training

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Measures in the disability eligibility system for adults in 2010- d410 item as an example

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Differences of values of the qualifiers between performance and capacity of d4 and d5 in stroke patients (n=110) (2010 ICF Trial study)

Mean SD t p

d4-capacity 2.31 1.34 5.7 <0.001

d4-performance 2.02 1.46

d5-capacity 2.30 1.44 3.46 0.001

d5-performance 2.02 1.46

(Liao, Hwang, Liou, Yen, et al., 2011, unpublished data) 8

As expected, qualifiers of performance were significantly lower than that of capacity due to the help of assistive devices

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WHO Disability Assessment Schedule II (WHODAS 2.0)

• 7 versions 36-item, interviewer-administered (2011) 36-item, self-administered 36-item, proxy-administered (2011) 12-item, interviewer-administered (2010) 12-item, self-administered 12-item, proxy-administered 12+24-item, interviewer-administered

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Correlation coefficients between d4 and scores of WHO DAS in stroke patents (n=110) (2010 ICF Trial study)

WHODAS Whole score

d4-capacity 0.89

d4-performance 0.92

d450-capacity 0.82

d450-performance 0.83

(Liao, Hwang, Liou, Yen, et al., 2011, unpublished data)

all values with P<0.01 (two tailed)

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d4 subscale scores were significantly correlated with WHODAS score

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Items in Scale Interrater reliability Test-retest reliability

d5 Self-care d510 washing oneself 0.90** 0.60**

d520 caring for body part 0.74** 0.45**

d530 toileting 0.80** 0.51**

d540 dressing 0.81** 0.74**

d6 domestic life d630 preparing meals 0.82** 0.79**

d640 doing housework 1** 0.68**

d650 caring for household objects 1** 1**

Inter-rater and Test-retest Reliability (Kappa value ) of disability score of 「ICF Activities of Daily Living Scale - Adult version」for Adults with Stroke (2010 Taiwan ICF trial)

**p<0.01 (Wu, et al., 2011, submitted) 11

d5 and d6 subscales of the eligibility measures showed acceptable inter-rater and test-retest reliabilities

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Convergent Validity of Qualifiers of Subscales of「ICF Activities of Daily Living Scale - Adult version」for Adults with Stroke (2010 Taiwan ICF trial) (n=50)

d510 d520 d530 d540 d550 d560 d570 d620 Bathing 1 0.81**

Grooming 1 0.50**

Toilet use 1 0.83**

Bowels 1 0.67**

Bladder 1 0.61**

Dressing1 0.75**

Feeding1 0.44**

Feeding1 0.50**

Taking medication 2 0.58**

Grocery shopping2 0.63**

** p <0.01, Spearman correlation coefficient test (Wu, et al., 2011, submitted) 1Barthel score 2 Instrumental Activities of Daily Living

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Population distribution of IRT-based scores of WHODAS 2.0

Higher score of WHODAS means more severe, 50% of general population has score less than 3

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Scores of Whole test and 6 Domains WHODAS 2.0 12-item interview version in persons with disabilities in Taiwan (N=206) (2010 Taiwan ICF trial)

Domain* Mean ± SD D1 Cognition 55.7±31.5 D2 Mobility 41.1±37.3 D3 Self-care 40.5±42.8 D4 Getting alone 51.1±36.3 D5 Life activities 48.6±39.5 D6 Participation 52.4±38.4 Overall score** 48.1±33.7

(Yen, Liou, 2011, unpublished data) 14

** IRT based scores

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Domain scores of WHODAS of 4 severity levels of old system for people with disabilities * (n=197) (2010 Taiwan ICF trial)

Level 1(n=51) Level 2(n=56) Level 3(n=60) Level 4(n=30) p-value

D1 35.3±24.7 45.8±28.2 67.9±27.5 73.8±30.3 < 0.001

D2 14.0±20.1 27.2±32.3 56.3±31.7 71.3±36.1 < 0.001

D3 6.9±17.7 30.1±36.4 55.6±42.9 73.3±38.8 < 0.001

D4 29.4±28.6 42.4±34.7 62.5±32.7 71.7±35.2 < 0.001

D5 22.2±30.1 39.0±34.1 62.8±37.1 72.8±37.8 < 0.001

D6 30.4±29.6 38.4±35.2 67.2±34.0 75.0±37.1 < 0.001

* The level of disability is administered by the disability registration system, Department of Social Affairs, Ministry of the Interior in Taiwan

(Yen, Liou, 2011, unpublished data)

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Significant differences of WHODAS scores among 4 severity levels

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Functional assessment for eligibility determination for adults (≧18 yrs) in 2011 trial

• Performance part, 6 domains Designed based on WHODAS 2.0 Modify the 36-item version (interviewer

administered and proxy-administered) according to the culture and language of Taiwan

• Additional parts, designed by the team Capacity part of 6 domains by interview Domain e (environment) by interview Domain d4 (capacities by direct testing and

performance by interview)

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Assessment content (d, e) design in 2011 • Five revisions of adults-version (April to Sept.) 14 expert meetings Based on WHO DAS II Suggestion by medical staffs and specialists in the

training courses Start to collect data in this Oct

• First draft of children-version Translated and revised from Child and Family

Follow-up Survey (CFFS) (Bedell, 2004) for eligibility determination use since July. 3 expert meetings Start training course in Oct. 2011 17

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Training courses for testers for data collection

• 25 training courses (21 for adults-form and 4 for children-form) , more than1500 professionals trained, from June to Oct. 2011

• 13000 persons with disabilities randomly stratified and selected in Taiwan will receive assessments

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Summary • Time pressure in preparation

• Purposes of the ICF research team To examine the clinical feasibility and to choose

appropriate cut-off points If the measure can clearly describe the characteristics and

needs of people with disabilities • Pilot testing in 2010

Four sites, totally 500 subjects with variety of disabilities

• Pilot study in 2011 Whole country, totally 13000 subjects with variety of disabilities

• The government system, nongovernment organization and academic society worked as a team

• Several unresolved issues Cutoff point for severity of disability

b/s categories are set as gatekeepers The distribution of resources

Balance between needs and limited budget 19

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Conclusions • The concept of ICF/ICF-CY has widespread in

Taiwan in recent years; including policy design, clinical practice, research and education.

• For the successful implementation of the policy, carefully designed programs, based on evidence; trainings of personnel as well as education for the public to facilitate the understanding of ICF/ICF-CY should be prepared in advance.

• Promotion of international communication and cooperation are needed to speed the usage of ICF/ICF-CY as a common language.

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Acknowledgements • This study is supported by the Department of

Health, Taiwan (No. 98M8178, 99M4080, and 99M4073).

• We also thank all the advisors who participated in the meetings. Taiwan ICF Team leaders include Yen-Nan Chiu, Tien-Chen Liu, Lu Lu, Shyh-Dye Lee, Fu-Sung Lo, Tai-Lung Cha, Yen-Ho Wang, Ben-Sheng Chang, Shu-Jen Lu, Ting-Fang Wu, Ti-Li Kao, Kuo-Lung Lee, Min-Huei Lin, Leang-Yang Lai, Man-Yen Chiu, Kuo-Yu Wang, Wan-I Lin, Lin-Ju Kan, Wei-Chang Chen, Shu-Jen Lun, etc…

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Thanks for your

attention! Members of the d4 group in 2010

ICF experts in the world meet Taiwan ICF team 22

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Thanks for your

attention!

ICF Training programs in

Taiwan

2009

2010

2011 23