Le financement des soins infirmiers à domicile en Belgique - KCE

KCE Report 122 Financing of Home Nursing 79
Their scope of activity is enlarged to handicapped persons and chronic patients.
Between 1980 and 2008, the number of places covered by the health insurance
increased from 3 500 to 90 000. However, the objective is to obtain a park of 232 000
places in 2025, by creating 6 000 places per year to 2010, and 7 000 additional places
per year since 2010.
Many SSIADs combine nursing care with home care and home help (domestic care and
meals on wheels). Home care provided by professionals are submitted to a medical
prescription and are covered by the health insurance 36 . Two thirds of available places
are managed by private organisations or not-for-profit organisations. More than 30% of
available places are managed by public hospitals, municipalities or (medico-)social
institutions.
The minimum level of personnel defined by SSIADs is composed of 4 nurses and 8
nursing aids for 60 persons, i.e. 1 carer for 5 patients. d To guarantee the 24/24 hours
and 7/7 days service, the SSIADs can contract with independent nurses (IDEL). More
than 80% of personnel in the SSIADs are nursing aides (aide-soignantes) and cover 80%
of all patients visits. They provide the basic care and support for the essential ADL,
under the responsibility of the nurse. Salaried nurses essentially provide coordination
and administrative tasks. For example, they organise evaluation visits to determine the
organisation of care and the follow-up. They also organise the work of the other carers
(nursing aids, psychological aids) and the contact with other professionals. Independent
nurses (IDEL), paid fee-for-service, are recruited on a regular basis or time to time.
They are competent for technical medical acts, for which only nurses are authorised to
provide. These nurses covered 13% of all patients visits 36 .
Since the mid-'80s, the percentage of nurses' activities of personal care has risen rapidly
compared to technical and clinical oriented tasks. This can be partly explained by an
increase in the number of disabled patients but the fee-for-service remuneration
scheme is supposed to have an effect too. Some abuses are even suspected. In an effort
to refocus nurses’ activity on the provision of clinical care a nursing care plan
"Démarche de soins infirmier" has been introduced 78 to reinforce the self-employed
nurse's role in the management and coordination of the care for dependent patients.
Once the physician prescribes a DSI, the nurse assesses the patient's health and social
needs, defines care objectives, and decides how they should be achieved using a
combination of nursing care (including monitoring and prevention), personal and social
care. This plan is validated by the physician and subsequently implemented by the nurse.
New services provided within the context of a DSI were explicitly included in the
nomenclature and are remunerated on a fee-for-service basis. The DSI is also expected
to improve the traditionally limited cooperation between the social and health sectors.
However, in daily practice, DSI is rarely implemented because of opposition of nurses
who refuse the transfer of basic activities to other social professionals or to the family
members, and the negative reaction of doctors due to the administrative burden linked
to IDEL prescription approval 78 .
Independent registered nurses (IDEL)
The group of independent nurses are the most important providers of nursing home
care. Independent nurses have the same training level as hospital nurses (BAC+3) but
need to have a professional experience of 36 months, full-time equivalent before
working as self-employed home nurses 37 .
Independent nurses perform the nursing activity under their own responsibility,
following the medical prescription and the order of mission. S/he uses his/her own
material and his/her own car. The independent nurse collaborates with nursing aids but
has no teaching/coordinating role.
d This was adapted to 1 carer for 4.48 persons after the working time reduction to 35 hours.