Home Care and Nursing Roles Revisited

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 1/2003

Abstract

The percentage of nurses' activities that are essentially the administration of personal care has risen rapidly (it represents nearly 70% of the services, the rest being more technical and clinically oriented). As an effort to recentre nurses activity on the provision of clinical care a nursing care plan ?Démarche de soins infirmier? has been introduced.

Purpose of health policy or idea

This project is known as the "Démarche de soins infirmier" or DSI; it replaced an earlier competing project labelled "Plan de soins infirmier" (PSI), both are nursing care plans for disabled people.

The core idea of this nursing care plan is 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 provided by herself or others. This plan is validated by the physician and subsequently implemented by the nurse.

A population of 350,000 disabled patients could benefit from such plans.

Objectives

• for nurses to concentrate their activities on clinical aspects, and to delegate and supervise other aspects of the care (i.e., personal care),
• to improve the care provided by increasing the coordination of the various professionals, in particular from the health and social services sectors,
• more indirectly, to encourage the development of home care and to limit the consequences of the shortage of nurses shortage by inducing them to focus on the clinical and technical part of their activity and delegate the personal and social care. 

Incentives

New services provided within the context of a DSI were explicitly included in the nomenclature and are remunerated on a fee-for-service basis.

In 2002, the DSI was included in the Nurses National Agreement (Convention*) as an AcBUS*. After a year, the savings (if any) will be shared with the nurses, under conditions that will be negotiated then.

If, within the framework of their National Agreement, the nurses choose to join the Professional Practice Contracts*, which includes specific commitments regarding the monitoring of their activity, training for the DSI, etc., they receive a flat-fee payment of 600€ per year.

Aside from these financial incentives, the idea is to give more autonomy to nurses and hence to enhance their professional status.

* see policy development N°1 " Global Reorganization of the Relationship Between Self-employed Health Professionals and Public Health Insurance Funds" for a detailed definition of these terms.

Main points

Main objectives

To reinforce the self-employed nurse's role in the management and coordination of the care for disabled patients by creating a specific nursing plan.

Type of incentives

Financial (inclusion of new services in the nomenclature, sharing of savings (if any), plus an optional conrtact which increases the remuneration, professional valorisation.

Groups affected

Nurses, Social sector workers, Patients

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Political and economic background

Since the mid-'80s, the percentage of nurses' activities that are essentially the administration of personal care has risen rapidly (it now represents nearly 70% of the services they provide, the rest being more technical and clinically oriented). This can be partly explained by an increase in the number of disabled patients but is also believed to be a consequence of their fee-for-service remuneration scheme. Some abuses are even suspected. The DSI represents an effort to re-centre the nurses activity on the provision of clinical care, in the hope of limiting health expenditure. It is also expected to improve the traditionally limited cooperation between the social and health sectors.

These issues have become increasingly important in the context of an ageing population and the search for solutions for developing home care. In 2002, the creation of a specific allocation for disabled individuals over 60, an initiative designed to help them finance their social care (Aide personnalisée à l'Autonomie, APA) is also a favourable element in this context.

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

The elaboration of the nursing care plan was first proposed in 1992 by a nurses' professional union called FNI and discussed jointly with the State and the public health insurance since inception.

A complete project (PSI) was elaborated by 1996.

In 1999, a unions federation (Convergence Infirmière) was created to oppose that project but also to voice a growing dissatisfaction with the way the FNI represented the professions' interests (FNI was for a long time the sole union in a position to sign the National Agreement). Convergence Infirmière elaborated an alternative project (DSI).

Late in 2000, a new minister of health was appointed. A series of actions and demonstrations against the PSI postponed its implementation.

In 2001, the union elections were won by Convergence Infirmière and saw a large drop in the support to the FNI.

In December 2001, the FNI terminated the National Agreement (Convention).

In February 2002 a new codicil to the National Agreement was signed by Convergence Infirmière which planned the introduction of the revised DSI. Substantial increases of all nursing fees were obtained in the process.

The codicil was later redrafted (official publication Feb. 2003) to make use of the new convention tools (AcBUS and Professional Practice Contract).

The new nursing care plan, DSI, has been officially in force, and thus available since the beginning of 2003.

Stakeholder positions

Opposition to the project

The professionals who oppose this project argue that their income will decrease if the care they provide is transferred to the social sector; they claim that their role in home care will become less important and resent what they perceive as increased control by physicians (the prescribing physician validates the project and the health insurance fund physicians are explicitly mandated to control this activity). Some also argue that the administrative procedure associated with the DSI is too cumbersome and that it creates an additional workload for tasks they were already doing.

Even if not explicitly discussed, it can be presumed that the départments' councils that help financing social care have misgivings about the increase of their expenditure the DSI could imply.

Influences in policy making and legislation

In October 2000, the nurses' fee schedule was changed to introduce the new services provided by the nurses administering care under the PSI (assessment of needs and drafting of a nursing plan, the visits necessary to its implementation, the clinical monitoring visits). In France, authorized procedures are organized into a relative hierarchy and are attributed a coefficient with respect to a unit of measurement, known as a 'key letter'. In this first version, the new procedures were attributed a specific coefficient based on the existing nurses' 'key letters'.

In June 2002, the fee schedule was changed again, and a new 'key letter' was created for the visit during which the nursing care plan is established. This symbolic change is presented by Convergence Infirmière as a first step towards the official recognition of the concept of "nurse's visit" (the existing key letters specifically referred to the technical or personal care provided, but not the more "intellectual" component of the activity).

The forms that nurses must fill in were published in October 2002.

In the codicil of the National Agreement published in 2003, the DSI is included in the new convention framework and a new incentive (Professional Practice Contract) has been added.

Adoption and implementation

The main actors involved in the implementation of the project are obviously the nurses, their unions, and public health insurance funds which will monitor the overall impact as well as the compliance of the nurses who sign the Professional Practice Contract.

Health insurance funds will send nurses the documents needed to implement the strategy, and some training will be provided by accredited training agencies. Local meetings will be organized to explain the nursing care plan.

One of the main obstacles of this reform is the fact that it was entirely elaborated by negotiations within the health sector. The social sector, which is already understaffed, may not be in a position to provide the expected services. The monitoring of the quality and quantity of personnel in that sector is also a crucial issue that will have to be dealt with.

It is difficult to predict the degree of success the DSI will have, and whether the financial incentives will be sufficient to modify nursing practices.

Monitoring and evaluation

Every six months, the health insurance fund will monitor the impact of the reform on health expenditure and the mix of care provided by nurses. A qualitative analysis of the reporting documents will also be conducted.

If the general quantitative objectives were met, the nurses could benefit from them. No penalties are planned for nurses who fail to comply with the specific commitments of the Professional Practice Contracts; but the public health insurance funds can however terminate their contract.

Expected outcome

The main expected result is a decrease in the volume of non-clinical care provided by nurses.

References

Author/s and/or contributors to this survey

Fabienne Midy

Suggested citation for this online article

Fabienne Midy. "Home Care and Nursing Roles Revisited". Health Policy Monitor, April 2003. Available at http://www.hpm.org/survey/fr/a1/4