Le financement des soins infirmiers à domicile en Belgique - KCE

34 Financing of Home Nursing KCE reports 122
Each item is scored on a four level ordinal scale (1 = independent 2 = moderately
dependent 3 = severely dependent 4 = totally dependent). A patient is considered as
dependent if he/she gets a score of 3 for the item. The combination of these scores
leads to an assessment of the dependency level of the patient (see supra):
• baseline level (no dependency or low dependency level);
• level A (dependency for bathing, dressing and transfer or toileting);
• level B (dependency for bathing, dressing, transfer, toileting and continence
or eating);
• level C (the highest score for at least five functions, except continence or
eating, which may have a score 3). For that category, the nurse is obliged to
make at least two visits a day.
Interpretation guidelines are published on the NIHDI website and are used to control
the nurse’s assessment of the dependent person by the medical advisors of the social
insurance agencies..
Each dependence level gives an all-in price for a day care. In 2009 these prices are:
Dependence Day price during Day price during
category the week the week-end
A € 15.15 €22.61
B € 29.19 €43.34
C €39.93 €59.47
Validity
A content validity analysis 38 shows that this scale only assesses dependency for Activities
in Daily Living (ADL) and does not assess the dependency for instrumental activities
(management, cooking, house holding, shopping, transport using, etc.) in daily living
(IADL). It focuses on incapacities and does not meet the ICF approach proposed by the
World Health Organisation International Classification of Functioning (ICF). Construct
validity is good: concurrent validity with the AGGIR scale is high (r²=0.89) and the scale
is correlated with the time spent for care for ADL (r² = 0.65). Cronbach alpha
coefficient is higher than 0.9. Test-retest and external reliability are good (coefficient
kappa >0.7).The mean time for care is significantly different in each group -A, B and C-
(ANOVA and Games-Howel post-hoc test.)
Falez (2006) 38 found that the median required time for daily care for ADL is 229
minutes for category C, 200 for category B and 145 for category A. The scale is subject
to a ceiling effect and underestimates high dependency levels when compared with the
AGGIR scale: the highest dependency category measured with this last scale needs a
median time for care of 240 min. It also seems to be subject to a “lower limit” effect,
neglecting lowest dependency levels when compared with the AGGIR scale.
Applicability for financing purposes
Falez (2006) 38 concludes that the scale is quite valid, since its construct validity is linked
with old concepts (incapacities in place of performance) and could theoretically be used
for a funding adapted to case mix of home nursing, because of the good correlation with
the workload. The Interface study (2005) 39 reported face validity of the scale used in
nursing homes. For the caregivers, this scale gets an incomplete vision of the patient and
does not give sufficient information for care planning. The advantage of this instrument
is that it is currently used by nurses. All caregivers are familiar with this scale, which
would not imply modifications (which imply learning) for them.