Le financement des soins infirmiers à domicile en Belgique - KCE

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12 Financing of Home Nursing KCE reports 122 The NIHDI publishes yearly the numbers of registered nurses and midwives who received an identification number from NIHDI. In the last 10 to 15 years, self-employment became more attractive, financially as well as organisationally 2 . Explanations for higher attraction of self-employment in home nursing might be that there is no hierarchical relationship with a supervisor and by visiting more patients and delivering more nursing care, self-employed nurses have the possibility to acquire a higher income. The personnel cost structure is different between selfemployed and employee-nurses. As a result, the proportion of the expenditures for home nursing spent in employee-nurses decreased from approximately 60% in the 1990s to approximately 40% of all NIHDI-expenditures in home nursing in 2005 2 . 2.4.2 Qualification levels Nurses who work in home nursing need to have one of both nursing qualifications that are recognized by the directive 2005/36/EC and have to apply for a NIHDI-identification number. In Belgium, two levels of nurses (bachelor-level (A1) and diploma-level (A2)) comply to the EC directive. As with other health care professionals, the authenticity of nursing diplomas is verified by provincial medical committees of the Federal Public Service Public Health, Food Chain Safety and Environment. Anyone who is not properly registered is not allowed to practise. The licence is given for an unlimited time – that is, once health care professionals have been given the right to practise, they do not have to prove continuing professional education. However, in cases of malpractice, licences can be withdrawn. Five qualification levels have been determined that provide care and nursing activities (Table 3). Nursing assistant is a lower educational level of the nursing profession (obtained after two years of professional nursing education); this qualification level is fading out. Two nursing specialties are recognized by NIHDI for nurses of both qualification levels after completion of a post-graduate 40 hours-course: specialist nurse in diabetes and specialist nurse in wound care. In 2007, pilot projects were launched on the employment of care assistants in home nursing. Care assistants are allowed to perform a limited list of nursing interventions which are delegated by a nurse and under supervision of a nurse (Royal Decree 12 January 2006, published on 3 February 2006). There are explicit requirements for the qualification and recognition as a care assistant (Ministerial Circular Letter of 8 November 2006, published on 14 December 2006). They can only be employed by services for home nursing which are eligible to receive financing for specific costs of services for home nursing. Table 2 : Overview of nursing formal qualifications Qualification Level of performance Nurse BA or Nurse (A2) + extra May perform all nursing interventions and some specific qualification interventions: diabetes education and visits for wound care advice Nurse BA level (A1) May perform all nursing interventions Nurse (A2) May perform all nursing interventions Nursing assistant May perform all nursing interventions except specific technical nursing interventions Care assistants Limited list of nursing interventions in experimental setting
KCE Report 122 Financing of Home Nursing 13 2.4.3 New organisational forms including nursing 2.4.3.1 Coordination of home care Initiatives for coordination of home care were implemented on the federal and the community level. Integrated Services for Home Care (ISHC; Geïntegreerde Diensten voor Thuisverzorging, GDT ; Services Intégrés de Soins à Domicile, SISD) were created in 2003 as a federal initiative. The main task of an ISHC is to organise multidisciplinary consultation of primary care professionals and to support the elaboration of multidisciplinary care plans. The reimbursed activities for ISHCs has grown from 222 cases in 2003 to almost 10 000 cases in 2007 (Table 3). Table 3: Yearly expenditures for the activities of Integrated Services for Home Care Yearly growth of number Year Number of cases* of cases Expenditures 2003 222 € 6 860 2004 3 147 / € 95 415 2005 4 266 + 35.6% € 127 195 2006 7 551 + 77.0% € 230 155 2007 Source: NIHDI; OW 2008/29 9 796 + 29.7% € 299 389 * ‘cases’ is the word used by NIHDI to identify how many times a nomenclature activity was administered to a patient. In this matter, a ‘case’ is an interdisciplinary consultation on a patient’s problems, in which at least the patient’s GP and home nurse participate. 2.4.3.2 Interdisciplinary primary care practices Another development is the integration of home nursing into interdisciplinary primary care practices. In an exploratory survey of general practitioner’s practices 11 , it was found that in 8 practices of 30 a nurse was practicing and in 7 out of 30 practices there were intentions to engage a nurse. Most nurses were part-time (a few hours per week) employees of the general practice, receiving wages. Self-employed nurses in the general practice are still exceptional. Tasks performed by nurses in general practices were reception and administration, coordination of the secretariat, first aid and nursing interventions such as blood sampling, ECG, spirometry tests, skin allergy tests, injections, diabetes consultations, blood pressure monitoring, … The nurse is reimbursed on the fee-for-service basis for the number of nursing interventions included in the nursing nomenclature. 2.4.3.3 Palliative support networks Palliative support networks were implemented since 1997 in population area’s of 300,000 to 1 000 000 inhabitants. Their objective is to provide support for the regular professional care providers in patients with palliative care: GPs, home nurses, social services, nursing homes, … Lump sum fees for palliative patients are provided for home nursing. 2.4.3.4 Care trajectories In 2009, care pathways were introduced with the objective of organising the multidisciplinary care for a patient with chronic disease-specific pathology (Royal Decree of January 21 st , 2009, published February 6 th , 2009). Patients with type 2 diabetes or with chronic renal insufficiency may agree on a care contract for four years with the GP and the medical specialist. From September 1 st 2009, home nurses are involved for giving education to patients with type 2 diabetes. Home nurses, having participated in the required training of a diabetes-educator, may request a specific registration number from NIHDI. Each of the educational nursing interventions is prescribed by the GP per session of a half hour.
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Le financement des soins infirmiers à domicile en Belgique - KCE

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