Le financement des soins infirmiers à domicile en Belgique - KCE

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32 Financing of Home Nursing KCE reports 122 Labour differentiation • Nursing organisations employ two times more nursing aids than nurses. Financing of home care nursing New developments in financing Nursing qualifications & financing France dependent (elderly) persons; The Netherlands Germany UK (England) 3. independent nurses (IDEL) (sometimes in collaboration with SSIADs). • Labour differentiation is breaking through by orienting nurses on technical nursing activities and delegating some basic nursing tasks to nursing aids. • Lump sum ‘per diem’ and fixed budget for the SSIAD. • Fee for service system for the IDEL. • Regional unions of health insurance funds can conclude local contracts with health care professionals, in addition to the national agreements. • Homecare organisations are financed based on a daily fixed price per patient taking into account average nursing time required and patients’ case-mix. • Qualification levels are not the basis for funding • The qualification structure for nurses is differentiated in five levels. • There is a trend to orient nurses on technical and specialized nursing activities by delegating basic nursing tasks to nursing aids and helpers. • Lump sum per patient on a needs assessment. • Contracting to introduce competition. • An emerging financing issue is the nursing and treatment provided after early discharge of a hospital. Transfer nurses are financed either by the hospitals themselves or through home care organisation. • Qualification levels are not the basis for funding. • Labour differentiation over different nursing categories to provide the different services. • The health insurance framework makes a strict hierarchy of service entitlement (specialized nursing, basic nursing, and home help as a supplement to nursing). • Mainly a fee-for-service basis using needs assessment. • Contracting to improve competition. • The introduction of morbidityoriented risk structure compensation ("morbi-RSA") in the financing system aims to prevent patient selection by sickness funds and to improve care for patients with chronic diseases. • Some pilot initiatives fund the development of integrated service provision in primary care settings. • The same care, provided by different qualification levels nursing or caring imply a different tariff. • Nurses training levels are highly differentiated. Nurses responsibilities are closely connected to these differentiated qualification levels. • Lump sum per patient, annual fixed budgets, reference costs. • Contracting to introduce competition. • The NHS uses a model of reference costs linked to Payment by Results. Extramarket forces costs are taken into account • Qualifications levels are not the basis for funding
KCE Report 122 Financing of Home Nursing 33 4 DEPENDENCY TOOLS FOR CASE-MIX FINANCING IN HOME NURSING 4.1 INTRODUCTION Since 2005, a discussion started on an alternative financing model in home nursing based on case mix instead of fee-for-service payment system (cf. Chapter 2 about disadvantages of the current funding system). A report of the NIHDI 2 already underlined the need for an adapted financing of home nursing. This report criticised the limited clinical use of the BESADL scale, the impossibility to establish a plan of care and to propose a good indicator of performed (and required) care. The determination of nomenclature tariffs was also criticized, not being carried out on objective bases. In this section we develop a review of tools and data needed related to case-mix financing. Various case-mix systems for home nursing care delivery will be discussed. A critical assessment will be made of case-mix measurement tools used for financing purposes in home nursing. This section aims at: • Describe and assess the tools, measuring the nursing dependency of patients cared at home, which could be an alternative to the current system, and that are actually discussed in Belgium. • Describe and assess potential relevant items to be recorded in order to calculate or adjust tariffs. 4.2 RESULTS 4.2.1 Nursing dependency scales Five nursing dependency tools are explored and described in detail: • The scale used in Belgium, i.e. BESADL, which is an adaptation of the Katz’s index; • The scale used in Belgium for eligibility to dependence allowance for elderly people (Aide à la Personne âgée –APA); • The minimum data set (MDS) of the Resident Assessment Instrument (RAI), home care version (RAI-HC); • The gerontologic autonomy ISO resource groups system (Autonomie gerontologique groupes iso-ressources, i.e. AGGIR) used in France; • The Functional Autonomy Measurement System (Système de Mesure de l’Autonomie Fonctionnelle, i.e. SMAF) used in Québec. 4.2.1.1 The Belgian Katz adapted scale (BESADL) Description The Belgian Katz adapted scale used in home nursing to assess the dependency level of the person is formed by six items: 1. Washing 2. Dressing 3. Transferring and moving 4. Going to the toilet 5. Continence 6. Eating
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