Comparative study of dependency assessment scales, KATZ and SMAF, on the care of elderly people in care institutions

 Corresponding author: Raymond ASSANI RAMAZANI. Copyright © 2025 Author(s) retain the copyright of this article. This article is published under the terms of the Creative Commons Attribution License 4.0. Comparative study of dependency assessment scales, KATZ and SMAF, on the care of elderly people in care institutions Aimé BULAYA BOTCHAKA 1, Raymond ASSANI RAMAZANI 1, * and Charles KAYEMBE TSHILUMBA 2 1 Section of Management of Health Institutions, Kisangani Higher Institute of Medical Techniques, The Democratic Republic of Congo. 2 Department of Internal Medicine, University of Kisangani, The Democratic Republic of Congo. World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 Publication history: Received on 01 April 2025; revised on 12 June 2025; accepted on 14 June 2025 Article DOI: https://doi.org/10.30574/wjarr.2025.26.3.1803 Abstract Background and aims: According to KCE (Federal Centre of Expertise for Healthcare) report 73B, SMAF (Functional Autonomy Measurement System of the Elderly), a tool for functional dependence of the elderly, little known in Belgium, offers better support from supervisory staff in care institutions. The study aims to assess the dependency of the elderly by the workload of the supervisory staff using the SMAF scale; and to demonstrate the impact of the use of the SMAF scale in Belgium for better financing of residential establishments for the elderly by supervisory staff. Methods: We experimentally verified this statement in a nursing home and nursing home (n=50) by making comparative evaluations between the Katz and SMAF tools; the first being the normative reference for financing in management personnel in Belgium. Results: At the end of our experiments, we arrived at a first result according to which SMAF, with more items, makes a better assessment of the dependency of the elderly compared to Katz. In addition to assessing activities of daily living (ADL), SMAF also assesses activities of domestic tasks (ADT). The items assessing cognitive abilities are more extensive than the Katz scale. In view of the results obtained, we reached a second result according to which the use of the SMAF scale in Belgium could be a good calculation basis for financing of paraprofessional care staff. On the other hand, with regard to other care professionals (Nurses and Kiné-Ergo-Logo), no clear trend was observed. Conclusions: we can say that SMAF is a good tool for assessing the dependency of the elderly. It can also be used as a basis for funding orderlies. As for other paramedical staff, we recommend working on a large sample. Keywords: Elderly People; Assessment of Dependency; Health Economics; Institution for The Elderly 1. Introduction The flat rate provision of care on the basis of a dependency measurement scale in institutions for the elderly people is one of the variable forms of mechanisms for regulating health expenditure in Belgium [1]. The financing of these healthcare institutions is calculated on the basis of the Katz evaluation scale, the application of which makes it possible to define four types of packages (O, A, B and C) according to the physical capacities of the patient to assume certain tasks of daily life. Two types of additional packages (Cd and D) make it possible to determine the patient's cognitive capacity. A patient who reaches a minimum score of 3 is considered dependent for a criterion. The level of package is proportional to the person's degree of dependence. World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2466 According to Iglesia et al [2], autonomy is defined as the ability to govern oneself. It presupposes the capacity for judgement, i.e. the ability to foresee and choose, and the freedom to act, accept or refuse according to one's judgement. Dependence is the partial or total inability of a person to carry out, without assistance, the activities of life, whether physical, mental or social, and to adapt to their environment. This freedom must be exercised in compliance with common laws and customs. A person's autonomy is therefore a matter of both capacity and freedom. Autonomy refers to the ability to make choices and manage one's own affairs. In the context of ageing, apart from dementia, dependence does not mean loss of autonomy [3]. According to Huisjman [4], in gerontology, the notion of "need" refers to a breakdown in the functional balance between a person or an elderly population and their living environment. This disruption requires a response and can be considered at three levels: that of the person or the elderly person, that of the person or the elderly person and that of the person's physical environment. Since it is difficult to objectify needs, we rely on an assessment of the degree of dependency using a validated scale [5]. The Katz evaluation scale is, however, very open to criticism for the following reasons • The workload is not always linked to dependence [2]; in fact, the same category can correspond to two patients for which the workload will be fundamentally different; • The nursing criteria relating to their different techniques (wound care, etc.) are not taken into account. • In practice, in Belgium, the nursing staff of accommodation institutions for the elderly people has noticed that the criteria for assessing the dependency of an elderly person cannot be used to finance support staff. As a result, there would be a problem with the objectivity of the tool used to determine the number of nursing staff necessary for the daily care of people as a basis for financing institutions. Certain services increase the workload of nursing staff. This observation reveals the pressure to which staffs are constantly subjected given the additional workload they are obliged to support. • The use of assessment tools of dependency for an elderly [2] person depends on the objectives pursued. These tools can, among other things, be used to: • Evaluate a person. In this case, the tool used aims at detecting deficiencies and disabilities, establish a care plan to limit the disability, communicate with other health professionals and follow the person concerned over time; • Evaluate the care burden. The organization of care requires adaptation to the dependency of the person being cared for. Nursing evaluation measures, for example, the time spent by caregivers for a person, or more broadly for a group of people within a functional unit, a department or an institution. There are time-consuming actions such as toileting or feeding aids, wound care, etc.; • Assess the cost of dependence. Dependency generates a direct cost in technical aid that is most often easy to assess. On the other hand, the evaluation of indirect costs is more complex to assess, such as the impact of dependence on the immediate environment, the evaluation of human assistance involving natural caregivers or social actors. The difficulty increases depending on the multiplicity of participants. Social costs are borne by the person concerned or their family and, failing that, by communities, through social assistance. SMAF (System for Measuring the Functional Autonomy) is a tool developed by Professor Réjean the needs of elderly people institutionalized or at home by measuring deficiencies, disabilities and handicaps [6]. This tool is designed based on the concept of disability and disability as described by the World Health Organization [7]. It assesses 29 functions distributed as follows • 7 items covering Activities of Daily Living (ADL); • 6 items on mobility; • 3 items on communication; • 5 items for mental functions; • 8 items for domestic tasks. It also includes a section allowing you to evaluate the resources in place to compensate for disabilities as well as the stability of these resources over the next three to four weeks. Each function of the SMAF is rated on a scale of 0 to - 3, according to precise criteria based on information obtained by a questionnaire, by observation of the resident and even, if necessary, by verification of their abilities. It is always important to corroborate the information collected from the resident by consulting their loved ones, because the person often tends to minimize their functioning problems, or simply not to recognize them. World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2467 The score 0 represents the autonomy of the old person, the score of - 0.5 means that the person is autonomous, but has difficulty carrying out the function, the score of - 1 means that the person requires supervision or stimulation to carry out the activity, the score of - 2 means that the person requires partial assistance to do the activity, and the score of - 3 means that the resident requires total help to do the activity. It should be noted that the evaluator must decide on what the user does and not on what he could or should do. The SMAF is under copyright and cannot be used without the authorization of the Center of Expertise in Health of Sherbrooke/Canada [8]. The assessment makes it possible to group residents into 14 ISO-SMAF profiles classified according to the intensity and type of service required to maintain their autonomy [9]. It makes it possible to establish the number of staff members and hours of care necessary and to calculate allocation needs more equitably. The ISO-SMAF profile gives a global representation of the person's needs. The fourteen ISO-SMAF profiles are divided into five different categories each representing different disabilities and/or impairments, as shown in the figure below. According to report 73B of the KCE (Federal Center of Expertise for Health Care) of 2008 [10], the SMAF (Measuring System of Functional Autonomy), a scale developed by the University of Sherbrooke in Canada with a recording duration of three quarters of an hour, is not really known in Belgium, but offers possible interest for financing to compare to other tools such as Belgium Geriatric Medical Screening Tools (BGMST), Comprehensive Geriatric Assessment (CGA), Resident Assessment Instrument (RAI) and Standardized Gerontological Assessment (SGA). To date, no serious study has yet been carried out with the aim of investigating the affirmation of this KCE report. The objective of this work is to carry out a comparative study between two dependency assessment tools, namely: the Katz scale used in Belgium and the SMAF. According to Hébert et al [11], autonomy must be measured precisely by an instrument that generates a score with demonstrated test-retest and inter-rater reliability and low measurement error. As a result, the test-retest and interrater reliabilities of the SMAF are demonstrated [12]. In addition, several validity tests have been carried out, in particular a correlation study with nursing time which shows a coefficient of 0.92 with the number of nursing hours required. The completion of this study allows us to formulate the following objectives • To assess the dependency of the elderly by the workload of the supervisory staff using the SMAF scale; • To demonstrate the impact of the use of the SMAF scale in Belgium for better financing of residential establishments for the elderly by supervisory staff. With a view to experimental confirmation of the KCE's assertions [13], the use of SMAF in Belgium will have a threefold benefit, namely • An improvement in the quality of work by increase in the number of management personnel and, consequently, by reducing the workload of the latter; • The satisfaction of elderly people living in rest homes and rest and care homes following the improvement in the quality of their care charge and better supervision; • An improvement in the level of financing and better functioning of rest homes and rest and care homes. • Ultimately, at the end of this work, it will be appropriate to determine the conceptual added value of SMAF in relation to the scale from Katz or vice versa. 2. Methods In order to assess the dependence of elderly people, we chose to use two tools for assessing functional dependence, namely, Katz (otherwise called appendix 41) and SMAF (training model) [14] while scrupulously respecting their user guides respective. These two tools were used for the assessment of residents living in a care institution for the elderly, Orelia-Ascot (an institution located in Flemish Brabant in Belgium), whose accommodation capacity is 52 approved beds with a occupancy rate of 96.15% (n = 50) at the time of our experiments. The assessment of the dependency of the elderly people was optimized thanks to the particular professional title of nurse specialized in geriatrics (Ministerial decree of April 19, 2007 and published in the Belgian monitor of June 8, 2007) that we hold [15]. World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2468 The initial assessments were scrupulously carried out by us. Their finalization is the work of a comparison of our own evaluations with the declarations of the healthcare professionals working in this institution. The evaluation of temporal, spatial and memory orientations which took place by interview in a relaxed atmosphere, was carried out using the Mini Mental State Examination (MMSE), an adaptation of the Dutch version Camdex [16] and the French-speaking version GRECO [17]. Categorization of nursing home residents or rest and care home was made after assessment of their dependence and on the basis of their respective medication treatment. The Care solutions IT platform for the Katz scale was associated with this. Residents in rest and care homes benefit from specific care requiring extensive care. Regarding SMAF, the Iso-SMAF profile and the categories are determined using an algorithm in the SMAF software [18]. The types of resources available to compensate for the incapacity of residents have been modified to respond to the operating context of rest homes and rest and care homes in Belgium. For this purpose, the term: “employee” (3) has been replaced by “cook”; “family assistant” (4) by “caregiver”; “other” (7) was identified as KEL (Physiotherapist-Occupational Therapist-Speech therapist) and “attendant” (8) was replaced by “cleaning lady”. All residents (n = 50) were freely consented to participate in this study which was carried out throughout the month of June 2020 both day and night. The case of refusal after reading the information letter to obtain informed consent was not observed. The protocol of this research received a favorable opinion from the Erasmus Ethics Committee of the Free University of Brussels in Belgium. 3. Results As our study was carried out in Belgium where the Katz scale is used as a benchmark for funding staff framing for houses rest homes and nursing homes and care, we applied the standards of the INAMI (National Institute for Health and Disability Insurance) in this regard [19]. Tables 1 and 2 present the distribution of residents according to their specific capacity in carrying out daily life tasks. Table 1 below presents all the results of the assessment of resident’s disabilities on the basis of the different SMAF items. The total SMAF ratings per resident of this care institution range from - 15 to - 76. The most severe rating being - 87 representing a person who presents maximum disabilities at all levels (Activities of Daily Live-ADL, mobility, communication, mental functions and activities of Domestic Tasks-ADT for a resident. The ISO-SMAF profiles were obtained via SMAF using an integrated calculation matrix which locates the profile for each disability of the person assessed in relation to the 14 centroids of this multidimensional universe of disabilities [14]. It is the closest profile that is retained and the distance, called Euclidean distance (DE), is the distance calculated in relation to the centroid. It indicates the similarity between individuals. It is a statistical indicator that reflects the consistency or inconsistency of the set of evaluations. There is inconsistency when its value is greater than 5 and consistency when the value is less than 5 [20]. From what is said above, we see consistency in our evaluations based on the SMAF scale. Table 1 The set of results from evaluation of inabilities of inhabitants on the basis of different items SMAF Inhabitant Total SMAF Profile ISO-SMAF ED ADL Mobility Communication MF ADT 1 -43.5 9 2.92 -10.5 -10 -1 -2 -20 2 -76 14 2.17 -21 -13 -7 -12 -23 3 -50.5 8 3.69 -8 -8.5 0 -11 -23 4 -33.5 5 3.13 -6.5 0 0 -5 -22 5 -36 6 3.76 -7 -7 0 -2 -20 6 -52.5 9 3.98 -18.5 -11 -1 -1 -21 7 -49.5 10 3.30 -9.5 -6 -1 -11 -22 8 -27.5 5 2.64 -3 -1.5 0 -2 -21 World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2469 9 -27 5 4.14 -6 0 0 -5 -16 10 -21 5 3.02 -3 0 0 -1 -17 11 -69 14 2.63 -21 -12 -2 -11 -23 12 -69 14 2.63 -21 -12 -2 -11 -23 13 -65 13 2.71 -21 -12 -2 -8 -22 14 -41.5 8 3.23 -6.5 -8 0 -5 -22 15 -52 9 3.97 -18 -11 0 0 -23 16 -32 5 3.94 -5 0 -1 -4 -22 17 -65 13 2.95 -21 -12 -2 -8 -22 18 -44 7 4.05 -10 0 -1 -10 -23 19 -42 8 3.47 -6 -5 -3 -5 -23 20 -38 8 2.85 -7 -5 0 -3 -23 21 -26 5 3.53 -6 -1 0 0 -19 22 -63 13 3.42 -20 -10 -4 -6 -23 23 -22 3 3.38 -3 0 -1 0 -18 24 -25.5 6 2.83 -3 -5 0 0 -17,5 25 -69 14 2.39 -21 -12 -3 -11 -22 26 -51.5 10 3.12 -11.5 -3 -1 -13 -23 27 -71 14 2.11 -21 -12 -2 -13 -23 28 -22 5 3.12 -3 0 0 -2 -17 29 -60 13 2.57 -18 -11 -1 -7 -23 30 -15 2 2.75 -1 0 0 0 -14 31 -63 13 2.12 -20 -11 -2 -7 -23 32 -46 9 3.74 -14 -7 0 -4 -21 33 -71 14 2.10 -21 -12 -3 -12 -23 34 -18 3 2.97 0 0 0 0 -18 35 -21 3 2.65 -3 0 0 -1 -17 36 -33 7 2.99 -5 -1 0 -6 -21 37 -27 6 3.16 -4 -4 0 0 -19 38 -34 7 3.10 -5 0 0 -7 -22 39 -62 12 2.51 -18 -8 -2 -11 -23 40 -45.5 8 3.96 -9 -3.5 0 -10 -23 41 -37.5 7 3.11 -8 -1.5 -1 -5 -22 42 -62 12 3.019 -16 -11 -2 -11 -22 43 -73 14 2.95 -21 -12 -3 -14 -23 44 -56 11 3.22 -16 -9 0 -8 -23 45 -19 3 2.94 0 0 0 -1 -18 46 -61 13 2.82 -19 -12 0 -8 -22 World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2470 47 -44 9 3.87 -13 -6 0 -3 -22 48 -31 6 2.44 -4 -5 0 -1 -21 49 -40 8 3.59 -10 -3 0 -5 -22 50 -23 5 2.95 -4 0 0 -1 -18 Table 2 Presentation of residents according to their category/group and Iso-SMAF profile Number of Residents 1 2 3 4 5 6 7 8 9 10 Team RH RCH RH RCH RCH RCH RCH RH RH RH Katz-INAMI O Cd B B B C B O O O SMAF 9 14 8 5 6 9 10 5 5 5 Number of Residents 11 12 13 14 15 16 17 18 19 20 Team RCH RH RCH RCH RCH RCH RCH RCH RCH RCH Katz-INAMI C Cd Cd B C B Cd B B B SMAF 14 14 13 8 9 5 13 7 8 8 Number of Residents 21 22 23 24 25 26 27 28 29 30 Team RCH RCH RH RH RCH RCH RCH RH RCH RH Katz-INAMI B Cd O B Cd Cd Cd O Cd O SMAF 5 13 3 6 14 10 14 5 13 2 Number of Residents 31 32 33 34 35 36 37 38 39 40 Team RCH RCH RCH RH RH RCH RH RCH RCH RCH Katz-INAMI C B Cd O O B O B Cd B SMAF 13 9 14 3 3 7 6 7 12 8 Number of Residents 41 42 43 44 45 46 47 48 49 50 Team RCH RCH RCH RCH RH RCH RH RCH RCH RH Katz-INAMI Cd B Cd Cd O Cd B B B O SMAF 7 12 14 11 3 13 9 6 8 5 (RH: Rest Homme; RCH: Rest and Care Home) Table 2 above presents all the residents evaluated by the Katz-INAMI and SMAF scales. This table gives us an idea of the potential concordance between the two tools used. We note that certain profiles are found simultaneously in several categories such as Iso-SMAF profiles 5, 7, 9, 10, 12 and 13. Table 3 presents the distribution of Iso-SMAF profiles of residents by category of dependency. Table 3 Correspondence between the categories/group and the profiles of all residents evaluated respectively by the Katz scale and the SMAF KatzINAMI O A B C Cd RH - RH RCH RCH RH RCH SMAF 2-3-5-9 - 5-6-7-8-9-10-12 6-8 9-13-14 14 7-10-11-12-13-14 World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2471 Table 4 Nursing staff supervision in full-time equivalent (FTE) per resident and by dependency profile according to INAMI standards. (-): not applicable Category of residents RH RCH Nurses Nursing assistants KEL Nurses Nursing assistants KEL O 0.1000 - - - - - A 0 0 - - - - B 0.1400 0.2667 - 2.8333 2.9367 0.5667 C 0.1367 0.1687 - 0.5000 0.6200 0.1000 Cd 0.1367 0.2020 - 0.2333 3.1267 0.4667 Total FTE 0.5134 0.6374 - 3.5666 6.6834 1.1334 Table 5 shows the distribution of current management personnel compared to the standards imposed by INAMI. For information, the management present, that is to say the professional and para-professional workforce in activity, must always be higher than the standards imposed under penalty of lack of funding. Table 5 Number of care personal in FTE and by professional team, with regard to norms of INAMI on the basis of evaluation in using scale of Katz-INAMI Nurses Nursing assistant KEL TOTAL Present care 7.25 8.6 1.5 17.85 Norms of care 4.0800 7.3208 1.1334 12.5342 Table 6 Distribution of median professional (Nurses and KEL), paraprofessional (nursing assistants) and care hours (Nurses + KEL + Nursing Assistants) necessary for the supervision of residents of Orelia-Ascot based on the SMAF scale Profile Number of residents Percent ILC sum Professional hours (HP) Paraprofessional hours (HPP) Care hours (HS) 1 0 0.0 0.000 0.000 0.000 0.000 2 1 2.0 0.370 0.024 0.274 0.393 3 4 8.0 1.757 0.916 1.928 3.024 4 0 0.0 0.000 0.000 0.000 0.000 5 8 16.0 3.877 2.296 5.360 7.696 6 4 8.0 2.061 1.252 2.716 4.412 7 4 8.0 2.318 1.340 4.320 5.912 8 6 12.0 3.637 2.292 7.410 9.906 9 5 10.0 3.974 2.165 11.430 13.810 10 2 4.0 1.547 0.958 4.572 5.364 11 1 2.0 0.866 0.582 2.613 3.201 12 2 4.0 1.662 0.952 5.072 6.092 13 6 12.0 5.404 4.152 15.714 20.340 14 7 14.0 7.000 6.643 21.539 28.336 TOTAL 50 100 34.473 23.572 82.948 108.486 World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2472 TOTAL FTE 3.102 10.914 14.274 Table 6 shows a distribution median hour of professional (HP), paraprofessional (HPP) and care (HS) necessary for the supervision of Orelia-Ascot residents based on the SMAF scale. The clientele heaviness index (ILC) of each profile is the division ratio between the hours associated with this profile and the hours of profile 14 [21]. It ranges from 0 to 1; 0 being the index of the lightest profile (profile 1) and 1 being the index of the heaviest profile (profile 14). The use of the client burden index allows a quick and simple assessment of the burden of care and services for a given sector. The hours represented in the table above have been calculated on the basis of 24 hours. For the sole purpose of having comparable results with INAMI standards, these hours have been converted into full-time equivalent (FTE). For this, the Orelia-Ascot residence like all private institutions, 1 FTE corresponds to 7.6 hours (7 hours 36 minutes) of work per day, that is to say 24 hours. The hours of work of management staff were expressed as medians according to the compilation of the Sherbrooke health center of expertise (CESS). According to the latter, medians are preferred to averages in all work on profiles. They are also used to calculate the ILC [22]. As shown in Figure 1 below, the distribution of care hours does not follow a normal distribution [23]. This also applies to professional and paraprofessional hours considered separately. Figure 1 Distribution of care hours (professional hours and paraprofessional hours). We note that the excessive dispersion of the data is the logical consequence of the presence of outliers in the data set: the FTEs of profiles 13 and 14 are too high while the profiles 1 and 4 are not represented in the study population Table 7 below presents a summary, in FTE, of the hours worked by all care management staff in this institution for the elderly analyzed. Table 7 Distribution of hours of professional (Nurses + KEL) and paraprofessional (nursing assistants) care provided to residents of Orelia-Ascot based on the Katz and SMAF scales Nurse KEL Nursing assistant Total Katz-INAMI 4.08 1.13 7.32 12.53 MAF 3.1 10.91 14.01 It seems obvious to us to elucidate a certain number of considerations relating to hours linked to care (professional hours: nurses and KEL; and paraprofessional hours: Nursing assistants) as defined in table 6 presented above. All these hours are directly linked to compensating for the loss of functional autonomy of elderly people. According to Hébert [14], for the purposes of calculating care hours, only the time dedicated to direct care and services to users by each personal category of care is considered. The time dedicated to direct care and services for the elderly corresponds to the time during which care staff (nurses, caregivers and KEL) provide care and services directly to World Journal of Advanced Research and Reviews, 2025, 26(03), 2465-2477 2473 residents (e.g. nursing care, hygiene and comfort care, feeding assistance, etc.), or carries out another resulting activity (e.g.: note in the resident's file, updating of the therapeutic nursing plan, participation in meetings of the multidisciplinary or interdisciplinary team, etc.). Indeed, this excludes all so-called administrative tasks (for example: development of action plans, compilation and analysis of clinical-administrative data, schedule management, department meetings, supply management, etc. Table 8 Comparative table representing the conceptual added value of SMAF compared to Katz. (-): non-existence of evaluation; (x): existence of eval DIABILITY ASSESSMENT KATZ-INAMI SMAF Activities of Daily Living Feeding (Eat) x x Washing x x Dressing x x Self-care - x Bladder function x x Continence (bladder and intestinal function x x Going to the toilet (using the toilet) - x Mobility Transfer/movement and walking indoors x x Prosthesis or orthotics instalment - x Moving in a wheelchair indoors x x Using stairs - x Moving around outdoors - x Communication Seeing - x Hearing - x Speaking - x Mental Functions Memory - x Orientation (Time and space) x x Understanding - x Judgment - x Behaviour - x Domestic Tasks (Activities of domestic life) Maintaining hands - x Cooking meals - x Shopping (planning) - x Doing laundry - x Using the telephone - x Using means of transportation - x Take your medication - x Manage your budget - x 4. Discussion The genesis of this research arose from the assertion of the KCE in its 73B report, according to which the SMAF scale is a little-known tool in Belgium, but offering possible interest for financing, to be compared to other tools such as Belgium