Abstract:
Performance Oriented Payment System for Rehabilitation (LTR)

Abstract (English)

The project "Performance Oriented Payment System for Rehabilitation" aims to establish unified tariff schemes in neurological, muscle skeletal, cardiac and pneumological rehabilitation. On the basis of weekly collected patient data categories of nursing, and of medical-technical and therapeutical interventions are generated.

The current study was based on patient data from the Zürcher Höhenklinik Wald (ZHW) covering a 4 year period (between 2006 and 2009), and cost covering a 3 year period (between 2006 and 2008). To assess the patient status, the FIM instrument (Functional Independence Measure) was applied weekly. Lately, the themes of treatment were recorded by means of ICF (International Classification of Functioning, Disability and Health) within the framework of the weekly interdisciplinary team conference. The delivery of nursing care was assessed daily using LEP scores (Workload Measurement in Nursing). Monetarised relative value units of performed treatments per diem were used to weight medical-technical and therapeutical interventions.

After statistical data corrections and adjustments had been carried out, the data of 1'830 neurological patients (9'094 weeks, 413'805 days) were left for further analysis.

With regard to nursing, patient categories where being sought that would explain daily nursing workload on the basis of motor and cognitive FIM scoring. To assess the explanatory power, in addition to the generally used variance reduction (r2), the more robust reduction of absolute deviations from median (r1), which is easier to interpret, was applied.

With regard to the medical-technical and therapeutical interventions performed, as a first step, a cost classification of interventions based on weekly totals of monetarised relative value units of medical-technical and therapeutical interventions, was compiled. As a second step, cost categories based on ICF groupings and intervention intensities will be established.

Based on 16 neuro-FIM classes, which can be interpreted directly from a clinical point of view, 4 new nursing cost categories for neurological rehabilitation were defined, under which the neuro-FIM classes with similar cost structures were grouped. The explanatory power regarding daily nursing interventions measured in LEP hours in 2009 amounted to: r2 = approx. 72 %, r1= approx. 52 %, the weighting hereby lying in the range of 1.28 to 6.39 LEP hours (factor 5.0).

The classification of medical-technical and therapeutical interventions based on relative value units covers 4 medical-technical and therapeutical cost classes.

Owing to the high proportion of dependent patients, FIM-based patient categories can be established even for severely limited patients.

Even though a partitioning of FIM values according to motor and cognitive items can be discussed as a controversial issue from a statistical point of view, it was still applied, since it appears to be sensible from a clinical standpoint and further facilitates interpretation of the patient categories established.

Owing to the small figures collected regarding monitored neurological patients and cognitively severely impaired patients, differentiated proposals for tariffing such patient categories will be able to be made at a later stage only.

The model developed for neurological rehabilitation for now is suited to be applied within other rehabilitation areas as well. Possible inclusion of further patient assessments for coding comorbidity and pain is currently being investigated.

The established model allows for a good clinical interpretation of the developed categories which are further characterised by adequate economical homogeneity. The model is ready for practical usage in neurological rehabilitation now.

In a second step, an ICF-based classification of medical-technical and therapeutical interventions shall be developed, and further studies will be carried out, Finally, there are further investigations under way concerning similar designed categories in other rehabilitation areas (especially: muscle skeletal, cardiac, pneumological and internal medicine rehabilitation).