Rehabilitation Frameworks

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Introduction

Rehabilitation is a goal-oriented process that enables individuals with Impairments, Activity Limitations and Participation Restrictions to identify and reach their optimal physical, mental and social functional level through a patient-focused partnership with family, rehabilitation providers and the community. Rehabilitation focuses on optimising function and aims to facilitate independence and social integration, and includes prevention of injury/illness recurrence and/or secondary conditions.

Rehabilitation Frameworks provide guidance to support clinicians, managers and planners to improve access to quality, sustainable rehabilitation services and outline the key elements foundational to rehabilitation services and promote a shared understanding of rehabilitation through provision of a common language and definitions for concepts relevant to rehabilitation and serves as a guide for planning, managing and delivering consistent and preferred rehabilitation approaches to meet patient, client and community needs. There are a range of different frameworks that underpin rehabilitation services within different contexts including Competency Frameworks, Standards of Practice and Models of Care.

The International Classification of Functioning, Disability and Health (ICF) Model produced by the World Health Organization (2001) is foundational to most rehabilitation frameworks, taking a biopsychosocial approach to health that is patient-centered and recognises the many factors that influence health. The model encourages rehabilitation providers to look at how health conditions interact with contextual factors (both internal and external to the individual) to impact the individual’s daily activities and their participation in society. Adopting this model will assist rehabilitation providers, researchers and administrators to shift practice to focus more on function and will give guideposts for planning and evaluating rehabilitation service

Rehabilitation in Health Framework

The Rehabilitation in Health Framework informs the Systematic Assessment of Rehabilitation Situation guidance by providing a common structure and organization of rehabilitation within health care. Across countries there is significant variation in the configuration of rehabilitation. This framework highlights common types of rehabilitation and suggests an optimal mix of rehabilitation in a country. It integrates rehabilitation into the pyramidal structure commonly used to illustrate the organization of tertiary, secondary and primary health care and places community-delivered rehabilitation under this. The framework highlights the different types of rehabilitation and the settings where it commonly occurs. The types of rehabilitation are: specialized (dedicated), high-intensity rehabilitation that is commonly delivered through longer-stay facilities; rehabilitation that is highly integrated across a wide range of medical specialties in tertiary and secondary health care; rehabilitation integrated into primary health care; community-delivered rehabilitation that may be dedicated or integrated into a range of community-delivered health programmes and the informal and self-directed care that occurs in community settings. Figure 5 illustrates this framework, while Annex 2 includes more detailed definitions for each level within it.

Competency Frameworks

Competency frameworks can serve a range of purposes. Historically, they emerged with two distinct aims: to support the development of capabilities (generally the primary concern of the education sector), and to help define standards of performance (generally the primary concern of the labour sector). Currently, many competency frameworks aim to achieve a hybrid of both, yet each requires specific characteristics.

Competency frameworks, which comprise organized statements that communicate the expected or aspired performance of a particular workforce, can be valuable resources in addressing workforce challenges in many settings. These challenges generally relate to a shortfall of workers, deficiencies in quality of care, and a mismatch between workforce capabilities and population needs. Competency frameworks can help address these challenges at the individual, institutional, service and system level. Rehabilitation Competency Frameworks define the core values and beliefs shared by the rehabilitation workforce, and encompasses the competencies, behaviours, knowledge and skills required to perform the range of activities and tasks involved in rehabilitation practice and service delivery.

• Regulatory or accreditation bodies use competency frameworks to communicate the standards expected of a profession. When applied to pre-and post-service education and enforced through audits and other mechanisms, they form a integral component of quality assurance.

• Education institutions use competency frameworks for articulating the outcomes of their courses. They can be used to shape the learning outcomes of courses, and to ensure that the knowledge and skills taught by the institution are aligned with population needs.
• Services use competency frameworks in workforce planning and human resource management. In the context of planning, they enable services to successfully align their staff competencies and activities with population needs and service objectives and help to identify knowledge and skill gaps and performance deficiencies. In the context of human resource management, competency frameworks define performance excellence and provide a benchmark against which workers are assessed. They are also integral to establishing individual and service-wide development priorities.
• Ministries of health can apply competency frameworks in workforce evaluation and planning, such as in conduct competency gap analyses.

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WHO Rehabilitation Competency Frameworks

The Rehabilitation Competency Framework is a model that communicates the expected or aspired performance of the rehabilitation workforce across different countries and settings to enable quality care and service delivery.

The Rehabilitation Competency Framework comprises of five domains centered around core values and beliefs which sit at the heart of the framework. This core help shape the behavior of a rehab worker and their performance of tasks across all the RCF domains.

The four core values are;

1. Compassion and empathy
2. Sensitivity & respect for diversity
3. Dignity & human rights
4. Self-determination.

The four core beliefs are that rehab should be;

1. Person centred,
2. Collaborative,
3. Available to anyone who needs it and
4. Functioning is central to health.

The Five Domains are:

1. Practice
2. Professionalism
3. Learning and Development
4. Management and Leadership
5. Research

The domains collectively capture how the rehabilitation workforce behave in order to perform effectively (competencies), and what they do (activities). Competencies are broken down into behaviours; and activities into tasks. Each is described across four levels of proficiency. Each domain also describes the knowledge and skills that underpin the activities and competencies. These include core knowledge and skills, as well as those that are specific to an activity. The components of the RCF along with the competencies, activities and tasks are explored in detail within the framework document.

International Standards of Practice

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Models of Care

A “Model of Care” broadly defines the way health services are delivered. It outlines best practice care and services for a person, population group or patient cohort as they progress through the stages of a condition, injury or event. It aims to ensure people get the right care, at the right time, by the right team and in the right place. Models of Care often have their origins in care management for chronic conditions. These models share many components because they seek to address the multiple determinants of health that are common across conditions. The Chronic Care Model, is an organizational approach to caring for people with chronic disease in a primary care setting, provides an excellent framework to understand the rationale for the common components across models of care. The system is population-based and creates practical, supportive, evidence-based interactions between an informed, activated patient and a prepared, proactive practice team.

Integrated care Pathways

An integrated care pathway (ICP) is an interdisciplinary outline of anticipated care, placed in an appropriate timeframe, to help a patient with a specific condition or set of symptoms move progressively through a clinical experience to positive outcomes. While variations from the pathway may occur as clinical freedom is exercised to meet the needs of the individual patient, ICP’s can help to reduce unnecessary variations in patient care and outcomes. They support the development of care partnerships and empower patients and their carers. ICPs can also be used as a tool to incorporate local and national guidelines into everyday practice, manage clinical risk and meet the requirements of clinical governance8. The ICP for patients with spinal cord injuries span numerous service delivery sites, beginning at the time of initial presentation through to long term management in an appropriate setting. The ICP will include reference to the breadth of the patient journey and address issues that include Pre-hospital care, Reception & Intervention, Reconstruction & ongoing care (including acute rehabilitation), Post-Acute Rehabilitation and Life-long care.

ICPs are important because they help to reduce unnecessary variations in patient care and outcomes. They support the development of care partnerships and empower patients and their carers. ICPs can also be used as a tool to incorporate local and national guidelines into everyday practice, manage clinical risk, and meet the requirements of clinical governance.

When designing and introducing ICPs, it is important to incorporate them into organizational strategies, and choose appropriate topics that provide opportunities for improvement.

The ICP should be able to address the following issues;

• Who does what?
• Where was it done?
• When is it done?
• How much does it cost?
• Why was it not done?
• What was the valued outcome?

Resources

• Mills JA, Middleton JW, Schafer A, Fitzpatrick S, Short S, Cieza A. Proposing a re-conceptualisation of competency framework terminology for health: a scoping review. Human Resources for Health. 2020 Dec;18(1):1-6.
• Le Deist FD, Winterton J. What is competence?. Human resource development international. 2005 Mar 1;8(1):27-46.
• Bruno A, Bates I, Brock T, Anders on C. Towards a global competency framework. American Journal of Pharmaceutical Education. 2010 Apr 12;74(3).
• World Health Organization. Global strategy on human resources for health: workforce 2030.