Abstract
Objective
This study aimed to clarify the current status of collaboration between type-B continuous employment-support facilities and psychiatric care in Japan and determine the intention of these facilities toward medical collaboration.
Methods
A self-administered anonymous questionnaire survey was conducted by mail. Basic descriptive statistics were calculated for the questions with multiple-choice responses. For the free descriptions of medical collaborations, we grouped sentences with similar meanings and generated categories.
Result
Of type-B employment continuation support offices, 76% collaborated with psychiatrists. However, only 6% incurred an additional fee for the medical collaboration system. They attempted to collaborate with medical care by contacting doctors and nurses and accompanying them during medical examinations. Some respondents stated that they did not need to collaborate with medical care. Type-B facilities often require support from doctors and nurses regarding support for psychiatric symptoms, guidance on medication, and other problems related to illnesses and treatment. Other opinions suggested that persons with mental disabilities should solve their problems themselves without intervention by doctors or nurses and that the support they want is absent. Among type-B continuous employment-support facilities that do not hire nurses, 25% would be unable to hire them, although desired, because of financial difficulties or other reasons, and 72% did not consider doing so.
Conclusion
Among the type-B continuous employment-support facilities, 76% collaborated with the psychiatric department. Some respondents indicated that medical collaboration was “Not required”. Among the types of support expected from doctors and nurses, those related to illness and treatment were the most commonly requested. But opinions emerged, including “No support is sought”. Many type-B continuous employment-support facilities that do not employ nurses, do not consider hiring nurses, and the most common reason is “Economically difficult to hire”.
Keywords: type-B continuous employment-support facilities, persons with mental disabilities, medical support
Introduction
In proportion to the increase in the number of regularly employed persons with disabilities, the number of persons using Hello Work (the public employment security office established by the Japanese Ministry of Health, Welfare, and Labour) has been increasing every year. In 2006, approximately 25,000 jobs were for people with physical disabilities, 11,000 for those with intellectual disabilities, and 6,739 for those with mental disabilities. In 2023, the number of persons with physical, intellectual, and mental disabilities was approximately 22,912; 22,201; and 60,598, respectively, with a marked increase in the number of persons with mental disabilities employed1). This is because persons with mental disabilities wish to work. Additionally, this can be explained by their inclusion in the actual employment rate of companies since FY2006 and that persons with mental disabilities are included in the calculation basis for the legal employment rate from 2018 based on the revised Law for the Employment Promotion of Persons with Disabilities enacted in 2013. Thus, promoting the employment of persons with disabilities through Hello Work increased the number of employed persons2).
Employment-related welfare services for persons with disabilities under the Services and Supports for Persons with Disabilities Act include “employment transition support”, “employment settlement support”, “Type-A continuous employment support”, and “Type-B continuous employment support”. According to the Services and Supports for Disabled Persons Act, “transition from welfare facilities to regular employment” was listed as one of the goals of the fifth Welfare Plan for Persons with Disabilities; a specific goal was to increase the actual transition to regular employment by 1.5 times in four years from 2016, and various employment supports were addressed in each employment-related welfare service for persons with disabilities3). Consequently, the number of persons with disabilities who were regularly employed through employment-related welfare services for persons with disabilities increased from approximately 2,460 in 2006 to 26,586 in 20234).
Currently, 38,496 persons with physical disabilities, 155,374 with intellectual disabilities, and 127,581 with mental disabilities are using employment-related disability welfare services5). Every year, persons with mental disabilities are increasingly using type-B continuous employment-support facilities, and their proportion is larger than that of those with intellectual and physical disabilities. Additionally, the number of users aged 65 years is increasing annually, which reflects the current situation. Specifically, the employment-support needs of users are met depending on the actual conditions of the community while responding to the aging population and the characteristics of their disabilities.
To meet the diverse needs of persons with mental disabilities who use type-B continuous employment-support facilities, daily life supporters have to possess various professional skills and collaborate with other professionals in various fields. At present, the main personnel at type-B continuous employment-support facilities are assigned as “service manager”, “vocational guidance staff”, and “daily living support staff”. No stipulated qualifications, licenses, or work experience are required for daily life supporters; however, they comprise numerous persons, including social workers, psychiatric social workers, and certified care workers6). Social workers are subject to additional compensation, as evidenced by the “additional compensation for placement of welfare specialists” in the unit price of compensation7).
Furthermore, another opinion suggested that occupational therapists should also be newly evaluated as a qualified worker in the “additional fee for placement of welfare specialists” to promote the transition to regular employment. The employment rate at employment transition support facilities with occupational therapists was more than twice that at facilities without occupational therapists. Data showed that more people continue to work at employment transition support facilities with occupational therapists than at facilities without occupational therapists. Therefore, occupational therapists are also expected to play an active role in the transition support services8). Although the personnel standards do not currently stipulate the assignment of nursing staff as part of the system for providing medical and nursing care at type-B continuous employment-support facilities, an additional fee is stipulated for nursing staff in collaboration with the facility, as shown in the “Additional fee for medical collaboration system”9).
Some persons with mental disabilities use type-B continuous employment-support facilities cannot concentrate on their work because of psychiatric symptoms10). Thus, these facilities must assess their psychiatric symptoms, support them to stabilize their symptoms, and encourage them to seek medical care when their psychiatric symptoms worsen. Regarding the current calculation of the “additional fee for medical collaboration system” for employment support, the number of facilities that calculate the “additional fee for medical collaboration system II” to provide nursing care for 2–8 users is increases annually (62 facilities in 2017 and 408 facilities in 2020). Nevertheless, nationwide, of the 9,176 type-B continuous employment-support facilities, 408 had calculated the additional fee for medical collaboration system II (in 2020)—approximately 4% of the total number of facilities9). This situation raised the question of how type-B continuous employment-support facilities are currently collaborating with psychiatric care and what these facilities’ intentions are regarding their collaboration with medical care.
Patients and Methods
This study clarifies the current status of collaboration between type-B continuous employment-support facilities and psychiatric care and the intention of these facilities for medical collaboration.
Study design
This is a cross-sectional study using a self-administered anonymous questionnaire via mail.
Participants
Managers of type-B continuous employment-support facilities for persons with mental disabilities participated in this study. Among the type-B continuous employment-support facilities registered nationwide in the “Information on Employment Support for Persons with Disabilities-National Version”, which is posted on the website of the “General Incorporated Association SHISHIN”11), we randomly selected 400 facilities used by persons with mental disabilities, excluding those with physical or intellectual disabilities. We sent the following documents to the managers of type-B facilities: “Request for participation in the survey (request document)”, “To the manager who will cooperate in the study (research instructions)”, and “Questionnaire survey form”. Consent to participate in this study was obtained by scanning the quick response (QR) code on the “Questionnaire survey form” and checking the box “I understand the content of the research instructions and agree to participate in the study”.
Data collection period
The data collection period was December 1, 2023, to March 1, 2024.
Survey items
The questions were answered using Microsoft forms, and the study participants were asked to respond by reading the URL or QR codes. The survey items are listed in Table 1.
Table 1. Questionnaire.
| Questions about the administrator | 1. Age |
| □20–29 years old □30–39 years old □40–49 years old □50–59 years old □60 years old or older | |
| 2. Years of experience as a manager | |
| □Less than 6 months □6 months to 1 year □1–3 years □3–5 years □5 years or more | |
| 3. Job title (qualifications) of the manager *More than one. | |
| □Social worker □Mental health worker □Occupational therapist □Clinical psychologist □Doctor | |
| □Nurse (public health nurse) □Care worker □Home care worker □Other | |
| Questions about our offices | 4. Maximum number of mentally disabled persons using your establishment |
| □20 people or less □21–30 people □31–40 people □41–50 people □51 people or more | |
| 5. Number of users with mental disabilities who currently use your office | |
| □1–10 □11–20 □21–30 □31–40 □41–50 □51 or more | |
| 6. Average number of mentally disabled persons using your establishment per year | |
| □20 people or less □21–30 people □31–40 people □41–50 people □51 people or more | |
| 7. Average length of stay for mentally disabled persons currently using your business | |
| □Less than 6 months □6 months to 1 year □1–3 years □3–5 years □5 years or more | |
| 8. Number of life guidance staff belonging to your establishment | |
| □1–2 people □3–5 people □6–8 people □9–10 people □11 or more people | |
| 9. Job titles of staff belonging to your establishment | |
| □Social worker □Mental health worker □Occupational therapist | |
| □Clinical psychologist nurse (public health nurse) □Assistant nurse □Care worker □Helper □Others | |
| 10. Does your establishment have a psychiatric hospital to collaborate with? | |
| □Operating body works with the same psychiatric hospital | |
| □There is no psychiatric hospital with which we collaborate | |
| Questions about medical cooperation | 11. Please tell us about any situations in which you have determined that the mentally disabled persons who use your office need support from doctors and nursing staff for their illnesses or therapeutic problems. Please list many situations. [Free description]. |
| 12. Please tell us about any situation in which a mentally disabled person using your facility was judged to need support from a doctor or nurse for a problem in their life. Please tell us about any situation in which a doctor/nursing staff identified the need for assistance. [Free description] | |
| 13. Please tell us about any situation in which a mentally disabled person using your office was identified as needing assistance from a physician or nursing staff for a work-related problem at your office. [Free description] | |
| 14. How do you collaborate with doctors and nurses when it is determined that a person with mental disabilities using your facility needs support from doctors and nurses? [Free description] | |
| 15. Are there any users with mental disabilities who are currently receiving the “Additional fee for medical cooperation system”? | |
| □No □1–5 people □6–10 people □11 or more people | |
| 16. (Managers who chose “1 peaple or more people” in 15) Please tell us about the specific care you are providing. [Free description] | |
| 17. (Establishments not staffed with nurses) Would you like to hire nurses in the future? | |
| □Would like to hire □Would like to hire but cannot □Do not plan to hire | |
| 18. (Managers who chose “Would like to hire” in 17) Please tell us why you want to hire them. [Free description] | |
| 19. (Managers who chose “Would like to hire but cannot” in 17) Please tell us why you want to hire but cannot. [Free description] | |
| 20. (Managers who selected “Do not plan to hire” in 17) Please tell us why you are not considering employment. Please tell us the reason why you are not thinking about employment. [Free description] | |
Analysis method
Basic statistics were calculated for questions concerning the attributes of the managers participating in this study (Questions 1–3), attributes of type-B continuous employment-support facilities (Questions 4–10), and questions concerning medical collaboration (Questions 14 and 15). For the free descriptions of medical collaboration (Questions 11–14, 16, 18–20), we grouped sentences with similar meanings and generated categories. These categories are described in [].
Ethical considerations
This study was approved by the Ethics Review Committee for Research Involving Human Subjects of the Bukkyo University (C2023-1). The participants, protection of their human rights and personal information, and possible disadvantages to persons resulting from the study were considered. No conflicts of interest were to be declared.
Definition of terms
Type-B continuous employment-support facilities
Type-B continuous employment-support facilities are disability welfare services that provide work opportunities without an employment contract for persons with disabilities who find it difficult to work under an employment contract. This service aims to help those persons to work for regular companies under employment contracts. It intends to help them acquire the necessary skills to transition to regular employment.
Additional fee for medical collaboration system
The additional fee for the medical collaboration system is the fee levied when nurses visit welfare service facilities for persons with disabilities in collaboration with medical institutions, provide nursing care to persons and children with disabilities, or instruct authorized specific action service workers (e.g., care workers) for sputum suctioning.
Results
Of the 400 type-B continuous employment-support facilities to which survey forms were mailed, 65 managers responded, and 63 agreed to participate and were included in the study (response rate: 15.75%).
Attributes of managers and type-B continuous employment-support facilities
Twenty managers (32%) aged 50–59 years accounted for the largest age group. The most common duration of managerial experience was five years or more (n=38 managers [60%]) (Table 2). The most common job title (qualification) for managers was mental health worker (n=25 [33%]), followed by nurse and public health nurse (n=6 [8%]). For facility staff, the most common job title (qualification) was mental health worker (n=30 [24%]), followed by nurse and public health nurse (n=8 [6%]) (Table 3).
Table 2. Administrator attributes (n=63).
| Age of manager | 30–39 years, n (%) | 7 | 11 |
| 40–49 years, n (%) | 19 | 30 | |
| 50–59 years, n (%) | 20 | 32 | |
| 60 years or older, n (%) | 17 | 27 | |
| Years of management experience | Less than 6 months, n (%) | 1 | 2 |
| 6 months to less than 1 year, n (%) | 1 | 2 | |
| 1–3 years, n (%) | 12 | 19 | |
| 3 to less than 5 years, n (%) | 11 | 17 | |
| More than 5 years, n (%) | 38 | 60 | |
Table 3. Job titles and qualifications of managers and their staff (n=63).
| Admin. Job Title and Qualifications | Mental health welfare professional, n (%) | 25 | 33 |
| Social worker, n (%) | 11 | 15 | |
| Caregiver, n (%) | 8 | 11 | |
| Nurses and public health nurses, n (%) | 6 | 8 | |
| Licensed psychologist, n (%) | 5 | 7 | |
| Not qualified, n (%) | 5 | 7 | |
| Child care workers, n (%) | 2 | 3 | |
| Social welfare officer, n (%) | 2 | 3 | |
| Initial caregiver training, n (%) | 1 | 1 | |
| Teaching license, n (%) | 1 | 1 | |
| Occupational therapists, n (%) | 1 | 1 | |
| Workplace adjustment assistants, No. 1 n (%) | 1 | 1 | |
| Clinical psychologist, n (%) | 1 | 1 | |
| Belonging to a Business Staff Positions and Qualifications | Mental health welfare professional, n (%) | 30 | 24 |
| Caregiver, n (%) | 29 | 23 | |
| Social worker, n (%) | 20 | 26 | |
| Nurses and public health nurses, n (%) | 8 | 6 | |
| Not qualified, n (%) | 7 | 6 | |
| Cook, n (%) | 4 | 3 | |
| Service manager, n (%) | 3 | 2 | |
| Occupational therapists, n (%) | 3 | 2 | |
| Social welfare officer, n (%) | 3 | 2 | |
| Nutritionists, n (%) | 2 | 2 | |
| Licensed psychologist, n (%) | 2 | 2 | |
| Vocational instructor, n (%) | 2 | 2 | |
| Child care workers, n (%) | 2 | 2 | |
| Home care workers, n (%) | 2 | 2 | |
| Clinical psychologist, n (%) | 2 | 2 | |
| Peer support specialist, n (%) | 1 | 1 | |
| Helper level 2, n (%) | 1 | 1 | |
| Elementary school teachers, n (%) | 1 | 1 | |
| Life guidance staff, n (%) | 1 | 1 | |
| Life support staff, n (%) | 1 | 1 | |
| Public health nurses, n (%) | 1 | 1 | |
| Kindergarten teachers, n (%) | 1 | 1 | |
(Multiple answers allowed).
Current status of collaboration between type-B continuous employment-support facilities and medical institutions
Forty-eight (76%) type-B continuous employment-support facilities collaborated with psychiatrists. Fifty-nine facilities (94%) did not calculate additional fees for their medical collaboration system (Table 4).
Table 4. Establishments with persons with mental disabilities for which the additional fee for medical coordination system is calculated (n=63).
| Establishments with mentally disabled persons for which the additional fee for the medical coordination system is calculated | 0 person, n(%) | 59 | 94 |
| 1–5 persons, n (%) | 2 | 3 | |
| 11 or more, n (%) | 2 | 3 | |
| Total | 63 | 100 | |
When mentally disabled persons using type-B continuous employment-support facilities need support from a doctor or nurse, the methods for medical collaboration were categorized as follows: [Contact and coordinate with social workers], [Call us for a consultation], [Contact and coordinate with physicians and nurses], [Accompanying a patient to a medical examination], [Organize meetings and conferences], [Provide information in print], [Encourage the individual to see a doctor and consult with them], [Not required], and [Hear information from the person in question] (Table 5).
Table 5. Responses when medical cooperation is deemed necessary at type-B employment-support facilities (Total number of codes=69).
| Categories | Representative data (69) | Examples of codes |
|---|---|---|
| Contact and coordinate with social workers | Communication through a mental health worker at the hospital | 17 (24.6%) |
| Cooperation with consultation support offices | ||
| Contact your caseworker to inform your doctor, etc. | ||
| Call us for a consultation | Call us for a consultation | 15 (21.7%) |
| Call us immediately and ask for instructions, etc. | ||
| Contact and coordinate with physicians and nurses | I try to consult directly with my doctor or nurse | 12 (17.4%) |
| Information sharing with visiting nurses | ||
| I’m asking for a medical information form | ||
| I am a nurse, so I consult directly with the healthcare providers, etc. | ||
| Accompanying a patient to a medical examination | Accompanying regular hospital visits | 12 (17.4%) |
| Accompany users to confirm instructions, etc. | ||
| Organize meetings and conferences | Conferences and staff meetings at medical institutions | 5 (7.2%) |
| Have a meeting of persons in charge be held with consultation support specialists, etc. | ||
| Provide information in print | Create a hospital visit letter to be given at the time of hospital visit to let the patient know how they are doing on a daily basis | 3 (4.3%) |
| Have the doctor read it to you when you visit the doctor, etc. | ||
| Encourage the individual to see a doctor and consult with them | Recommend the user to see a doctor | 2 (2.9%) |
| Ask for information from the person | ||
| Not required | None in particular | 2 (2.9) |
| There is no need for it to be | ||
| Hear information from the person in question | interview the person after visiting a medical institution and hear from them | 1 (1.4%) |
Situations requiring support from doctors and nurses at type-B continuous employment-support facilities
The following categories were generated for the situations in which support from doctors and nurses was needed at type-B continuous employment-support facilities: [When psychiatric symptoms must be dealt with], [When physical problems occur], [When aggression occurs], [When unable to concentrate on work], [When guidance on medication is needed], [When support for sleep is needed], [When there are changes in interpersonal relationships], [When there are problems with daily living], [When the number of days of attendance to the facility decreases], [When support for the method of attendance is required], [When support is needed for the living environment], [When the frequency of attendance changes], [When guidance is needed regarding work methods], [When consideration is needed regarding work hours], [When persons themselves solve their problem], and [No support is sought] (228 codes in total).
For the “Support for illness and treatment problems (88 codes)”, the most common situation requiring support from doctors and nurses was [When psychiatric symptoms must be dealt with] (40 codes).
For the “Support for problems in daily life (79 codes)”, the most frequent need for support from doctors and nurses was [When there are problems with daily living] (21 codes). For the “Support for work-related problems at facilities (61 codes)”, the most frequent need for support from doctors and nurses was [When unable to concentrate on work] (7 codes). Nonetheless, [When no support is sought] (20 codes) was frequently mentioned (Table 6).
Table 6. Situations requiring support from physicians and nurses at Type-B employment support facilities.
| Categories | Examples of codes | Support for illness and treatment problems Typical code | Examples of codes 88 (100%) | Support for problems in daily life Typical code | Examples of codes 79 (100%) | Support for work-related problems at facilities Typical code | Examples of codes 61 (100%) |
|---|---|---|---|---|---|---|---|
| When psychiatric symptoms must be dealt with | 53 (22.8%) | When auditory hallucinations worsen When the anxiety gets too much When suicidal thoughts persisted When the obsession is strong When the delusional state becomes stronger, etc. |
40 (45.5%) | When there is trouble among family members and
auditory hallucinations are evident When interpersonal relationships exacerbate psychiatric symptoms When depressive symptoms worsen When helping with addictions (alcohol, gambling, etc.) When weight loss due to eating disorders, etc. |
10 (12.7%) | When panic symptoms do not subside When an adult with a developmental disability needs assistance When symptoms worsen during work |
3 (4.9%) |
| When physical problems occur | 24 (10.3%) | Diarrhea and vomiting When symptoms of cardiovascular disease are observed Physical symptoms of falls When an injury occurs during work When hypoglycemic symptoms occur, etc. |
10 (11.4%) | In case of worsening of physical illness
When a person with an eating disorder needs physical treatment When dietary restrictions or diabetic dietary support is needed Weight loss in patients with eating disorders When menopausal symptoms or physical changes are observed, etc. |
9 (11.4%) | When infection prevention measures are required
In the event of physical illness When absent due to illness When you are injured in the course of your work In the event of an accident during work |
5 (8.2%) |
| When aggression occurs | 16 (6.9%) | When he becomes aggressive as if his personality has
changed When he suddenly became aggressive When the person becomes aggressive or has an extremely poor attitude toward the work, other |
14 (15.9%) | (No data) | 0 (0.0%) | When many offensive remarks were made When you have been working roughly |
2 (3.3%) |
| When unable to concentrate on work | 13 (5.6%) | When you are working and you raise your voice
When you only make your point and do not listen to others at all When the motivation to work declines, etc. |
6 (6.8%) | (No data) | 0 (0.0%) | When you feel sleepy in the morning and cannot
concentrate on your work When anxiety is high and work is out of control When you need advice on how to respond effectively to a situation in which you become restless while working, etc. |
7 (1.5%) |
| When guidance on medication is needed | 23 (9.9%) | When problems related to medical care occur, such as
refusal of medication When symptoms worsen and the need for prescription adjustment is felt When the action of the drug therapy is too strong (is it too much drug or side effect?), etc. |
14 (15.9%) | When they stop taking their medication When the drug was found to be negligent When assistance is needed for those who cannot manage their medications, etc. |
9 (11.4%) | (No data) | 0 (0.0%) |
| When support for sleep is needed | 11 (4.7%) | When sleep disturbances worsen When you are not getting a good night’s sleep and feel unwell The situation in which the individual has persistent insomnia and finds it difficult to cope on their own, and other situations |
4 (4.5%) | When sleep becomes irregular When insomnia persists When complaints of inability to sleep become frequent, etc. |
7 (8.9%) | (No data) | 0 (0.0%) |
| When there are changes in interpersonal relationships | 15 (6.5%) | (No data) | 0 ( 0.0%) | Need assistance when problems arise in relationships
When the patient does not respond to the voices of supporters and family members due to neighborhood troubles, etc., or when the patient is in a state where they do not respond to the voices of supporters and family members, etc. |
13 (16.5%) | When there is a change in the relationship with
other users When you need counseling and support in your relationships within the office |
2 (3.3%) |
| When there are problems with daily living | 25 (10.8%) | (No data) | 0 (0.0%) | When you cannot eat In case of a disturbance of the
purity of the water When a house is trashed, other |
21 (26.6%) | When assistance is needed for those who show signs
of incontinence (urine, feces) When I tend to be withdrawn When there is a change in behavior, such as difficulty in moving due to side effects of medication, or when there is a change in the way you feel, please consult with your doctor, etc. |
4 (6.6%) |
| When the number of days of attendance to the facility decreases | 7 (3.0%) | (No data) | 0 (0.0%) | When the commute is delayed | 1 (1.3%) | When the number of days of attendance decreases
When late arrivals and early departures increase, etc. |
6 (9.8%) |
| When support for the method of attendance is required | 2 (0.9%) | (No data) | 0 (0.0%) | When you want to live alone When you feel you need respite due to domestic violence, etc. |
2 (2.5%) | (No data) | 0 (0.0%) |
| When support is needed for the living environment | 1 (0.4%) | (No data) | 0 (0.0%) | When assistance is needed for those who have difficulty in getting to and from the office | 1 (1.3%) | (No data) | 0 (0.0%) |
| When the frequency of attendance changes | 6 (2.6%) | (No data) | 0 (0.0%) | (No data) | 0 (0.0%) | When there is a request for a change in the number of days of attendance In the case of a change in the number of days of attendance, etc. | 6 (9.8%) |
| When guidance is needed regarding work methods | 3 (1.3%) | (No data) | 0 (0.0%) | (No data) | 0 (0.0%) | When assistance is needed for those who cannot
understand the instructions When age-related problems cause a decline in work movement and comprehension When you teach them a task, but they do not learn it and forget it soon |
3 (4.9%) |
| When consideration is needed regarding work hours | 2 (0.9%) | (No data) | 0 (0.0%) | (No data) | 0 (0.0%) | When work time needs to be taken into consideration
When you need to take a break and take care of your health |
2 (3.3%) |
| When persons themselves solve their problem | 2 (0.9%) | (No data) | 0 (0.0%) | We basically solve our own problems in life | 1 (1.3%) | Users who think their doctor’s wishes are absolute are asking their doctor’s opinion | 1 (1.6) |
| No support is sought | 29 (12.5%) | (No data) | 0 (0.0%) | None in particular | 5 (6.3%) | None in particular | 20 (32.8) |
Employment of nurses
Among the type-B continuous employment-support facilities that do not include nurses (53 facilities in total), two facilities (4%) “would like to hire” nurses, 13 (25%) “would like to hire but cannot”, and 38 (72%) “are not thinking about hiring” nurses (Table 7). The most common reason for “want to hire but cannot” and “are not thinking about hiring” was [economically difficult to hire]. Other reasons for “would like to hire but cannot” and “are not thinking about hiring” were [do not feel the need for support from nurses], [have medical collaboration with other institutions], [have medical collaboration within the same corporation], [have collaboration with other facilities], and [not involved in personnel affairs] (Table 8).
Table 7. Intentions regarding employment of nursing professionals (n=53).
| Idea of hiring nurses | Number of offices | % | |
|---|---|---|---|
| Idea of hiring nurses | Would like to hire | 2 | 4% |
| Would like to hire but cannot | 13 | 25% | |
| Are not thinking about hiring | 38 | 72% | |
| Total | 53 | 100% |
Table 8. Reasons for being unable to hire or not considering hiring nurses (Total number of codes=48).
| Categories | Representative data | Examples of codes |
|---|---|---|
| Economically difficult to hire | Labor costs cannot be afforded | 21 (43.8%) |
| Economically demanding | ||
| Not paid enough to hire, etc. | ||
| Do not feel the need for support from nurses | We had nurses in place before, but there was not much need for them | 13 (27.1%) |
| Medical care is done by medical care, and welfare is done by welfare, and medical care and welfare work together | ||
| Many of them have basically stable medical conditions (medication management, regular visits to the hospital, etc.) | ||
| The idea of a nurse in the field of welfare had never occurred to me before, etc. | ||
| Have medical collaboration with other institutions | Those who need medical support use visiting nurses and helpers | 7 (14.6%) |
| In collaboration with a psychiatric hospital | ||
| The company can resolve issues in cooperation with medical care outside the business site , etc. | ||
| Have medical collaboration within the same corporation | The care service business is already staffed with nurses for multifunctional operations | 5 (10.4%) |
| As the president and former director (board member) are nurses, other, etc. | ||
| Have collaboration with other facilities | Additionally, the company will collaborate with other Type-B facilities operated by medical institutions and refer those who require medical care to them | 1 (2.1%) |
| Not involved in personnel affairs | The head office manages personnel affairs | 1 (2.1%) |
Discussion
Current status of collaboration with psychiatric care at type-B continuation employment-support facilities
Four facilities (6%) did not calculate the additional fees for the medical collaboration system. However, 76% of the facilities collaborated with the psychiatric department; they provided support while being aware of the need for collaboration with psychiatric care. Nevertheless, although the facilities required support from doctors and nurses in dealing with psychiatric symptoms and problems with daily living activities, a number of facilities stated that [No support is sought], indicating the diversity of needs and expectations regarding medical collaboration. Because the need for and content of medical support varies from one user to another, the need for support through medical collaboration may be relatively low in some facilities. Specifically, as some persons with mental disabilities using type-B continuous employment-support facilities can establish themselves in the community, they control their symptoms because they understand their psychiatric symptoms12) and voluntarily receive medical care, even without support through medical collaboration. Presumably, introducing an additional fee is not necessary for a medical collaboration system for persons with mental disabilities.
Additionally, the distance from medical institutions and medical collaboration systems varies by region and facility, which may influence the introduction of the additional fee. Establishing a system allowing seamless services from nursing care to home medical care is necessary more in rural areas where support is scarcer than in urban areas where multiple medical and nursing care supports are available13). Thus, these regional factors contribute to the variability in the degree of medical collaboration.
When looking at the regular income status of persons with mental disabilities who use outpatient services, only 21.8% included salary in their regular income, many depended on other income sources besides earned income such as assistance from parents and siblings or public assistance, and 18.1% had no regular income—they are in a difficult economic situation14). Many persons with mental disabilities use the psychiatric outpatient care system (a subsidy system for medical expenses for persons with mental disabilities in the medical expenses subsidy system for persons with disabilities called the Medical System for Services and Supports for Persons with Disabilities)15), in which 10% of the total medical expenses are paid by the patient. Thus, many people who use type-B continuous employment-support facilities may be economically inadequate and react negatively to accepting the additional fee because of the direct burden of the increased medical expenses. Furthermore, if they find the benefits of the additional fee difficult, they may perceive the additional financial burden as a “loss”. To eliminate such misunderstanding and resistance, facilities must carefully explain the mechanism and purpose of the additional fee system while focusing on its benefits for persons with mental disabilities. To accelerate the understanding of the introduction of additional fees, promoting medical collaboration is crucial to improve the quality of support for users, which leads to stability in their lives, and increases employment opportunities. Users concerned about the increase in out-of-pocket expenses because of the additional fee must be informed of financial support through deductions for medical expenses, the use of welfare services, and subsidy programs at municipal level to reduce their actual burden. In particular, for users in difficult financial situations, establishing a support system to minimize their burden would be an important factor to promote medical collaboration.
Furthermore, some users may feel that aminimal medical collaboration is sufficient. In psychiatric care, empathizing with the thoughts and wishes of people with mental disabilities is important when they convey their thoughts and wishes to medical institutions so that they can decide16). Therefore, to respect the wishes of users is desirable without necessarily forcing them to accept additional fees, and seek a flexible form of medical collaboration that meets their individual needs. Expectations are that through such a response, users will be more likely to accept the additional fee, and the quality and effectiveness of medical collaboration will be further enhanced.
Collaboration issues with psychiatric care at type-B continuous employment-support facilities
In these facilities, situations requiring medical support occur frequently, especially when dealing with psychiatric symptoms and behavioral problems in daily living. Support for all aspects of daily life is also important, including problems in daily living and difficulty concentrating on work. Thus, close collaboration between medical care and welfare is essential to provide employment-support to persons with mental disabilities.
The worsening of psychiatric symptoms creates a negative cycle of disruption of living conditions and an inability to perform tasks that were previously possible. An early medical approach is necessary to prevent such situations. Although collaborative measures such as “Organize meetings and conferences” and “Accompanying a patient to a medical examination” are effective, many facilities find it difficult to implement them in parallel with their daily work regarding the required time and manpower. Additionally, medical collaboration for users with mental disabilities requires individualized support, which can place a heavy burden on facilities. Because the facility usually requests medical care from a medical institution, the increasing burden is assumed to be on the facility.
Furthermore, if the facility does not recognize the need for collaboration, a risk exists that the necessary support may not be provided. Therefore, establishing a system in which medical institutions actively support the facility is desirable. Specifically, medical staff should regularly visit to check the health status of users. An online system for regular monitoring should be established to reduce the burden on the facility and ensure that the required medical support is promptly provided. Moreover, creating a system in which multiple facilities work together to share medical resources can reduce this burden. For example, multiple facilities could jointly employ medical staff.
If medical collaboration is not smooth, prompt action, such as “Accompanying a patient to a medical examination”, may not be taken in the event of an emergency, such as a sudden worsening of a user’s symptoms. In particular, action may be delayed in rural facilities, where collaborative measures are limited or full-time medical staff are not available. Employment-support facilities often contact medical institutions to ask “what to do” only when they are at a loss for a response—when they are in dire straits17). The psychiatric emergency medical care system is an important foundation for supporting the community life of persons with mental disabilities18). Building strong partnerships with medical institutions and local emergency systems that can respond immediately in emergency situations is needed. For example, establishing a dedicated point of contact for emergency responses and strengthening local medical networks would enable rapid assistance. Importantly, regular simulation drills should be conducted to familiarize staff with emergency responses.
However, when type-B continuous employment-support facilities determine the need for medical collaboration for persons with mental disabilities using the facilities, opinions also emerged, including “Recommend the user to see a doctor”, “Ask for information from the person”, and “interview the person after visiting a medical institution and hear from them”.
In other words, to settle persons with mental disabilities in the community, they should appropriately understand and manage their symptoms and treatment status and maintain links with psychiatric care, allowing users to consult and receive medical examinations as needed. Nevertheless, as persons with mental disabilities have little awareness of their illness, they cannot adequately self-manage their medication at home after discharge from the hospital, resulting in recurrence or relapse of their illness and repeated re-hospitalization, which is a “revolving door phenomenon”19). In type-B continuous employment-support facilities, some users experience difficulties in working because of their illnesses, such as not being able to meet expectations, feeling limited in their work, not being able to concentrate on their work, having difficulty working long hours, and not being able to simultaneously do many things at once10). Therefore, support for such persons with mental disabilities need clarification to proactively maintain their connection with psychiatric care, their problems and worries, what they do to overcome them, and the social resources they use must be explained.
Many facilities do not employ nurses because of financial constraints. The percentage of unprofitable type-B continuous employment-support facilities was 35%; more than one-third of the facilities struggle to run their services. Although type-B support facilities require specialized staff and support personnel, securing such staff is increasingly difficult20). The assignment of nursing staff is considered ideal; however, budgetary constraints continue to make this difficult. Additionally, some facilities do not feel the need for nursing staff, because medical collaboration is supplemented by other agencies within the corporation. Furthermore, medical collaboration is left to the users themselves; however, this does not necessarily apply to all users because they require the ability to self-manage their psychiatric symptoms. Worsening psychiatric symptoms significantly impact daily life and work, and symptom stability is essential for continued employment. Therefore, a certain level of a medical support system is required, and collaboration with medical care is an essential element for fulfilling the employment needs of job retention21). For facilities that do not include medical personnel, including nurses, the importance of medical collaboration and need for early response to users’ health conditions should be highlighted. The effectiveness of medical support and case studies should be shared through training and seminars, recognizing the need for medical collaboration and eventually promoting collaboration between facilities and medical care. These measures are expected to aid the smooth and effective implementation of medical collaboration and strengthen medical support for users at type-B continuous employment-support facilities.
Conclusion
Current status of collaboration between type-B continuous employment-support facilities and medical institutions
Among type-B continuous employment-support facilities, 6% calculated an additional fee for the medical collaboration system, although 76% of these facilities collaborated with the psychiatric department. The methods of medical collaboration for persons with mental disabilities who use type-B continuous employment-support facilities were as follows: [Contact and coordinate with social workers], [Call us for a consultation], [Contact and coordinate with physicians and nurses], [Accompanying a patient to a medical examination], [Organize meetings and conferences], [Provide information in print], [Encourage the individual to see a doctor and consult with them], and [Hear information from the person in question]. Some respondents indicated that medical collaboration was [Not required].
Situations requiring support from doctors and nurses in type-B continuous employment-support facilities
Situations in which support from doctors and nurses is needed in type-B continuous employment-support facilities were as follows: [When psychiatric symptoms must be dealt with], [When physical problems occur], [When aggression occurs], [When unable to concentrate on work], [When guidance on medication is needed], [When support for sleep is needed], [When there are changes in interpersonal relationships], [When there are problems with daily living], [When the number of days of attendance to the facility decreases], [When support for the method of attendance is required], [When support is needed for the living environment], [When the frequency of attendance changes], [When guidance is needed regarding work methods], and [When consideration is needed regarding work hours]. Other opinions emerged, including [When persons themselves solve their problem] and [No support is sought]. Doctors and nurses often request support for illness and treatment problems.
Employment of nurses
Many type-B continuous employment-support facilities that do not employ nurses, do not consider hiring nurses. The most common reason is financially difficulty to hire them.
Conflict of interest
The author declares no conflicts of interest.
Funding information
Graduate School of Social Welfare, Bukkyo University and Wakayama Faculty of Nursing, Tokyo Healthcare University.
Ethics approval and consent to participate
This study was approved by the Ethics Review Committee for the “Research Involving Human Subjects” at Bukkyo University (C2023-1). Informed consent was obtained from all participants after full disclosure of the aims and procedures of the study.
Consent for publication
I consent to publication in the Journal of Rural Medicine.
Data availability statement
Data supporting the findings of this study are available from the corresponding author upon request.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Data supporting the findings of this study are available from the corresponding author upon request.