Assessment of the Economic Situation and Development Prospects of Nursing Care Centers in Local Healthcare Services

Following its investigations, the Igas mission highlighted the significance of nursing care centers (CSI) - where they are located - in providing local nursing care, their successful integration into the local healthcare and medico-social ecosystem, and their strong commitment to prevention. Nevertheless, many of these structures face significant challenges. The 2020 health crisis and its collateral damage on nursing care centers: Nursing care centers are healthcare facilities staffed almost exclusively by nurses who provide nursing care to patients in their homes. As of early 2022, there were 520 such centers in France according to the E-CDS/ATIH database. These are small-scale structures (with an average of around ten employees) and 70% of them fall under the collective agreement of the home care and support sector ("BAD" agreement).

By letter dated May 5, 2022, the Minister of Solidarity and Health entrusted the General Inspectorate of Social Affairs (Igas) with an evaluation mission regarding the funding of nursing care centers following the salary increase for employees covered by the BAD agreement, which was approved and came into effect on October 1, 2021 (Amendment 43). The scope of the investigation covered both CSI covered by the BAD agreement and those under other statuses (e.g., National Convention 51, Croix-Rouge collective agreement) due to the recurring structural difficulties in the sector. Despite a significant investment during the health crisis, nursing care centers did not benefit from the "Ségur" bonus, unlike hospital healthcare workers. This led to a differential loss of attractiveness in terms of salaries in the sector.

Furthermore, while some establishments under the BAD agreement received financial compensation in return for implementing Amendment 43 (e.g., EHPAD, SSIAD), the same did not apply to CSI, which are paid on a fee-for-service basis, similar to independent nurses. In response to alerts from representative federations of CSI under the BAD agreement, the government allocated a compensatory aid of 4 million euros in February 2022 (approximately one-fifth of the full-year cost increase of Amendment 43 for CSI) and initiated the current mission. A risk of CSI closures mainly caused by HR difficulties in 2021: Contrary to fears in the autumn of 2021 among sector stakeholders, there was no massive closure of centers in the first six months of 2022. In reality, more than half of the CSI did not implement Amendment 43 at the time of its entry into force in 2021.

The majority of them waited until the second quarter of 2022, when the exceptional financial aid was approved. Additionally, most of them can employ various strategies to delay the potentially harmful financial effects of Amendment 43 on the financial stability of the structures: the use of pre-existing reserves, revision of previous non-conventional salary benefits, various management actions (e.g., optimizing fee coding, managing supplier debts, optimizing nurse schedules for productivity gains). In practice, between late 2021 and early 2022, the few centers identified by the mission that closed, suspended their activities, or drastically reduced their range of services were centers that did not fall under the BAD agreement and were facing major HR difficulties in recruiting nursing staff. Salary tensions led other centers to grant salary benefits to staff to facilitate recruitment and retain employed nurses, which had the effect of worsening the financial balance of these structures. CSI under the BAD agreement and those not under the BAD agreement therefore find themselves in relatively similar situations, facing HR difficulties and financial vulnerabilities, with the greatest risk of short-term closure for a CSI being insufficient staff to operate the center.

Increasing financial difficulties: the Igas report from 2013 on healthcare centers indicated that nursing care centers had long been in better economic health than medical or multipurpose healthcare centers. However, recent data shows that the financial health of nursing care centers has deteriorated significantly over the past three years. Even before the COVID-19 health crisis, nearly 40% of CSI were in deficit in 2019. The situation continued to deteriorate (46% of CSI in deficit in 2020, 44% in 2021, prior to Amendment 43 to the BAD agreement). Therefore, even if CSI implemented Amendment 43 with a time lag, it will have a very strong financial impact on them. Each center is impacted differently depending on the qualifications and seniority of its staff and the choices made in reclassification within the salary grid. Nevertheless, the overall financial impact is significant: the typical cases before/after Amendment 43 established by the mission show that, for nurses (excluding coordination nurses, IDEC), the salary increase is close to 15% (note: administrative staff are also affected by the salary increases).

Since nurses make up the majority of personnel expenses for the centers, which themselves represent over 80% of CSI expenses, Amendment 43 represents a direct increase of more than 10% in their expenses, not offset by additional revenue (unchanged NGAP, fee-for-service accounting for nearly four-fifths of CSI's income). For CSI under the BAD agreement, Amendment 43 therefore represents a direct increase of over 10% in their expenses, not offset by additional revenue (unchanged NGAP, fee-for-service accounting for nearly four-fifths of CSI's income). As a comparison, the upward trend in CSI salaries in the BAD sector allows employees to benefit from substantially higher salaries compared to those in other sectors that have not yet adopted conventional revaluations (e.g., a 17% to 24% difference between BAD and National Convention 51 depending on seniority, in favor of nurses covered by the BAD agreement).

To determine whether the financial difficulties are recent/conjunctural (or not), the centers were invited to respond to an online questionnaire in the summer of 2022, with an exceptionally high response rate for this type of survey (80%). This allowed for strong simulations to support the economic situation of the sector. Salary increases exacerbate the deterioration of the accounts for many CSI: by applying an average increase of 15% to the salary mass of BAD centers for the year 2021 (equivalent to a projection of end-of-year 2022 results, all else being equal, as 2022 is supposed to be the first full year of Amendment 43), between 83% and 90% of BAD CSI are projected to end the year in deficit without financial compensation (and without any other management measures to limit the deficit). The risk of degrading access to care in already vulnerable territories in the event of CSI closures: The mission has also constructed composite indicators of HR and financial fragility for centers that allow for an objective assessment of the impact of CSI difficulties in territories. One-third of CSI (31%) encounter strong difficulties (after Amendment 43) while being located in vulnerable territories in terms of healthcare desertification (understaffed nursing areas, QPV, ZRR) or at risk of becoming so if the CSI were to close (intermediate nursing zoning). By extrapolation, this represents a little more than 160 CSI in France for which public authorities should have enhanced attention.

To understand the local access to care issue, it is important to note the disparity between the national and local significance of CSI: CSI represents a very small part of the national offering of local nursing care (less than 5%), but where they are located, their role is major. They represent, on average, 50% of the offerings in their municipality (57% when the municipality is in intermediate nursing zoning and 75% when it is in understaffed nursing zoning). Therefore, there is a significant risk of severely and suddenly degrading access to care for the populations in the affected territories, which calls for immediate and longer-term intervention by public authorities - unless the primary care utilization rate is to deteriorate. The primary objective is, for the immediate term, to limit the risk of center closures through exceptional assistance. Urgent financial support to secure struggling CSI in the very short term: two distinct strategies can be considered in the short term to provide financial support to CSI adhering to the national health insurance agreement (96% of CSI are members):

1.  a logic of compensating for the financial cost induced by Amendment 43 of the BAD agreement (total cost increase of 19.8 million euros);
2. an exceptional cash assistance to CSI, BAD or non-BAD, in deficit by the end of 2022 (total projected deficits estimated at 16.9 million euros).

In addition to the fact that some BAD CSI are not in deficit (compensation windfall) and that conversely, some CSI not covered by the BAD agreement are in deficit (for example, because they have granted non-conventional benefits to their staff to limit departures), the mission suggests that it is preferable to prioritize the second scenario of exceptional aid unrelated to Amendment 43 of the BAD agreement. Depending on the overall aid allocation, aid per CSI can be targeted or adjusted based on several parameters: the extent of the projected deficit for 2022, the presence or absence of reserves with the CSI manager, the location of the CSI in a vulnerable territory (understaffed nursing zoning, QPV, ZRR), or one at risk of becoming so if the CSI were to close (intermediate nursing zoning), patient profile (vulnerability). Such one-time aid will provide short-term security for the CSI network.

Other avenues for sustaining center activity with effects as early as 2023: In the short term, to ensure better visibility, local authorities must verify and secure the participation and integration of nursing care centers in health projects led by territorial professional healthcare communities (CPTS) in areas where difficulties are reported - as well as ensure their proper involvement in various health crisis plans. To secure their local presence, it is the responsibility of CSI to locally seek possible synergies and mutualizations with structures (autonomy services - SSIAD, SAAD, SPASAD, HAD, health centers) and healthcare professionals (physicians) in the vicinity. This facilitates the coordination of professionals and streamlines patient journeys, expanding the scope of internal nursing skills, with a view to retaining resources. Several missions undertaken by CSI deserve better compensation through the national agreement for healthcare centers, in line with the time and investment required. This includes better compensation for local collective prevention, screening, health promotion, and therapeutic education activities, as well as the supervision of nursing student internships at nursing schools (IFSI - Institut de formation aux soins infirmiers).

Furthermore, the implementation of a special system for reimbursing travel expenses for CSI is necessary when patients are not taken care of by the nearest independent nurse (IDEL). This rule in the act nomenclature (NGAP) known as "reimbursement to the nearest healthcare professional" proves to be a financial trap for centers and, more importantly, carries a risk of non-coverage for patients. Structural developments for the long-term development of nursing care centers: Once a CSI has established partnerships with nearby healthcare structures/professionals (physicians), several evolution hypotheses are opened. Firstly, CSI should be able to become a place for sharing skills among healthcare professionals: physicians, nurses (IPA...), nursing assistants, to concentrate physicians and nurses on the most technical procedures. In this regard, the recognition in the national healthcare agreement of the employment of advanced practice nurses (IPA) and nurses responsible for the follow-up of patients with chronic diseases (ASALEE) by CSI would make working in CSI more attractive not only for nurses but also for future physicians (see below, transformation of CSI into CDS).

Furthermore, the mission recommends launching an experiment allowing the financing of nursing assistants in nursing care centers, supervised by nursing personnel. The risk of duplication of care between CSI and SSIAD (future autonomy services at home) seems to be able to be eliminated as long as CSI, like independent nurses, perform hygiene procedures accessible to all (unlike SSIAD patients, who are targeted at disabled or dependent elderly people) and if it is ensured beforehand that patients eligible for a place in SSIAD practically cannot obtain one. CSI facilities - with varying configurations - should be optimally utilized: as with other CDS, it is necessary to remunerate the optional implementation, in centers with suitable facilities, of unscheduled care services, with and without appointments, for patients who can travel.

Additionally, several centers interviewed have expressed their desire to participate in the local emergency services system, which involves providing facilities - and staff - for the provision of low-level care prior to resorting to hospital emergency services, an evolution of local proximity healthcare services that deserves examination. Finally, the use of CSI facilities during the health crisis (vaccinations, PCR tests) should encourage regional health agencies (ARS) to take better account of this actor, whose responsiveness can be beneficial to their crisis management plans. In France, there are areas with a shortage of nursing personnel (e.g., Centre-Val-de-Loire).

The creation of CSI supported by calls for projects from ARS could be an effective lever to stem the desertification process: in addition to the fact that salaried work can initially attract nurses who are not motivated by private practice, nursing practice in CSI (autonomy, home care, elderly patients) has regularly been presented to the mission as a "school for the liberal world," with some CSI nurses going into private practice after a few years as employees. Newly created CSI could thus play a role as a "fertilizer" for local nursing care offerings. Encouraging the transformation of CSI into versatile CDS, when possible and relevant (especially in areas with a shortage of physicians), is also important. In line with the national health strategy that promotes the creation of health centers and healthcare centers where professional practice is coordinated, the mission proposes expanding eligibility for available assistance to finance a policy of transforming local CSI into versatile medical CDS (project engineering, start-up aid, balance subsidy for the first two years, as exemplified in the Pays de la Loire region).

The mission notes that CDS created from CSI have a potentially more balanced economic model than existing CDS, combining home nursing care and medical consultations in center facilities. Finally, regarding structural changes in the pricing model, several experiments conducted under Article 51 are being quantitatively evaluated, including the Equilibres experiment, which substitutes the fee-for-service payment model with an hourly payment model (aiming to limit the distortions currently caused by the gap between fee coding and the duration of care provision). The economic model of healthcare centers (nursing and medical multipurpose) could significantly evolve if successful experiments are generalized throughout the country.