Le financement des soins infirmiers à domicile en Belgique - KCE

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36 Financing of Home Nursing KCE reports 122 (17) Health conditions (18) Service utilisation. The second part consists of 30 problem-focused Clinical Assessment Protocols (CAPs) covering conditions that are common risks for home care clients. The CAP’s areas are: (1) Functional performance (2) Sensory performance (3) Mental health (4) Bladder management (5) Health problems/syndromes (6) Service oversight. A guideline book (265 pages for the French version 2003) should support the assessor to adequately complete the form. RAI-HC is a member of the family of RAI. The data are collected with a so-called “Minimum Data Set” (MDS.) Once the assessment is done, it is possible to detect problems labelled “Client Assessment Protocols (CAP)” and to refer to guidelines for care planning. The data collected can be used to develop “Quality Indicators” for potential problems. For example, rate of pressure ulcers or rate of restraint and so on. Based on data, patients are grouped in different categories according to care load and type of care delivered by caregivers. These categories are labelled “Resources Utilization Groups (RUG)”. The RUGs are based on an hierarchical method. For each RUG it is then possible to evaluate the costs of a day care b . Resource utilisation groups (RUG) are derived from the first part of the MDS-HC 38, 41 . They are called RUG-III/HC by analogy with the RUG-III (third version of RUG) used in the United States for the Prospective Payment System (PPS) in nursing homes. The RUG-III/HC uses seven hierarchical levels: rehabilitation, extensive services, special care, clinically complex, impaired cognition, behaviour problems and reduced physical functions. It differs from RUG-III used in skilled nursing facilities (SNF) by collapsing several groups and using instrumental activities of daily living (IADL) in addition to activities of daily livings to form 23 resources utilisation groups in place of 53 in SNF. Informal care, i.e. care delivered by non professional caregivers is used in the RUG-III/ HC. Informal care time is assigned a lower cost. Case-mix indices, one for formal care alone and a second for both formal and informal care are produced. RUG III has been tested 42 and refined for long-term home care clients in Canada in a study including 804 individuals seeking home care through the Michigan Care Management Program on the home and Community Based Waiver for the Elderly and Disabled. In this study, RUG III explained 33.7% of the variance of per diem cost, using cost weighted formal and informal care as the dependent variable. Resource use within groups was relatively homogeneous. Validity In the United States, the RAI-HC is used by the department of Veteran Affairs for home care clients. Hawes et al. (2007) 43 reported that RAI-HC showed good consistency in five countries (United States, Canada, Japan, Australia, and the Czech Republic). Content validity was tested, and convergent validity with the Barthel ADL index, the Lawton Instrumental Activities of Daily Living Scale and the Mini Mental State examination was good. Reliability across nursing home and home- and community based settings has been established. b This method is used in the USA to fund the care of the Skilled Nursing Facilities, residential care rehabilitation facilities for older people after an acute care episode in the hospital.
KCE Report 122 Financing of Home Nursing 37 Poss et al. (2008) 41 , tested the validity of RUG-III/HC in Canada. They found that most care episodes concerned the groups of reduced physical functions (56.1%) and that less than 1% concerned extensive services and behaviour problems. Tests for homogeneity showed low coefficient of variation (CV) except for two groups for formal costs. Combined formal and informal costs showed lower CV values. Explained variance for formal and informal costs had a value of 37.3%, but was 20.5% for formal costs only. However, nursing costs (3.0%) and other professional service components (physical therapy 0.7% and occupational therapy 2.3%) did not fit well by RUG-III/HC. The authors discuss that case-mix indices (CMI) set for adjusting payments to an agency responsible for formal care alone should be those based on formal care alone. The poorer fit to formal costs should not influence the choice of the CMI’s. They concluded that informal care is an important piece of the cost structure in home care. Dubuc et al. (2006) 44 report that RUG-III focuses on the therapy and that the patient actually receives rather than he/she needs. Bernabei et al. (2008) 45 report examples of using RAI-III/HC in the Aged in Home Care (AdhOC) data set constructed in 11 European countries. Studies on prognostic factors showed that oral problems, particularly chewing problems were associated with a significant difference in one-year mortality. Some results suggested that the use of the MDS could reduce costs, avoiding nursing home admissions. Actually, outcomes intervention studies showed that the risk of nursing home admission was significantly lower for patients having case management. Quality indicators should provide meaningful information about the quality of care provided by the home care agencies. An international comparison using RAI-HC across 11 European countries showed that what is called “home care” has different meanings in different countries. However, the authors recognise concerns with regard to the quality of data and the training of personnel. The instrument is perceived as too long which could impact on data entry 45 . Dalby, Hirdes and Fries (2005) 46 underline the necessity to use risk adjustment methods for home care quality indicators in order to make fair comparisons across providers. A type of risk adjustment intended to control bias at the provider’s level is the agency’s ability to identify differences in client’s clinical characteristics and select patients for admission. In Canada, an instrument derived from RAI-HC, the Method for Assigning Priority Levels (MAPLe) identifies predictors for nursing home placement, caregiver’s distress and for being rated as requiring alternative placement to improve outlook. For every increment in MAPLe, there is a substantial increase in risk of nursing home admission. The pattern for caregiver distress is more pronounced. Higher MAPLe priority levels are associated with higher weekly costs of formal care and hours of informal care. It is not recommended to use this instrument as an automated decision-making system but should help case managers to engage in a full discussion with the client and his family to develop person-based recommendations 47 . Applicability for financing purposes We did not find any literature about funding experiences based on the RUG derived from RAI-HC. The RAI-HC was primarily designed to assess the needs of patients with severe functional problems often requiring intensive care services at home (several times per day), usually by different professionals. This objective explains the complexity of the instrument. Consequently, the scoring of MDS is very detailed and it takes on average one-hour to record all information. According to the Qualidem study 48 , MDS-RAI is the most suitable instrument in the home care sector, being the only tool that offers much more added-value for the preparation and development of an individualized plan of care. This study did not evaluate the quality of RAI for financing purposes.
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Le financement des soins infirmiers à domicile en Belgique - KCE

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