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202 Musculoskeletal & Neurological Rehabilitation KCE reports 57 classification system (Figure 9.1). ICF can already be used as a conceptual framework for an outcome model but the application of ICF in clinical practice and for financing purposes only fits long term vision. Figure 9.1: Principles of an ideal Patient Classification System Patient Classification System Outcome measures Outcome model Rehabilitation Budget Quality system Patient classification system Managerial level Clinical level Rehabilitation Services Outcome measures, outcome models and patient classification systems exist but are not explicitly linked. The implementation of ICF as an outcome model depends on its compatibility with measures used in rehabilitation and the improvement of its applicability. FIM and Barthel Index are tools measuring level of dependence related to activities of daily living. The results of this measurement can be used to estimate workload, but neither FIM nor Barthel Index measure rehabilitation needs. In Belgium only MVG-RIM2 includes functional items. It could be considered to use the MVG-RIM2 as an intermediate profiling tool of post-acute rehabilitation, using the “fingerprints”. However, the necessary reluctance is needed: MVG-RIM is not a tool enabling to score for paramedical (occupational therapy, physical therapy, psychology,…) activities, neither to monitor or assess the effectiveness of therapy or different aspects of rehabilitation activities. It could be an option to validate MVG-RIM2 with other instruments currently tested in other countries even though MVG-RIM2 will at the earliest be implemented in Belgium in 2008. Organisation and financing of rehabilitation was analysed in five countries. All countries are struggling with these issues and developing new solutions. In The Netherlands rehabilitation is organised within 4 levels and patients need an indication setting. There is basic set of performance indicators as well as a rehabilitation treatment framework, intended as quality and accreditation instrument. In France rehabilitation is conceptually organised around three levels of care and has a clear regional orientation. There is no systematic model of indication setting. Medical post-acute rehabilitation in Germany is mainly offered in specialised rehabilitation clinics, although outpatient and part-time inpatient care grows considerably. Approvals by the insurance companies for admission to rehabilitation facilities are needed. Quality assurance programs intend to impact on the allocation of patients as well as the financing of the rehabilitation services. In Sweden rehabilitation is organised at county level, taking into account the level of specialisation and the population’s needs. The rehabilitation has a clear orientation on home and ambulatory care, but a differentiation is made between at least two levels of facilities. The quality assessment is stimulated by both national health care agencies and
KCE reports 57 Musculoskeletal & Neurological Rehabilitation 203 rehabilitation professionals. Registers are an important support tool in this quality approach. In the US different facilities provide post-acute care rehabilitation services. A preadmission screening process is needed within Medicare as stays in a Medicare inpatient rehabilitation facilities (IRF) are funded by a prospective payment system. The unit-of-payment is a Medicare covered hospital stay. Patients are classified with a patient assessment instrument (IRF PAI). Quality of care is not uniformly assessed, although efforts are made to develop a quality approach based on registration. Services can be accredited by the Commission on Accreditation of Rehabilitation Facilities (CARF) based on preset standards. In this and the following chapters the organisation and financing of musculoskeletal and neurological rehabilitation in Belgium is discussed. This discussion is based on the input of national experts and elements from literature described in previous parts. Several models are proposed and recommendations applicable to the Belgian context are made. 9.1.2 Optimising the organisation and financing of post-acute musculoskeletal and neurological rehabilitation in Belgium The current organisation and financing of musculoskeletal and neurological rehabilitation in Belgium requires an important revision. The conventions 9.50 and 7.71 have to be revised and elaborated in the context of an overall strategic vision on rehabilitation in the Belgian health care approach. In their current form the conventions do not differentiate enough from, or offer added value to K-nomenclature. Belgian health care services are in general characterised by a wide accessibility and affordability by a universal social security system. The development of a vision on the organisation and financing of rehabilitation services and facilities should fit in this tradition. The new conceptual approach of rehabilitation should be built on the interaction between financing, organisation and quality of rehabilitation services (Figure 9.2). A line of reasoning developed in this chapter, takes these issues into account. Figure 9.2: Interaction in policy making Necessary interaction for policymaking Rehabilitation Budget Quality system Rehabilitation Services Similar to international debates, Belgium needs to develop an explicit conceptual framework for the organisation of musculoskeletal and neurological rehabilitation. It is proposed to develop a stratified rehabilitation model in which the roles of rehabilitation organisations can be identified, taking into account characteristics of patients’ needs, disease trajectories, rehabilitation goals and epidemiological and geographical needs. Resource allocation must become more transparent and related to the effective service delivery for particular patient characteristics.
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Dépôt légal : D/2007/10.273/19
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