The implementation of the International Classification of Functioning, Disability and Health in Germany: experiences and problems.

The bio-psycho-social model of the International Classification of Functioning, Disability and Health (ICF) has already found wide acceptance in Germany. In particular, the introduction of contextual factors (environmental factors and personal factors) is welcomed. Several rehabilitation facilities have used the model and the chapters of the revision version (Beta-2) as guidelines for documenting their interviews with rehabilitation patients. Their experiences are encouraging. However, it has already been recognized that coding with the ICF will be difficult and time consuming. Thus, the practicability of the ICF should be improved. Training in the use of the ICF is absolutely essential. It is welcomed that the ICF provides a common vocabulary for both people with disability and for professionals in the fields of rehabilitation and disability. This is particularly important in Germany because we have a rather complicated social system. In contrast to the International Classification of Impairments, Disabilities and Handicaps (ICIDH), the ICF, in general, contains neutral terms only. Many of our physicians in rehabilitation complain about that. Obviously they also need to be able to express the signs and symptoms of restrictions of functioning in negative terms and in this respect they feel that the ICIDH was more helpful. While both the concept of activities and the concept of participation are clearly understood from the point of view of content some of us have severe problems with the operationalization of both concepts via qualifiers. From a theoretical perspective we regret that the concept of activity is not theory driven and that the concept of participation is not operationalized independently from the concept of activity. A proposal for solving these problems is given. In Germany, the ICIDH, or the ICF latterly, has been taken into account in the following areas. The new German Social Code Number IX (SGB IX) from 2001, Rehabilitation and participation of people with disabilities, is based on the ICF. All guidelines and general recommendations within the context of rehabilitation have been adjusted to the ICF. The ICF plays an important role in the training for the medical field of physical medicine and rehabilitation and is also included in the training curricula of the medical specializations of social medicine and rehabilitation. The German research programme "Rehabilitation sciences" includes some projects dealing with the ICF. The model of consequences of diseases (ICIDH) has been part of the rehabilitation quality insurance programme of the German Pension Insurance since 1994. Since 1 April 2004, the institutes of the German Health Insurance have applied the ICF to their rehabilitation application form.