Purpose: This study describes a case formulation approach applying a prospective ICF derived clinical tool to assess rehabilitation needs for a community dwelling stroke survivor with care from an outpatient rehabilitation medicine clinic.
Method: Case history data on the person were assessed for rehabilitation management planning using a prospective tool to interlink current with projected future functional status in everyday settings. Implicit assessment with reflective action informed decision points at each stage of the rehabilitation process.
Results: As a result of reflective action using the prospective tool, rehabilitation management led to significant changes in client participation after limitations to mobility and self care were mapped to the living conditions of the stroke survivor. The context sensitive rehabilitative plan resulted in higher subjective health-related quality of life in the stroke survivor and significant other and enhanced their capacity for participation.
Conclusions: Reflective action informed assessment applying ICF concepts to clinical problem solving resulted in positive gains in health-related quality of life in a stroke survivor.