Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 57
As a result of a shortening of length-of-stay and more day-care in hospitals, more
attention will have to be paid to seamless or integrated care initiatives guaranteeing the
continuity of adequate (nursing)- care for patients. But as in Belgium hospital care is
organised on a politically different level than home care, the reduced length-of-stay in
hospitals cannot be easily connected to formal policy initiatives on the development of
new organisational modes (including the financing). This trend towards more need for
care in the communities should go hand in hand with a reflection on a transfer of
resources from hospitals towards the home or community care sector. At this stage,
some disease related initiatives have recently been launched illustrating a disease
management approach. There are clear indications though that disease oriented
organisation modes (and the financing regimes) should be complemented with
“function” oriented approaches (mainly because of the problematic issue of comorbidities
and the complexities of care needs).
This implies that a political reflection is needed on the intended role of health services
functions within an overall vision health services provision. A clear assessment should
be made of the competencies needed to provide services of high quality. For this
reason, some countries (e.g. the Netherlands, Germany) have chosen to finance postacute
specialised nursing within the framework of hospital activities, but allowing to
contract home nursing providers. The financing schemes are also oriented on the
quality of care provided. Other countries (such as France) have not adapted their
financing regime for home nursing but introduced management approaches integrating
task differentiation within nursing activities between carers and nurses. The recently
launched pilot projects of the NIHDI on the employment of care assistants in home
nursing test a similar turn. Special legal measures are taken in which nurses get the
responsibility (and are financed) for the supervision and support for the care assistants.
These initiatives legitimise the nurse as a supervisor of lower qualified personnel.
Although these approaches are mainly a reaction to labour market conditions, they
should be considered in the broader system perspective of changing roles and functions.
The political intention to revalue primary care is expressed in Belgian documents 2 and
Protocol Agreements between federal government and the community governments
have already been signed in 2001. The Integrated Services for home care were
established in 2003. Recent Decrees from the Flemish Government realized some of
the intentions formulated in the Protocol Agreement: the Collaboration Initiatives for
primary care.
6.2.2 Economical factors
Economic studies on home nursing in Belgium are scarce. Little is currently known on
the cost structure of home nursing. It is thus very difficult to assess objectively to what
extent the current financing is covering the real costs of home nursing provision. In the
Belgian debate the discussion evolves also on the differences in cost between selfemployed
and home nursing organisations. However, none of the neighbouring
countries studied have a financing mechanism based on the real daily cost of individual
providers; they calculate reference tariffs for contract negotiations, use fee for services
for technical acts (sometimes corrected for qualification levels), or pay lump sums
without differentiating for the type of provider.
The information collected indicates that the current financing of home nursing in
Belgium could take into account more cost generating elements for home nursing
organisations. It was suggested during stakeholder meetings to compare the home
nursing with the financing principles introduced for Belgian nursing homes because of
the important role of nurses. These financing principles incorporate many different
incentives with the underlying idea to improve quality of care. However, this research
did not aim at comparing the relevance, feasibility or impact of financing principles from
another sector for the home nursing sector.