[Relevance of personal contextual factors of the ICF for use in practical social medicine and rehabilitation]

Personal contextual factors play an essential part in the model of the International Classification of Functioning, Disability and Health (ICF). The WHO has not yet classified personal factors for global use although they impact on the functioning of persons positively or negatively. In 2010, the ICF working group of the German Society of Social Medicine and Prevention (DGSMP) presented a proposal for the classification of personal factors into 72 categories previously arranged in 6 chapters. Now a positioning paper has been added in order to stimulate a discussion about the fourth component of the ICF, to contribute towards a broader and common understanding about the nature of personal factors and to incite a dialogue among all those involved in health care as well as those people with or with-out health problems in order to gain a comprehensive perspective about a person's condition.

[Shaping the future of vocational rehabilitation of adults: eight fields of action as starting points for a cross-actor innovation process]

Established by the Federal Ministry of Labour and Social Affairs (BMAS) in October 2007, the Scientific Expert Group RehaFutur had been commissioned to elaborate cornerstones for the medium- and long-term development of vocational rehabilitation of adults with disabilities (re-integration). Initial questions inter alia were as follows: Which function should vocational rehabilitation have in a service- and knowledge-oriented working world that will increasingly be affected by demographic change? How can disabled persons' right to occupational participation by way of vocational rehabilitation, a right stipulated both under the German constitution and in German law, be realized as needed also in the future? Various fields of action have been derived on the basis, for one, of an investigation of the factors, social law, social and education policy as well as European, influencing vocational rehabilitation and, for the other, of an evaluation of current labour market and demographic developments. Dealt with in the fields of action outlined are the aspects: equitable opportunities of access, developmental and needs orientation, closeness to the real occupational and working world, as well as the role of self-determination and self-responsibility. The fields of action are to be understood as framework concept for shaping a cross-actor innovation process. Sustainable vocational rehabilitation is characterized in particular by the fact that it is specifically targeted at promoting disabled persons' self-determination and self-responsibility actively using these in the process and that it strengthens an independent lifestyle, ensures social participation by inclusive structures; also, it facilitates continued participation in working life by ongoing education involving holistic development of professional and personal competencies oriented towards the individual's resources and potentials, safeguarding it by systematic networking with companies. The concept presented for vocational rehabilitation of adults with disabilities encompasses a change of paradigms which service carriers and providers will have to face jointly and including the service users, the rehabilitants.

[Standard of integration management at company level and its auditing]

SITUATION

Responsibility at company level for the employment of workers with health-related problems or disabilities has increased, inter alia because of integration management at company level according to section 84 (2) of the German Social Code Book IX. Although several recommendations exist, no standard is available for auditing and certification. Such a standard could be a basis for granting premiums according to section 84 (3) of Book IX of the German Social Code. AUDIT AND CERTIFICATION: One product of the international "disability management" movement is the "Consensus Based Disability Management Audit" (CBDMA). The Audit is a systematic and independent measurement of the effectiveness of integration management at company level. CBDMA goals are to give evidence of the quality of the integration management implemented, to identify opportunities for improvement and recommend appropriate corrective and preventive action. In May 2006, the integration management of Ford-Werke GmbH Germany with about 23 900 employees was audited and certified as the first company in Europe. STANDARD OF INTEGRATION MANAGEMENT AT COMPANY LEVEL: In dialogue with corporate practitioners, the international standard of CBDMA has been adapted, completed and verified concerning its practicability. Process orientation is the key approach, and the structure is similar to DIN EN ISO 9001:2000. Its structure is as follows: (1) management-labour responsibility (goals and objectives, program planning, management-labour review), (2) management of resources (disability manager and DM team, employees' participation, cooperation with external partners, infrastructure), (3) communication (internal and external public relations), (4) case management (identifying cases, contact, situation analysis, planning actions, implementing actions and monitoring, process and outcome evaluation), (5) analysis and improvement (analysis and program evaluation), (6) documentation (manual, records).

[Vocational rehabilitation in transition--challenges and perspectives]

The present article outlines the challenges in occupational rehabilitation arising from the successive erosion of the financial foundations of the welfare system, from changes in industry as well as in health, education and labour-market policy. Five perspectives are discussed to design and develop strategies in occupational rehabilitation. Among these are: (1) Rehabilitation in companies is mostly based on miscarried efforts to prevent separation. The discontinuance and the re-integration in a position or in a company have therefore to be regarded as an interlocking process between vocational training centre, social insurance agencies and employers; (2) Regional vocational rehabilitation centres with the objective to promote participation in work life may advance to institutionalized junctions to connect the rehabilitation landscape and would represent the logistic context; (3) The development of participation benefits should mainly be directed towards individualized allocation of resources as well as the possibility of direct transfer to work in close cooperation with employers; (4) Structural solutions and process-innovation could be supported by application-orientated research; (5) A new consensus to assign future tasks and objectives should be defined among the responsible bodies and service organisations involved in occupational rehabilitation.

Zur Problematik der Implementierung des betrieblichen Eingliederungsmanagements in kleinen und mittleren Unternehmen

At company level responsibility increases for the employment of workers with health-related problems or disabilities, but realisation in small and medium-sized enterprises (SME) is lacking. Therefore a model is developed based on theory and a survey.

SITUATION

Minimum requirements for "betriebliches Eingliederungsmanagement" (integration management at company level) according to section 84 (2) SGB IX Book 9 of the German Social Code, the main products of the international movement "disability management", a description of roles for realisation and the main sources of employers' support are described. Although external supporting of SMEs is unquestioned, it is expensive and retards own initiative and own activity counting solely on this.

HYPOTHESIS

Only by developing a minimum of SME's awareness, acceptance and competence, this will open up to (currently suboptimal) external support.

SURVEY

Goal is identifying SME managers' attitudes, activities, proposals and expectations referring integration management at company level to derive concepts of SME's support. 13 interviews are analysed by qualitative content analysis identifying the following barriers: information deficit, absence of priority, limited possibilities for transitional work, cost, partially limited workers' self-responsibility, illness as a "tabes" subject. Possibilities overcoming these barriers are delineated. On that basis a model is presented: pragmatically for realisation, a company contact person with minimum competence, uniform external support, institutional partners' integration and quality assurance according to disability management.

OUTLOOK

Interlocking SME world and social insurance world means first to support SME's awareness, acceptance and competence, second to create for SME a central contact in the "rehabilitation jungle" and third to develop SME-suitable premiums according to section 84 (3) SGB IX, Book 9 of the German social code.

[Health, social, societal and organizational political effects of the implementation of the ICF on integrated rehabilitation--a vision of the conversion and its consequences]

Fundamental joint principles on expert opinions according to the social law code no. IX (SGB IX) and their application to a virtual individual case history were published recently in this journal. They are based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). A visionary review of the chances and prospects for the further development of the rehabilitative system is outlined and the necessary steps for their implementation are demonstrated.

Trägerübergreifende Aspekte der Begutachtung nach dem SGB IX

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurance. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[Aspects of expertising which are jointly valid for German sociomedicine and statutory health care]

A project group of the Medical Advisory Board of the German Federal Rehabilitation Council (BAR) developed fundamental joint principles on experts' opinions according to the social law code no. IX (SGB IX). The principles aim at medical experts working in different social organisations and statutory health care insurances. It was intended to create a "sociomedical language" which should be used as jointly as possible by experts in rehabilitation and social medicine and which is based on the ICF (International Classification of Functioning, Disability and Health, WHO 2001). Its stringent application will increase the utility of medical expertise across different institutions. The authors recommend to evaluate whether this model could provide a tool in the communication and cooperation between different sectors of the health system. Part I describes the theoretical model, Part II its application to a virtual individual case history.

[Change in technical aids (AT)--a technology assessment from the viewpoint of rehabilitation-anthropology]

Practical experience in adjusting complex computer-assisted (CAS) communication aids has resulted in a search for prognostic criteria useful in evaluating the efficacy of technical aids. Such evaluation implies a holistic approach as is included in the ICIDH-2. These circumstances are demonstrated by examples ranging from mechanical to computer-assisted (CAS) aids. "Reciprocity" has turned out to be a valid semi-qualitative criterion in describing the dynamic equilibration of the rehabilitative issues involved. Only a dialogical situation with reciprocity will lead to sustainable participation. In case of technical aids, a conjunction of abilities and the qualitative level of activities in disabled people have to be taken into account to provide all dimensions of participation. In this holistic approach, social participation and balance will equally be respected. The differentiation of social systems with unequal consequences for people with disabilities in terms of environmental factors, or e-code of the ICIDH-2, have to be considered for prognostic evaluation with regard to efficacy and possible participation. A comprehensive psycho-socio-functional rating therefore has to include a comparative (socio-structural or morphological) analysis of the environment at hand. This approach will invariably show that technical aids alone are unable to ensure individual independence but, rather, may lead to isolation if there is no regional or local networking based on partnership and close interpersonal relations to be drawn on "technically".

[Value of the Susan Isernhangen Evaluation of Functional Capacity Scale in medical and occupational rehabilitation]

In Germany, Susan Isernhagen's Functional Capacity Evaluation (FCE) system has increasingly come into use over the last few years at the interface between medical and vocational rehabilitation. With implementation of these work-related tests of functional capacity it is possible to obtain valid statements concerning the further vocational prognosis. Along with evaluative testing by experts from different disciplines, the further steps towards integration occur on a well-founded basis. Therapies may thus be adjusted to the requirements of work, either at the former workplace or a new one, or possibly of a vocational (re-)training measure. Also, it is possible to directly deal with work-related issues in the report given at the end of rehabilitation, to initiate preliminary integrative steps in order to achieve a seamless, job retention-focussed transition back into work life. Work is simulated at different levels of loading capacity, the functional deficits of the rehabilitees are addressed in a specific, job-related manner, so as to enable an early return to work after rehabilitation.

[Value of the ERGOS work simulator as a component of functional capacity assessment in disability evaluation]

The use of assessment instruments in evaluating functional capacity is an important element in the process of social-medical judgement of whether a person will likely be able to reintegrate into working life. Standardized work processes are used in simulating occupational reality over several hours, with all the requirements involved, and the performance found is contrasted with the requirements to be expected at a workplace. Time-tested in the U.S. for more than 20 years and applied throughout Germany for some two years now, the ERGOS work simulation system is presented in the article, using a case example for more detailed description. Using five different work stations, performance data are collected for job tasks such as carrying, working in kneeling position or overhead, and subjected to computer-based comparison with the job requirements information contained in relevant databases. This enables computerized identification of excessive demands, and hence may point to a need for further rehabilitative action. An important feature is objective assessment, as subjective information on the basis of observation or reports of painfulness are raised separately, hence do not influence the findings of the work simulation performed.

[Profile comparison systems and performance diagnostic, electronic data processing-supported technology--their use in improving responses to social medicine questions and expert assessments and planning of rehabilitation measures]

Systems for comparing ability and requirement profiles as well as instruments for evaluating functional capacity are current topics in rehabilitation. Only few of them however are related to vocational rehab. This article describes the present state of affairs in the development in procedures, instruments and methods to measure work-related human functional capacity with the aim of vocational rehabilitation and integration, helping to obtain objective results to decide about further steps. They are an addition to sociomedical advice in assessment and vocational centres, and serve to expand the common basis of the WHO International Classification of impairments, disabilities and handicaps (ICIDH). The purpose is intervention. Abilities are contrasted with requirements, as the basis for defining a need for intervention and realizing appropriate action. This is the thinking integrated in the German profiling assessment and documentation system IMBA--Integration von Menschen mit Behinderungen in die Arbeitswelt (Integration of people with disabilities into worklife). Diagnostic, computer based technology and work simulation and measurement to evaluate functional capacity as developed and used in the U.S. is complementary to IMBA. Work simulation is based on databases, such as the D.O.T., and includes standardized work requirement profiles. Such systems have been imported from the United States of America to Switzerland and the Netherlands and now to Germany. There are numerous connections with German assessment systems, and the fundamentals of ICIDH are included. Common application in the field of rehabilitation is dealt with, also in view of pensioning issues. The need for user training and quality management are reported in this article as well.

[Assessment methods for vocational integration of disabled persons--from ERTOMIS methods to the IMBA information system]

The background for the development of actual assessments for evaluation of vocational integration of disabled people (i.e., EAM, IMBA) in Germany is described. Resulting perspectives for future procedural approaches are presented. So far, the EAM, Ertomis Assessment Method, approach has gained limited acceptance only. In light of WHO and European impulses, as well as the economic constraints at hand, it remains to be seen whether the IMBA information system will turn out a practical and problem-focussed tool. A critical review is done to provide constructive suggestions for further applications of IMBA.

[Assessment of capacity and job requirements at the interface between medical and occupational rehabilitation]

The article deals with the development, nationally and internationally, of assessment systems permitting parallel appraisal of an individual's abilities and the requirements presented by the working conditions at hand. By comparison of abilities and requirements, these assessments are aimed at concretizing individual need for intervention as well as prompt practical implementation in view of occupational placement of people with disabilities. The course of development is of special interest in this context as the description of abilities starts out from the basic concepts of the ICIDH while description of the working conditions is based on ergonomic concepts. Uniting these different developments in an integrated system for assessing abilities and requirements, has been achieved by ERTOMIS Foundation, with effective support on the part of K.-A. Jochheim, through an empirically-practically oriented approach, whereas a corresponding multidisciplinary research project funded by the Federal Ministry of Labour, in light of its scientific-theoretical background gave preference to a hierarchical-modular structural concept. At a European level as well, both the European Council (partial agreement) and the European Union Helios II working groups have exclusively acknowledged assessment systems of this kind as providing an important bridge between the field of rehabilitation and the world of work.

[References for evaluation instruments in quality assurance in rehabilitation--3. The EAM profile system--capacity and requirement profile as a decision aid in the tension field between (medical) rehabilitation and vocational integration]

The EAM profile system is characterized by enabling comparison of a subject's abilities with the requirements present on the job. The article initially outlines the structure of the necessary abilities and/or requirements profiles, describes the assessment criteria used, and concludes by presenting a case example, showing that the question of individual employability and placement can be answered by acting upon profile comparison findings.

[Occupational health care as a basis of occupational medicine monitoring in small companies. Common occupational medicine/ergonomic approach to prevention]

Set out from various specific angles, the concept concerning a modern common industrial medicine/safety/ergonomics approach can be fitted into the present legal framework. Adapted according to specific needs, this approach can equally be applied in all areas--health promotion, prevention, cure, rehabilitation. Those involved in the current debate about industrial health policies start out from the premise that industrial medicine could contribute strongly in this respect. While the workmen's compensation scheme, together with the industrial medical profession, is to a considerable extent involved in the subject as a whole on the basis of the industrial safety Act, its competencies are however limited, being in actual fact confined to the field of health maintenance in the occupational context. The examinations they effect in this framework cannot be based on a holistic medical orientation, because our constitution has expressly excluded the private sphere of the individual (self-management domain). Hence, there are very little chances of success for any attempt of changing current health care practice solely via the workmen's compensation administrations. It currently is, rather, the health and pension insurance schemes who hold the potential for influence. The common approach of industrial medicine, safety and ergonomics outlined may be of considerable use also in view of their goals, and holds sufficient justification for their intervening favourably in the ongoing debate about quality and quantity of industrial medical service provision with the ministries in charge.

[Occupational medical counseling in rehabilitation]

The present contribution seeks to outline the counselling possibilities on the part of the industrial medical service. Starting out from the legal bases (the Act concerning safety at work), the scope for action available internally and externally is examined. Towards the background of the assertion (which is in agreement with numerous other authors) that rehabilitation invariably means teamwork, the author seeks to describe the internally competent authorities and departments in terms of internal team, and to contrast it with the external team involved. A number of opportunities for cooperation are outlined, and already implemented practical approaches are pointed out. The company services are viewed in a community based rehabilitation context, and the relationships with the financially responsible administrations and their facilities in respect of vocational and medical rehabilitation are set out. Systematic in-plant procedures are explained by a conceptual model, practical implementations (for ex. in the EAM system) are touched on.

[The ERTOMIS Assessment Method EAM system--an aid in the rehabilitation of handicapped patients at work]

ERTOMIS Foundation, prompted by the WHO publication in 1980 of the International Classification of Impairments, Disabilities, and Handicaps (ICIDH), has developed an assessment system for vocational integration and placement of disabled persons. This EAM System is based on the comparison of requirements and abilities profiles, both comprised of 65 identically worded criteria for describing elemental functions. A pilot study was carried out by Forschungsgemeinschaft Arbeitsmedizinisches Zentrum Siegerland/ERTOMIS Stiftung, of Siegen, verifying the EAM system's effectiveness and reliability on two groups of industrial medical clients, i.e. "routine cases" (severely disabled workers) and "problem cases" (workers with performance alterations). Study findings show that the presence of overstrain can be reliably proven and necessary action be reliably inferred by means of the EAM system. This permits workers to be retained while safeguarding their continued good health. The system moreover shows where remedial action has to be taken from a preventive point of view. On account of its use of elemental criteria, the system can be applied across trades and occupations, and is neither restricted to a specific branch of the social protection system.

[Industrial medicine counseling in rehabilitation]

The present contribution seeks to outline the counselling possibilities on the part of the company medical service. Starting out from the legal bases (the Act concerning safety at work), the scope for action available internally and externally is examined. Towards the background of the assertion (which is in agreement with numerous other authors) that rehabilitation invariably means teamwork, the author seeks to describe the internally competent authorities and departments in terms of internal team, and to contrast it with the external team involved. A number of opportunities for cooperation are outlined, and already implemented practical approaches are pointed out. The company services are viewed in a community-based rehabilitation context, and the relationships with the financially responsible administrations and their facilities in respect of vocational and medical rehabilitation are set out. Systematic in-plant procedures are explained by a conceptual model, practical implementations (for ex. in the EAM system) are touched on.