Le financement des soins infirmiers à domicile en Belgique - KCE

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38 Financing of Home Nursing KCE reports 122 4.2.1.4 The Gerontological autonomy ISO resource groups (Autonomie gérontologique groupes iso-ressources- AGGIR Description This assessment tool is made of two parts. The first part assesses the dependency for daily living activities and cognitive troubles. It consists of ten items, called discriminant variables: (1) orientation, (2) behaviour, (3) bathing, (4) dressing, (5) eating, (6) elimination, (7) transfers, (8) moving in home, (9) moving out of home (10)communication. The first eight items are used to classify the person in six iso-resources groups, i.e. groups of persons needing similar levels of care for activities of daily living. Some isoresource groups classify persons with different dependency profiles but with close needs for help: for example, iso-resource group 2 classifies persons with important orientation troubles and able to moving (wandering persons) and bedridden persons without cognitive disorders. The classification has been constructed by statistical methods using ascending hierarchical classification of Ward and multiple correspondence analyses. The iso-resource group 1 (GIR 1) classifies persons who are totally dependent. The isoresource group 6 classifies persons without any dependency for the ADL but needing some help for the instrumental activities of daily living (IADL). The last two items are used at home for persons with low level of needs but having partial or total problems to move outside home and/or for calling for help (groups 6B and 6C; groups 5B and 5C.) The system assesses what the person makes actually and does not assess the capacities to do. In that way, the assessment method meets the approach used by the World Health Organisation (WHO) International Classification of Functioning (ICF.) Each item is scored following an ordinal method. If the person performs the activity in a coherent way, usually, entirely and alone the score is A. If the person does not perform the activity at all, the score is C. If the person performs the activity partially (i.e. not totally and/or not usually and/or not alone) the score is B. Guidelines help the assessor to choose the adequate score. Software calculates the iso-resource group. For each resource group, it is possible to get a relative level of care needs. If the GIR 1 gets the value of 1 000, GIR 2 gets a value of 840, GIR 3 a value of 660, GIR 4 a value of 420, GIR 5 a value of 250, GIR 6 a value of 70. It is so possible to calculate a case-mix index for a population, called weighted mean GIR. That index allows comparisons between different care services and could be a method for payment based on case mix. The second part of the instrument consists in 7 items, assessing the dependency for instrumental activities of daily living (IADL) and called “illustrative variables” because they are not taken into account for the determination of the groups: management, cooking, house holding, shopping, transport using, medications and leisure. These items are used for patients at home but could also be used in nursing homes. They are scored in the same way than the discriminant variables.
KCE Report 122 Financing of Home Nursing 39 Validity Benaim (2005) 49 reports that the AGGIR scale was built in institutional setting and that its use was later extended to assess dependency at home without specific validation. Such extension is doubtful because some relevant issues are not solved, as the need of supervision at home and because some productive disorders like restlessness and running away from home are not taken into account. Moreover, this scale is not a tool allowing a follow-up of the dependent person and the geriatrics generally do not recommend integrating it in the medical file. Using a principal components analysis, Roudier and Al-Aloucy (2004) 50 found five factors explaining 90% of the variance. They concluded that the scale mainly takes the physical dependency into account. Dependency related to dementia would require an adaptation of the scale, integrating cognitive and behavioural troubles. Fanello et al. (2000) 51 observed a relationship between the AGGIR scale and the Mini Nutritional Assessment (MNA), iso-resource groups 4, 3, 2 and 1 presenting a higher risk of malnutrition. Lafont et al. (1999) 52 found a relationship between global cognitive performance and the dependency evaluated by the AGGIR scale but concluded that the model seems to lack sensitivity for taking in account functional impairment associated with dementia. IADL should be considered in the classification. Falez 40 assessed the content validity, and concluded that this scale assesses dependency for activities in Daily Living (ADL) and for instrumental activities in daily living (IADL). He concludes that the scale meets the International Classification of Functioning (ICF) approach. Construct validity is good. Concurrent validity with the Belgian scale is high (r²=0.89) and the scale is correlated with the time spent for care for ADL (r² = 0.63.) Cronbach’s 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 iso-resource group (ANOVA and Games-Howel post-hoc test). Falez(2006) 38 found a high correlation between the weighted mean GIR and the required time for ADL care (r²=0.86). He found that median required daily care time for dependence for ADL is 236 minutes for iso-resource group 1, 194 minutes for isoresource group 2, 158 minutes for iso-resource group 3, 99 minutes for iso-resource group 4, 38 minutes for iso-resource group 5 and 21 minutes for iso-resource group 6. The author concludes that the scale is valid and could allow a funding of home nursing care by case-mix based on the AGGIR scale. The Interface study reports face validity of the scale as used in nursing homes. For the caregivers, this scale is evaluated as offering better insight in de condition of the patient than the Belgian scale, but does not offer sufficient information for care planning. Gervais et al. (2009) 53 compared AGGIR and SMAF. They found a good correlation between the two scales (r 2 =0.86) but also discrepancies in the way the two scales classify the patients. Coutton (2009) 54 compared the dependency categories of the AGGIR scale and the resources utilisation by dependent aged persons, but is not able to conclude neither whether the scale is valid nor whether the resources utilisation is adequate. Applicability for financing purposes Colvez et al. (2009) 55 presided a scientific committee entrusted by a French law, to adapt the dependency evaluation tools. This committee reported that the AGGIR scale alone does not constitute a complete assessment of the problems of the person. The hierarchy between discriminant and illustrative variables pushes the IADL variables, the relational life and the capacity to manage the daily life into the background. Moreover, the scale does not recognize the consequences of psychological disorders and the discriminant variables “moving out and alerting” are underestimated because they are not taken in account to calculate the iso-resource groups. Another problem reported by the committee is the small number of scientific validations of the tool. The scientific committee recommends that providers should be funded on a case-mix basis but recommends AGGIR scale only if it is integrated in a multidimensional tool allowing to develop a care plan.
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