Le financement des soins infirmiers à domicile en Belgique - KCE

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52 Financing of Home Nursing KCE reports 122 It would not be a good choice (as it was made in the Netherlands) to allow a third external party to perform the assessment and check the patient’s eligibility for nursing care. According to the stakeholders, the current financing system offers little incentives for prevention and rehabilitation nursing and restorative nursing care. 5.2.4.3 Topic 19: Comments on the assessment tools BESADL tool On the one hand there were negative critiques with regard to the limited validity and reliability of the current ADL evaluation scale in use. The BESADL tool only takes physical dependency into account, not social or other sources of need for nursing care. Persons characterized by the same level of physical dependency may represent very different workloads for home nurses. The ADL instrument is not adapted to assess the physical dependency of children. The use of the instrument does not take sufficiently into account a correction for the presence of assistive devices. On the other hand the merits of this ADL assessment instrument were highlighted. The instrument is not perfect but it demonstrated validity in differentiating groups of patients according to their need for nursing care. It is a simple instrument that is known by all nurses, it requires little time spending and resources. Alternatives As mentioned before, propositions for an alternative for the Belgian adapted KATZ assessment instrument varied widely. Between all the propositions, some stakeholders expressed their preference for the RAI assessment instrument for home care (RAI-HC). Advantages of RAI were emphasized: it is seen as a complete and adequate assessment and it offers an integrated approach enabling to serve several purposes simultaneously: quality indicators, financing, support for plan of care, outcome measurement, etc ... However, the RAI instrument is considered to be too complex, too difficult, to require too much administrative efforts by home nurses. A new instrument should be simple, easy to understand and interpret. Participants also requested a shorter screening instrument for detecting those patients who need a full RAI-assessment. It was also mentioned, both by home nurses and by representatives of sickness funds, that if RAI is used only for those patients requiring complex nursing care and/or multidisciplinary consultation, the time and effort which will be required for carrying out the assessment should be reimbursed. Key points • Registration and assessment tools were considered as an essential part of nurse’s role in home care. • Stakeholders did not agree on the objectives of the use of an assessment instrument: for control of care delivery, case-mix determination and financing, quality indicators, care planning, … • Stakeholders reflected on the administrative burden of a comprehensive assessment: some considered that such a data collection and information gathering was necessary and feasible, others pleaded for a simple instrument. Some stakeholders even suggested to develop a new instrument, specific for home nursing in Belgium.
KCE Report 122 Financing of Home Nursing 53 5.3 SUMMARY Four main themes were most prevailing: critics on the current system, arguments for reform, specific nursing related topics, assessment and registration instruments. Although the main critic on the current system was that a global vision on the organisation and financing system of home nursing was lacking, many stakeholders also emphasized the merits of the current system. Probably, many of the detailed critics might find their origin in this lack of global vision. A good example is the fee for the nursing consultation/assessment that was introduced in 2009. It makes use of a fee-forservice financing principles but from an integrated vision on home nursing it should be seen as an integral part of regular nursing care delivery. The absence of a dominant global vision on the financing of home nursing might also be the reason why most stakeholders preferred a gradual/incremental change towards new procedures for financing. Stakeholders demonstrated consensus on their preference for a mixed system of fee-for-service and lump sum financing. With regard to chronic care patients, it was expected that the future lump sum payments would be based on a global case-mix index for a practice or a service of home nurses. Although there were no propositions/statements on control procedures, optimizing control procedures was requested by both, representatives of home nurses and stakeholders from sickness funds. There were only minor differences between opinions of stakeholders from selfemployed nurses and representatives from organisations of employee-nurses. They agreed that fees should not be different for self-employed nurses and employee-nurses. They also agreed on the fact that different cost structures could be taken into account by the financing system. Recent developments in the nursing profession might require higher levels of specialisation among home nurses, more autonomy and less dependency on GP’s prescription on the one hand, and more delegation of nursing care delivery to care assistants and professional carers on the other. These developments towards new nurses’ roles and tasks were mentioned, but few propositions were made on how these tasks should be financed in the (near) future. With regard to registration and assessment instruments, different opinions were mentioned. Although most stakeholders emphasized the importance and urgent implementation of a new instrument, there was no agreement on the objectives of its use: control of care delivery, case-mix determination and financing, quality indicators, care planning, ... The administrative burden of an instrument that would require a lot of data collection, was another source for disagreement between stakeholders: some considered that such a data collection and information gathering was necessary and feasible, others pleaded for a simple instrument than the existing instruments. Some stakeholders even suggested to develop a new instrument, specific for home nursing in Belgium. Analysis and comparison of the written scores, comments and arguments revealed no major differences with the opinions that stakeholders expressed in the discussions. The stakeholder discussion revealed on the one hand a demand for fundamental change of the evaluation/assessment instrument, on the other hand a demand for adaptations on (sub)parts of the complex financing system which seem not to function adequately rather than a revolutionary reform of the current Belgian model. Aspects/parts of the financing system which will need adaptations are: control and sanctions, task differentiation, case-mix financing, integrating ‘new’ nursing interventions, coordination, continuity of care, pay for quality, ...
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Le financement des soins infirmiers à domicile en Belgique - KCE

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