Le financement des soins infirmiers à domicile en Belgique - KCE
Le financement des soins infirmiers à domicile en Belgique - KCE
Le financement des soins infirmiers à domicile en Belgique - KCE
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62 Financing of Home Nursing <strong>KCE</strong> reports 122<br />
• RAI-HC is curr<strong>en</strong>tly tested in Belgium by the FPS Public Health with the<br />
collaboration of some nursing home facilities and home care ag<strong>en</strong>cies. RAI<br />
seems to be the more complete method to assess the geriatric problems and<br />
is recognized as a complete tool for care planning at home. The derived<br />
RUG-III explains more than 38% of the variance of the costs. However, we<br />
did not find any method allowing a case-mix funding calculation based on<br />
RUG-III/HC for home care. Moreover the methodology used to obtain the<br />
differ<strong>en</strong>t RUGs could be subject to further discussions especially for supplier<br />
induced effects: nurses could be <strong>en</strong>couraged to produce more care than<br />
needed in order to classify the pati<strong>en</strong>t in a higher category of paym<strong>en</strong>t. The<br />
correlation betwe<strong>en</strong> the RUGs-III and the care costs are quite low. Higher<br />
values should be preferable for funding home care.<br />
• The SMAF was never tested in Belgium. The most interesting developm<strong>en</strong>t<br />
regarding the ISO-SMAF seems to be the link betwe<strong>en</strong> the ISO-SMAF profiles<br />
and the theoretical costs for required time of: nursing care, personal care and<br />
support services. The ISO-SMAF profiles take also in account the IADL<br />
dep<strong>en</strong>d<strong>en</strong>cy and is pot<strong>en</strong>tially useful for Integrated Home Care Services<br />
(IHCS).<br />
• There is very little sci<strong>en</strong>tific evid<strong>en</strong>ce about AGGIR The AGGIR scale<br />
correlates well with the ISO-SMAF It seems theoretically possible to create a<br />
case-mix funding for home care with the AGGIR scale.<br />
A particular question is how to take into account the part of the interv<strong>en</strong>tion covered<br />
by the family and informal caregivers. There is a lack of knowledge and expertise in this<br />
area in Belgium.<br />
In the stakeholders’ discussions, there were mixed opinions on the use of the<br />
alternative assessm<strong>en</strong>t instrum<strong>en</strong>ts (SMAF, RAI, ...) to the BESADL especially since<br />
these instrum<strong>en</strong>ts are expected to serve differ<strong>en</strong>t purposes at the same time. These<br />
mixed purposes g<strong>en</strong>erally lead to a debate on usability, validity and reliability issues with<br />
regard to each of these purposes. The choice for an instrum<strong>en</strong>t requires a thorough<br />
debate and assessm<strong>en</strong>t of its utility for the int<strong>en</strong>ded purposes. One of the main relevant<br />
topics is the administrative burd<strong>en</strong> of data registration and on how this will be handled<br />
and integrated in the daily activities both of individual nurses as well as home nursing<br />
organisations. It could also be discussed to what ext<strong>en</strong>t the same level of detail for<br />
registration is needed for pati<strong>en</strong>ts with differ<strong>en</strong>t needs. The curr<strong>en</strong>t pilot experi<strong>en</strong>ces<br />
with the RAI instrum<strong>en</strong>t give indications that such a differ<strong>en</strong>tiation might be required to<br />
implem<strong>en</strong>t a feasible registration, not impacting too much on the core activities of<br />
health professionals.<br />
Moreover, other nursing need assessm<strong>en</strong>t instrum<strong>en</strong>ts (such as North-American<br />
Nursing Diagnosis system (NANDA), the Home Health Care Classification (HHCC) or<br />
the OMAHA system 59-63 ) exist that we did not discuss in this report. These tools are<br />
g<strong>en</strong>erally int<strong>en</strong>ded to assess the needs of pati<strong>en</strong>ts and organise nursing care 64 but not<br />
for financing purposes. It has to be reminded though that the RAI instrum<strong>en</strong>t was<br />
initially developed for clinical and care planning purposes, and was only proposed as a<br />
tool for case-mix financing.<br />
Besi<strong>des</strong> pati<strong>en</strong>ts needs, other pati<strong>en</strong>t related variables are considered too: urban area,<br />
availability of informal caregivers and supportive devices, home nursing for pati<strong>en</strong>ts living<br />
in nursing homes. A similar adoption is se<strong>en</strong> in France and the UK where a special rate<br />
for metropolitan and rural areas is used. In 2005, a proposal for such a case-mix<br />
financing was pres<strong>en</strong>ted in the Agreem<strong>en</strong>t Committee for home nursing 34 . Curr<strong>en</strong>tly a<br />
special fee is already paid for home nursing in rural regions to comp<strong>en</strong>sate for longer<br />
distances betwe<strong>en</strong> pati<strong>en</strong>ts, but there are no additional paym<strong>en</strong>ts for the city related<br />
problems such as traffic jams, parking and safety problems in urban areas. Stakeholders<br />
also warned that these problems hold a risk for insuffici<strong>en</strong>t future supply of home<br />
nursing in urban areas (e.g. Antwerp, Brussels).
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