Le financement des soins infirmiers à domicile en Belgique - KCE

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.