Collaborative goal setting for patients with heart failure based on the ICF to support integrated care
Authors: Pfeifer Bernhard , Costa Ursula , Krestan Susanne , Hartmann Victoria , Huber Andreas , Neururer Sabrina 
Published: January 2024

Heart failure (HF), a noncommunicable disease (NCD), is one of the main reasons for hospitalization of older patient groups. The prevalence in adults is estimated to be 1-2% and is described to be increasing in the older population (11,8%). The participatory involvement of clients and relevant professionals in the goal setting process, has shown positive effects related to clients’ adherence and volition and is perceived being key for health-related outcomes.
A regional telehealth care program for people with HF in Tyrol, Austria aims to ensure, evaluate, and further develop quality of integrated care, interprofessional cooperation and supporting participatory goal setting and, thus, patient adherence. Therefore, an IT-supported ICF-documentation system, based on a regionally developed core set of the International Classification of Functioning, Disability and Health (ICF) was envisioned for persons with HF.
ICF offers a framework for the collaboration of health professionals to coordinate their expertise in person-centred, context-sensitive, participation-oriented health care provision. It enables users to structure their diagnostic reasoning along the ICF-domains and categories and to create a multiprofessional tuning along the intervention process, considering relevant aspects of body structures, body functions, activity, participation and personal as well as environmental context factors.
The implementation process of this IT-based documentation system, using the ICF as a reference model expresses and is intended to facilitate a biopsychosocial understanding of health, functioning and disability within the interprofessional team of cardiologists, specialised nurses, psychologists, training specialists, occupational therapists, and social workers.
It further aims to supports a common language and understanding on health within the interdisciplinary team along the corresponding health care settings. Collaborative assessment, goal setting, intervention as well as documentation and evaluation enables the multiprofessional health care team in its interprofessional efforts.
Current practice, experiences and reflections relevant to goal setting and intervention planning, integrating any profession-specific perspectives of this regional expert cardio-rehabilitation team were gathered in individual and group expert discussions, thematically analysed and synthesised.
An ICF core-set for HF has been developed through a systematic, iterative process for regional use and further development.
Throughout the joint project of a regional governmental health care provider and two local universities, an interprofessional team of cardiologists, specialised nurses, occupational therapists, psychologists, sport scientists, physiotherapists, and IT- specialists has contributed to these developments up to the current date.
The ICF has great potential in facilitating collaborative goal setting, offers a frame for a common understanding expressed through person-centered and context-sensitive, participation-oriented language, reasoning, intervention, and evaluation, and thus supports integrated care.
The successful introduction of a common language and an intervention-focus explicitly including not only body functions and activities, but also personal and environmental context factors being key for participation and health condition-related outcomes may have positive effects on quality of care as well as the development of sustainable interprofessional team efforts.
Further development and research by using a shared IT-platform, built on the identified ICF-core set for HF is planned.