HEArT v ICF

ICF helps you understand functioning in context. HEArT helps you understand what may be getting in the way of action.

The International Classification of Functioning, Disability and Health—the ICF—is the World Health Organization's framework for describing health and disability in the context of a person's actual life.

If you trained in physical therapy, occupational therapy, or rehabilitation medicine in the last twenty years, the thinking behind the ICF is probably familiar. It helped move rehabilitation beyond a purely biomedical question—What is wrong with the body?—toward a much broader one:

What can this person do, in this environment, and how is their health affecting participation in life?

The ICF considers body functions and structures, activities, participation, and contextual factors, including environmental and personal factors. That perspective changed how rehabilitation professionals think about goals.

Increasing shoulder flexion to 120 degrees may matter clinically.

Reaching an overhead cabinet to prepare dinner independently tells us why it matters.

That distinction is important. It connects impairment to function, function to participation, and treatment to a person's actual life.

But knowing what matters does not necessarily tell us what is getting in the way of getting there.

The ICF can help us recognize an activity limitation, participation restriction, or environmental barrier. It can help us think broadly about the personal and contextual factors surrounding a health condition.

It was not designed, however, to give clinicians a step-by-step process for evaluating what is happening within an interaction when the patient isn't moving toward the plan.

What happens when the functional goal looks excellent on paper, but the patient doesn't actually care about it?

What happens when they understand the home program but don't do it?

What happens when fear changes how they interpret your recommendation?

What happens when the environment, a previous healthcare experience, competing demands at home, or something they haven't told you yet changes what is realistically possible?

This isn't a shortcoming of the ICF. The ICF was never designed to solve that problem.

This is where HEArT offers a different lens.

Imagine the goal is:

Patient will be able to pick up their grandchild within eight weeks.

That's a beautiful rehabilitation goal. It connects physical capacity with participation in something personally meaningful.

But writing the goal doesn't create the behavior required to reach it.

The patient still has to understand how today's seemingly boring exercises connect to holding that grandchild eight weeks from now.

They have to believe the plan is realistic. They have to tell you if they're afraid to move.

The plan has to fit into their actual life.

And when something interferes with progress, you need a way to determine what is getting in the way.

That's where the five HEArT stages become useful.

Hello → Evaluate the conditions.
What has this person experienced before you even begin?

Explore → Evaluate what you know.
What information is still missing?

Align → Evaluate the priorities.
Are you actually working toward the same goal?

resistance → Evaluate the friction.
What is making forward movement difficult?

Teach → Evaluate readiness for action.
Will this plan survive outside the clinic?

There is an especially interesting connection here with the ICF's contextual factors.

Environmental factors are formally classified within the ICF. Personal factors—things such as an individual's background and characteristics—are recognized as important contextual influences but are not classified within the ICF itself because of their substantial social and cultural variation.

HEArT doesn't attempt to classify them either.

Instead, it gives clinicians a repeatable way to notice, explore, and respond to the individual and contextual factors that emerge during care.

The frameworks therefore answer different questions.

ICF asks: How is this health condition affecting this person's functioning and participation in life?

HEArT asks: What is happening in this interaction that may be helping—or getting in the way of—movement toward action?

One helps us understand the person in context.

The other helps us evaluate what is happening as we try to move forward together.

The ICF helps define what meaningful function looks like. HEArT helps us evaluate what it may take to get there.