Disability degree assessment: A comprehensive approach according to Royal Decree 888/2022

Abstract

Background and objective

Royal Decree 888/2022 establishes that the evaluation of disability situations is carried out by multiprofessional teams responsible for assessing and recognising the degree of disability. The participation of professionals in the healthcare and social fields can be valuable in providing reports from which the necessary data for the proper assessment of disability can be obtained, with the ultimate goal of providing comprehensive assistance to people with disabilities.

Materials and methods

An analysis and summary of Royal Decree 888/2022, which has recently come into effect, is performed, focusing on the most relevant aspects for professionals in the healthcare and social fields.

Results

The recognition and classification of the degree of disability are the responsibility of the autonomous communities, and the assessments are issued by multiprofessional teams. To do this, four components are evaluated using the criteria outlined in the annexes of the Royal Decree itself. Each criterion generates a score that is combined to obtain a single score, the Final Disability Degree of the Person.

Conclusions

The pathology that causes the disability must have been previously diagnosed by the Healthcare System and considered permanent. Its evaluation is based on the evidence of objective clinical findings that are documented and supported by clinical reports. For this reason, it is important to maintain an accurate medical history, document reviews, and provide all relevant evidence.

Resumen

Antecedentes y objetivo

El Real Decreto 888/2022, de 18 de octubre, establece que la evaluación de las situaciones de discapacidad se efectúa por los equipos multiprofesionales de calificación y reconocimiento del grado de discapacidad. La participación de los profesionales del área sanitaria y social puede resultar útil al emitir informes de los que se puedan obtener los datos necesarios para la correcta valoración de la discapacidad, siendo el fin último una asistencia integral de las personas con discapacidad.

Material y métodos

Se realiza un análisis y resumen del Real Decreto 888/2022, de 18 de octubre, que ha entrado en vigor recientemente, centrándonos en los aspectos más relevantes para los profesionales del área sanitaria y social.

Resultados

El reconocimiento y calificación del grado de discapacidad corresponden a las comunidades autónomas, y los dictámenes son emitidos por equipos multiprofesionales. Para ello, se valoran cuatro componentes mediante la aplicación de los baremos recogidos en los anexos del propio Real Decreto. Cada baremo genera una puntuación que se combina para obtener una única puntuación, el Grado Final de Discapacidad de la Persona.

Conclusiones

La patología que origina la discapacidad debe haber sido previamente diagnosticada por el Sistema de Salud y considerarse como permanente. Su evaluación se basa en la evidencia de hallazgos clínicos objetivos que estén documentados y respaldados por informes clínicos. Por este motivo, es importante llevar a cabo una historia clínica precisa, documentar las revisiones y aportar todas las pruebas pertinentes.

Introduction

One of the main challenges of legislation and social policies in developed countries is to meet the needs of people with disabilities and those who require support to carry out activities of daily living, so that they can achieve greater personal autonomy and can fully exercise their citizenship rights.

Persons with disabilities include those whose physical, mental, intellectual or sensory impairments may prevent their full and effective participation in society when interacting with various barriers.

The International Classification of Functioning, Disability and Health (ICF)¹ is a reference classification which, together with the International Classification of Diseases (ICD),² is one of the most important classifications within the International Classification series of the World Health Organisation (WHO).³

The ICF is WHO's conceptual framework for a new understanding of functioning, disability and health. It is a universal, multi-purpose classification that establishes a standard language for describing health and its related dimensions. The ICF consists of three essential components: body function, body structure, activities and participation.^4,5

This biopsychosocial model of ICF, which integrates biological, psychological and social factors, is adopted by the International Convention on the Rights of Persons with Disabilities, approved by the United Nations (UN) General Assembly on 13 December 2006⁶ and entered into force in Spain on 3 May 2008.⁷ The purpose of this international treaty is to promote, protect and guarantee the full enjoyment of all human rights and fundamental freedoms by all persons with disabilities.

As a result of this convention, the Consolidated Text of the General Law on the Rights of Persons with Disabilities and their Social Inclusion, approved by Royal Legislative Decree 1/2013, of 29 November,⁸ incorporates the concept of disability and person with disabilities.

Following the approval of the Spanish Disability Strategy 2022–2030,⁹ which recognises the needs and situations of people with disabilities, the State Commission for the Coordination and Monitoring of the Assessment of the Degree of Disability proposed to adapt the scales for the assessment of the disability status established in Royal Decree 1971/1999, of 23 December,¹⁰ to the ICF.

As a result of this proposal, Royal Decree 888/2022 of 18 October¹¹ came into force on 20 April 2023, establishing the regulations for the recognition, declaration and qualification of the degree of disability and repealing Royal Decree 1971/1999 of 23 December. This new Royal Decree was drafted taking into account the biopsychosocial model of health developed at international level.

The purpose of Royal Decree 888/2022 of 18 October is to regulate the procedure for the recognition, declaration and qualification of the degree of disability, the establishment of the applicable scales and the designation of the competent bodies, with the aim of ensuring that the assessment of the degree of disability is uniform throughout the national territory.

Objective

The purpose of this paper is to summarise the procedure for recognising the degree of disability and to briefly outline the scales on which it is based for assessing disability status. This will enable health professionals to familiarise themselves with the process, which is often little known. A basic understanding of disability will help both to guide patients effectively and to write clinical reports that can be more useful to the assessment teams responsible for assessing disability status.

Material and methods

Regulatory framework

This study is framed within the recent entry into force of Royal Decree 888/2022, of 18 October, which establishes the regulations for the recognition, declaration and qualification of the degree of disability in Spain. It is important to note that this new Royal Decree repeals the previous Royal Decree 1971/1999, of 23 December, which regulated this matter beforehand. The regulatory change represents a significant milestone in the assessment and qualification of disability in the country.

The main objective of this study is to carry out an analysis and provide a detailed summary of Royal Decree 888/2022 of 18 October, focusing on the aspects that may be of greatest relevance to health and social professionals.

Methodology

To achieve this objective, we have carried out a systematic and detailed review of the text of Royal Decree 888/2022 of 18 October, taking into account its provisions, key definitions, procedures and assessment criteria. Furthermore, additional sources, such as technical documents and relevant publications, have been consulted to provide a comprehensive overview of the implications and scope of this new regulation in the field of disability.

The information collected has been subjected to an exhaustive analysis with the aim of identifying and highlighting the most relevant and significant aspects of Royal Decree 888/2022 of 18 October. Qualitative analysis tools and methods were used to contextualise the changes introduced and their impact on the assessment of disability in health and social care.

It is hoped that this study will provide a clear and understandable overview of the new disability regulations in Spain, with a particular focus on their application and relevance for professionals in the health and social sector. The results obtained will contribute to a better understanding of Royal Decree 888/2022 of 18 October and will provide valuable information to guide clinical practice and medical reporting in the context of disability assessment.

Results

Procedure for the recognition and qualification of the degree of disability

The competence for recognising and qualifying the degree of disability lies with the competent bodies of the Autonomous Communities and, in the case of Ceuta and Melilla, with the Institute for the Elderly and Social Services (IMSERSO). As it depends on the Autonomous Communities, the procedure to be followed will be developed by the respective Territorial Administrations. However, the State Commission for the Coordination and Monitoring of the Assessment of the Degree of Disability is the collegiate body of the General State Administration responsible for coordination and consultation between the various public administrations competent in this field.

These opinions are issued by multi-disciplinary teams for the qualification and recognition of the degree of disability. These teams are made up of health and social care professionals with at least a university degree or equivalent. Their activity is regulated by Law 40/2015, of 1 October, on the legal regime of the public sector.¹² In order to be closer to the people and to facilitate access, the assessment teams are based in the Centros Base de Valoración y Orientación (Assessment and Orientation Centres) for people with disabilities, which are attached to the provincial delegations. These Centros Base de Valoración y Orientación constitute the physical and functional area where the assessment teams evaluate disability situations and classify them into degrees using uniform technical criteria established by means of scales.

Assessment of functioning and disability

In order to describe and assess the functioning and disability of persons, Royal Decree 888/2022, of 18 October, follows the guidelines of the biopsychosocial model proposed by the ICF, which defines disability as that resulting from the interaction of the aforementioned essential components, and which Royal Decree 888/2022, of 18 October, divides into four blocks, assessing them with specific scales:

• 1

  Assessment of body functions and structures. The Baremo de Deficiencia Global de la Persona - BDGP (Person's global impairment scale), contained in Annex III, is used.

  Impairments of body functions and structures is the abnormality or loss of a body structure or physiological function (including mental functions). Impairment classes are described in terms of the foreseeable impact of the clinical manifestation of the health condition on the person's ability to perform activities of daily living (ADLs).

  The ADLs are classified on the basis of the ICF proposal and the AMA methodology,¹³ and for the purposes of Royal Decree 888/2022 of 18 October, as follows:

  • a

    Self-care activities: washing; care of body parts; personal hygiene related to excretory processes; dressing; eating, drinking; and self-care.

  • b

    Other activities: learning and application of knowledge; general tasks and demands; communication; mobility; domestic life; personal interactions and relationships; major areas of life (education, work, economy); community, social and civic life.

    The assessment teams will further assess these activities in relation to the life cycle in which the person is: pre-school, school, work and community life.

    The BDGP is based on criteria related to the findings associated with the diagnosis (ICD-10) of the health condition of the person to be assessed. The scale is divided into eight domains that contain 18 chapters, where all the body functions and structures of the different organs and systems are covered.

• 2

  Assessment of the ability to carry out activities. The Baremo de Limitaciones en la Actividad - BLA (Scale of Activity Limitations), contained in Annex IV, is applied.

  Activity limitations refer to the difficulties a person may experience in performing usual activities in a barrier-free environment. The assessment of this ability must take into account any prescribed assistive devices or the need for support from others, and after all therapeutic measures and rehabilitation and habilitation programmes have been implemented. In order to achieve greater precision in the assessment of activity capacity, there are further sub-scales. Thus, we find the Baremo de Limitaciones en las Actividades de Movilidad - BLAM (Scale of Limitations in Mobility Activities) which is applied in cases in which there is limitation in mobility, and the Baremo de Limitación Grave y Total para realizar Actividades de Autocuidado - BLGTAA (Scale of Severe and Total Limitation in Self-care Activities which is applied in situations that require significant help from another person, or severe limitation in self-care activities.

• 3

  Assessment of participation restriction in the performance of activities. The Baremo de Restricciones en la Participación – BRP (Participation Restriction Scale), contained in Annex V, is used.

  Restrictions in social participation are the problems a person experiences in performing activities and being socially involved in a real context or environment. The BRP establishes criteria for assessing the performance of the activities the person has carried out in the last month, taking into account the influence of environmental contextual factors. It is based on the information provided by the person in the Cuestionario de desempeño – QD (Performance Questionnaire).

• 4

  Assessment of Contextual Environmental Factors/Barriers. The Baremo de Factores Contextuales/Barreras Ambientales - BFCA (Scale of Contextual Factors/Environmental Barriers), contained in Annex VI, is used.

  Environmental and personal factors constitute the context of an individual's real life and determine the level and extent of functioning. The BFCA assesses those environmental and personal factors in a person's actual environment that interfere with functioning and can act as barriers, increasing disability and restricting full participation in society. Barriers are all those factors in a person's environment that limit functioning both physically and psychologically and lead to disability, such as an inaccessible physical environment, lack of appropriate assistive technology, or negative public attitudes towards disability.

Evaluation methodology

Each scale generates an independent score, which is then combined using a specific methodology. To assign the disability class, a scale is used, usually the BDGP scale, although in the case of multiple impairments the BLA scale is preferable. The disability class marks the starting point for the grade adjustment process, which is carried out by means of a hierarchical relationship between the BDGP, BLA and BRP scales. In this way, the Adjusted Degree of Disability is obtained, which interacts with the BFCA score to obtain a single score: the Person's Final Degree of Disability, which will be expressed as a percentage.

Assessment in childhood and adolescence

In the case of children and adolescents, an impairment or limitation in body functions and structures, in the ability to perform activities or in the restriction of participation, may reflect a developmental delay. Recognition of a degree of disability in this age group is based on a permanent impairment or developmental disorder that has been properly diagnosed, treated for a sufficient period of time and is well documented. However, there are two exceptional situations to be considered. Firstly, cases in which minors have serious illnesses with an uncertain prognosis that require prolonged treatment and affect the performance of activities; and secondly, cases in which the minor is diagnosed with an illness that is expected to cause significant permanent impairment in the short or medium term. In both cases, the possibility of recognising the condition of a person with a disability may be considered.

Discussion

As we have seen, the assessment of situations of disability and the qualification of their degree is regulated in Royal Decree 888/2022, of 18 October. Although the main responsibility for qualifying and recognising the degree of disability lies with multi-disciplinary teams, health and social care professionals can benefit from knowledge of these scales and interest would be focused on different aspects of their professional practice, such as patient orientation, the preparation of useful reports and expert assessment.

On many occasions we see patients who ask us for different examinations or complementary tests which can be submitted for assessment by the evaluation teams. In this way, we can include different aspects in our report and our evaluation that will subsequently help the assessment teams to obtain the necessary data and make the best decision regarding the degree of disability of the person; with the ultimate aim being to provide comprehensive care for people with disabilities. For this reason, it is important to be aware of the different aspects to be assessed in relation to the recognition and assessment of the degree of disability.

It is important to emphasise that the pathology causing the disability must have been previously diagnosed by the health system, and the appropriate therapeutic and rehabilitative measures must have been taken and duly documented. The assessment team does not therefore perform the function of diagnosis or treatment, and the assessment of the degree of disability is based on the medical reports provided.

The impairment being assessed should be considered permanent, meaning that it is not recoverable or improvable in the foreseeable future. The time required to be considered permanent may vary according to the pathology but should never be less than six months. Although the assessment teams are perfectly aware of when an impairment is considered permanent, it may be appropriate to provide relevant information in the clinical reports, such as indicating the expected course of the pathology we are treating, especially when it is a rare pathology, or when the clinical course is abnormal with respect to the usual clinical course and may cause an impairment that it does not normally cause. There is an exception to this period for considering the impairment as permanent, which is that of people in palliative care units, so it is important to point out this condition in our reports.

The assessment of disability is primarily based on objective facts, i.e. clinical signs. Symptoms, when they cannot be accompanied by objective clinical signs or evidence of impairment, will not generally be evaluated by assessment teams (e.g. fatigue, difficulty in concentrating, difficulty in falling asleep). However, there are situations where subjective information needs to be taken into account, such as in the case of pain.

The assessment is based on accurate medical records and the results of the physical examination and ancillary tests. Therefore, these findings must be documented and supported by clinical reports, so in addition to providing all the reports, we must add all the complementary tests available to us, and if our clinical specialty provides us with information that may be helpful, we can consider adding it to the reports, or at least point out the limitations that may be caused by the pathology for which we are treating the patient.

The intensity of signs and symptoms is assessed by considering the impact of the pathology on the performance of usual daily activities. This includes both the duration and intensity of the symptoms and their interference with ADLs. Duration will be assessed according to the percentage of time that the signs and symptoms are present, and intensity according to the percentage of interference with the performance of ADLs.

Information on how the pathology specifically affects the patient's daily life can be provided by the various health professionals, and this can be helped by including information in the medical records. This is because, in addition to a closer doctor patient relationship, we have a more precise knowledge of the natural course of each pathology and the limitations it causes.

The assessment of activity limitations is based on collecting information about the person's health, observing and reviewing his or her functioning, taking as a reference the most common baseline status in the last year, and would be considered a severe activity limitation if it is present 50% or more of the time or because it poses a vital risk to the person.

Consideration should be given to the increased effort the person makes, the discomfort or pain experienced, the slowness, or changes in the way he/she has to perform activities, as well as the need for support.

It is important to point out the degree of symptomatology control, both with medication and with therapeutic, postural or hygienic/dietary measures since the assessment team will take into account the type of treatment and the response to it in relation to symptomatology control.

Practitioners can provide information on the real benefits to the patient of using these interventions, as not all patients experience the same level of benefit from using them.

When a patient uses prostheses, orthoses or other assistive devices, assessment teams will evaluate how these devices affect the patient's functioning. Different professionals can provide information on the actual benefit the patient derives from the use of these devices, as not all patients experience the same level of benefit from using them. Activity limitation is also assessed taking into account the need for support from others and after all therapeutic measures and rehabilitation and habilitation programmes have been implemented. The need for personal assistance is not only physical but also psychological, such as counselling, guidance, supervision, encouragement, prompting, verbal or gestural support. Both the frequency and intensity of support shall be assessed.

If the pathology manifests itself in exacerbations, the assessment should be carried out when the person's condition is stabilised and undergoing maximum functional recovery, in the intercritical periods. However, the frequency and duration of flare-ups are also factors that need to be considered, as they interfere with the performance of ADLs. In this case it is useful to indicate the frequency of the flare-ups and how much time elapses between them. It would also be advisable to carry out an assessment after each flare-up in case of worsening.

As part of the assessment process, assessment teams will consider work capacity, limitations and necessary adaptations to the work environment. Therefore, the information that occupational medicine professionals can provide in this regard is very useful.

Each organ and system has its own particularities, as well as specific limitations and restrictions, which are detailed in the various sections of the corresponding scale of Royal Decree 888/2022 of 18 October, contained in Annexes III, IV, V and VI. These scales are the basis used by assessment teams to determine the degree of disability. Familiarity with these scales can be very useful in order to understand what aspects are being assessed and how they are taken into account. This knowledge can also be useful for experts acting in the field of disability, especially when a patient is not satisfied with the degree of disability recognised and wishes to file a prior claim, as well as for experts acting if there is eventually a claim through the social courts in accordance with the provisions of Article 71 of Law 36/2011, of 10 October.¹⁴

In conclusion, the assessment of the degree of disability is a complex and multidisciplinary process, in which health and social professionals play a crucial role in providing detailed and documented information about the pathology and its impact on patients' lives. Knowledge of the scales and criteria used in assessment can improve the quality of clinical reports and facilitate the process of recognising and qualifying the degree of disability, ultimately contributing to the provision of comprehensive care for people with disabilities.

Ethical considerations

This study has been conducted with the highest regard for the ethical and legal requirements in the field of research. Data confidentiality has been ensured and fundamental ethical principles in the collection and analysis of disability-related information and legislation have been observed.

Funding

None.

Conflict of interest

The authors declare that they have no conflicts of interest.