基于ICF构建综合性职业康复服务流程：理论架构与方法

doi:10.3969/j.issn.1006-9771.2024.12.003

摘要/Abstract

摘要：

目的本研究基于《国际功能、残疾和健康分类》(ICF)架构和工具，通过建立一个系统化、标准化的职业康复服务体系，对职业康复服务进行流程再造，以实现职业康复与其他康复服务的融合发展，提升残疾人的整体康复效果和生活质量。通过建立一个系统化、标准化的职业康复服务体系，提供功能导向的全人整体康复服务。

方法基于ICF架构和工具，对职业康复流程进行系统分析；在此基础上，根据功能特点并且系统应用基于ICF的工具，建构了职业康复流程，包括功能评估与康复目标确定、康复方案制定、多学科干预的实施、结局评估和生活质量评估，以及长期跟踪和支持。

结果基于ICF架构和运用ICF的工具，根据残疾人职业康复机构的特点和工作性质，构建了五步骤的职业康复流程，详细定义了各流程的主要活动内容，确定了运用的ICF工具以及运用方法。职业康复流程再造能够显著提升多学科综合康复的效率和质量。ICF架构和工具是多学科团队之间的沟通和协作的理论基础和平台，根据不同的职业康复流程，规范性运用基于ICF的工具可以确保制定科学有效的康复干预方案并且实施有效的康复干预。ICF工具的使用还可以整合职业康复与其他康复服务，实现不同康复服务和不同康复机构间的协同。

结论本研究基于ICF架构对职业康复流程进行了再造，建构了基于ICF的职业康复流程，包括以下5个关键流程：功能评估与康复目标确定、制定个性化整体康复方案、多学科团队实施综合干预策略、结局评估与生活质量评估以及长期跟踪与支持服务。运用ICF架构与工具，再造康复机构的职业康复服务流程，构建了整合的康复服务体系，提供功能导向的综合康复模式，残疾人能够获得全生命周期的全人康复服务。建立基于ICF的通用语言和工具，可以有效地提高各专业人员之间的沟通和协作，同时也为跨机构的服务整合提供了标准化工具，有助于实现不同康复机构之间的顺畅协作和信息共享，确保残疾人在不同康复阶段和机构之间的顺利过渡，确保康复过程的连贯性和完整性。

关键词: 国际功能、残疾和健康分类, 职业康复, 整体康复, 流程再造

Abstract:

Objective To reconstruct the vocational rehabilitation service process based on the framework and tools of the International Classification of Functioning, Disability and Health (ICF), to establish a systematic and standardized vocational rehabilitation service system to achieve the integrated development of vocational rehabilitation and other rehabilitation services, and to improve the overall rehabilitation effect and quality of life of people with disabilities. By establishing a systematic and standardized vocational rehabilitation service system, it provides function-oriented, holistic rehabilitation services for the whole person.

Methods This study adopted the ICF framework and tools to conduct a systematic analysis of the vocational rehabilitation process. Based on this, according to the functional characteristics and systematic application of ICF-based tools, a vocational rehabilitation process was constructed, including functional assessment and rehabilitation goal setting, rehabilitation plan formulation, implementation of multidisciplinary intervention, outcome evaluation and quality of life assessment, and long-term follow-up and support.

Results Based on the ICF framework and the application of ICF tools, according to the characteristics and nature of work of vocational rehabilitation institutions for persons with disabilities, a five-step vocational rehabilitation process was constructed. The main activity content of each process was defined in detail, and the ICF tools used and the methods of application were determined. The reengineering of the vocational rehabilitation process significantly improved the efficiency and quality of multidisciplinary comprehensive rehabilitation. The ICF framework and tools were the conceptual framework and platform for communication and collaboration among multidisciplinary teams. According to different vocational rehabilitation processes, the normative application of ICF-based tools ensured the development and implementation of scientific and effective rehabilitation intervention programs. The use of ICF-based tools also integrated vocational rehabilitation with other rehabilitation services, and achieved synergy among different rehabilitation services and different rehabilitation institutions.

Conclusion This study reengineered the vocational rehabilitation process based on the ICF framework, and constructed an ICF-based vocational rehabilitation process including the following five key processes, namely functional assessment and rehabilitation goal setting, formulating personalized and holistic rehabilitation plan, multidisciplinary team implementing comprehensive intervention strategies, evaluations of outcome and quality of life, and long-term follow-up and support services. Using the ICF framework and tools, the vocational rehabilitation service process of rehabilitation institutions has been reengineered, and an integrated rehabilitation service system has been constructed to provide a function-oriented comprehensive rehabilitation model, so that people with disabilities could receive whole-person rehabilitation services throughout their life cycle. Establishing a common language and tools based on ICF can effectively improve communication and collaboration among professionals, and also provide standardized tools for cross-institutional service integration, which is conducive to achieve smooth collaboration and information sharing among different rehabilitation institutions, ensuring the smooth transition of people with disabilities between different rehabilitation stages and institutions, and ensuring the coherence and integrity of the rehabilitation process.

Key words: International Classification of Functioning, Disability and Health, vocational rehabilitation, holistic rehabilitation, process reengineering

中图分类号:

R492

胡志活, 吴孟杰, 陈芷莹, 杨亚茹. 基于ICF构建综合性职业康复服务流程：理论架构与方法[J]. 《中国康复理论与实践》, 2024, 30(12): 1383-1390.

WOO Chi Wood, NG Mang Kit, CHAN Tsz Ying, YANG Yaru. Reconstruction of comprehensive vocational rehabilitation service process based on ICF: conceptual framework and approaches[J]. Chinese Journal of Rehabilitation Theory and Practice, 2024, 30(12): 1383-1390.

图/表 1

表1

基于ICF的职业康复流程再造"

步骤	活动内容	参与人员	基于ICF的工具	应用意义
功能评估与康复目标确定	对残疾人的身体、心理和社会功能进行全面评估，重点关注与就业相关的功能及职业康复需求，并与残疾人及其家属共同制定个性化康复目标。评估内容包括体能、认知功能、情绪管理、沟通能力及环境因素等。通过详细的评估，康复团队能够全面了解个案在各方面的健康和功能状况，进而明确残疾人的具体需求，并为制定个性化的康复目标提供科学依据	物理治疗师、职业治疗师、心理治疗师、社会工作者，与残疾人及其家属共同参与	ICF分类档案、SMART目标设定框架	建立残疾人功能基线，明确健康状态和功能需求，确保康复目标具体、可行、相关，并反映个体需求，同时为后续康复阶段提供科学基础和方向。通过与家属的沟通，确保康复计划获得充分理解和支持，从而提高残疾人及其家属对康复过程的参与度和依从性
康复方案制定	基于评估结果，制定多学科综合康复计划，明确干预的时间安排和具体的干预目标，涵盖物理康复、职业技能培训、心理支持和环境适应。各专业人员共同制定干预目标，并明确各自的职责和实施步骤。康复方案需要根据个案的具体需求进行定制，确保每一个康复阶段的干预内容都是科学有效的，并且能够最大程度地帮助残疾人实现康复目标	物理治疗师、职业治疗师、心理治疗师、社会工作者等	ICF干预表	设计有针对性的干预方案，明确干预频率和内容，以保障干预措施的系统性与综合性，确保所有干预步骤科学有效，最大限度提高康复成效，同时提供个性化的支持，使残疾人能够重建职业和社会功能。通过多学科合作，各专业人员可以互相协作，共同应对复杂的康复需求，保证康复的全面性和深度
多学科康复干预的实施	由多学科团队实施康复干预，各专业人员根据既定康复目标制定具体的干预方案，确定康复时间节点、主要的干预方法及每阶段任务分配，团队通过定期会议进行进度评估与沟通。康复干预的实施过程注重动态管理和灵活调整，根据个案的康复进展对干预计划进行适时修改，以确保最佳康复效果	物理治疗师、职业治疗师、心理治疗师、社会工作者等	ICF干预表	提供全方位的康复支持，确保干预的专业性和多维度协作，团队成员之间通过有效沟通与协作，确保干预计划的执行进度与质量，增加康复的透明度和患者参与度，实现干预方案动态调整和优化。通过定期会议和进度汇报，团队可以共同审视个案的康复进展，调整各自的干预策略，以确保康复目标的逐步达成，并根据需要提供个性化的支持
结局评估与生活质量评估	在康复干预结束后，对职业康复结局及生活质量进行系统评估，内容包括职业能力、社会参与、心理健康及整体生活质量的变化。通过对比初期评估和康复后的结果，确定康复目标是否达成，并提出进一步改进建议。评估过程注重残疾人在多方面的进展，并且特别关注他们的职业独立性和社会融入程度	康复团队、多学科评估专家	ICF功能评估表	全面评估康复的有效性，通过系统化和标准化的评估方法验证康复措施的成效，明确康复过程中存在的不足之处并提出改进措施，确保残疾人职业独立性和生活质量的最大提升，为未来康复方案的调整提供数据支持。结局评估的结果不仅反映康复效果，还为后续的长期支持和跟踪提供了依据，确保个案能够在康复后继续获得必要的支持和资源
长期跟踪与持续支持	对残疾人的康复效果进行长期跟踪，提供必要的职业指导、心理支持以及社区资源协助，确保康复效果的持久性和稳定性，帮助残疾人持续适应工作和社会生活。康复团队定期与个案联系，评估康复目标的长期达成情况，并根据需要调整支持内容。长期支持的内容包括定期心理辅导、职业适应性培训以及与社区服务的对接，确保个案能够获得持续的支持	社会工作者、职业指导师、社区支持人员	个案管理工具与长期跟踪表	确保康复效果的长期保持，帮助残疾人持续融入社会和劳动力市场，获得持久的职业独立性和生活质量，提供长期支持和监控，保证个案的康复效果得到最大限度保持，并持续优化其生活质量和社会适应性。通过持续的跟踪，团队能够及时发现个案在康复后的问题，并提供相应的解决方案，确保残疾人始终得到足够的支持和帮助，以应对生活中的挑战

表1

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