Historical Changes in Home Care Service and Its Future Challenges

Introduction

The pressing changes to Japan’s medical care delivery system as the population ages has been bringing attention to home care. As Japanese society ages, the elderly made up 23.1% of the population in 2010, the highest in the world, and this rate is expected to increase further. In these conditions, when we look at trends in the place of death in Japan, we find that the percentage of people who died at home was over 80% around 1950, while the percentage of hospital deaths was over 10%, but this trend has reversed since 1976, with 78.5% of deaths taking place in a hospital in 2011 and 12.5% at home.

The spread of medical technology previously only available in hospitals, such as artificial respirators, likely played a large part in this. This has resulted in a fact that very few people have the chance to experience a natural death in their own surroundings without using such an edging-cut device. At present, we rely on hospitals for end-of-life care and terminal care, but future estimates of terminal care locations suggests that even if the number of home deaths increases by about 1.5 times the current level, in 2030 about 470,000 people will not have a place for end-of-life care because of the limited capacity of the hospitals and nursing care facilities.

In a questionnaire asking respondents where they want to receive end-of-life care, about 60% said that they wanted to be treated at home for as long as possible, but many people also worried about burdening their families and about how sudden changes in their symptoms would be handled.

Indeed, in a patient survey carried out in October 2011, 110,700 people nationwide are expected to receive home care from either hospitals or clinics (visiting care or home visits by a doctor), but of these, 67,200 received visiting care, which is not very high. In order to deliver stable home care, a home care delivery system provided through inter-professional collaboration must be developed in collaboration with the hospitals that will be taking in emergency patients.

Historical Changes in Home Care Service(Table 1)

Table 1.

Changes in systems and programs related to the promotion of home care

Year	Medical fee	Medical service law and long-term care insurance act	Related programs
(Prepared by the author based on the Ministry of Health, Labour and Welfare: Fiscal 2012 materials 1. from briefing on home care collaborative base operations held on July 11, 2012.)
1981	Establishment of guidance and management fees for home care (guidance and management of insulin self-injection at home made eligible for insurance coverage)
1985		First revised Medical Service Law: community medical plans established
1986	Concept of visiting care introduced		Revisions to Health and Medical Service Act for the Aged (health care facilities for the elderly set up)
1991			Revisions to Health and Medical Service Act for the Aged (visiting nurse stations for the elderly set up)
1992	Comprehensive home care for bed-ridden elderly covered under insurance	Second revised Medical Service Law: “Homes” designated as health service delivery point
1994	Augmentation of assessment of end-of-life care at home (fees for medical management at home, end-of-life home care fees, terminal care made eligible for coverage)	Revised Health Insurance Act: Home care made eligible for insurance coverage; designated visiting nurse system set up
1998	24-hour collaborative system for comprehensive home care for bed-ridden elderly added to coverage
2000		Long-term Care Insurance Act goes into effect
2004	Home care for seriously ill and terminal patients augmented		Program to promote visiting nurses
2006	Home care support clinics established	Fifth revised Medical Service Law: Aspects related to ensuring home care included in medical plans, revised Long-term Care Insurance Act
2008	Home care support hospitals established
2011			Home care collaborative base program
2012	Enhanced home care support clinics and hospitals established	Guidelines for development of home care system released	Home care collaborative base program

Home care was institutionalized under the medical fee system in 1981 when self-injection of insulin became eligible for health insurance coverage. Subsequently, in 1986, the year after the community health care plan started under the first revised Medical Service Law, the Health and Medical Service Act for the Aged was revised, and visits to bedridden elderly people became eligible for insurance coverage. In 1992, the second revised Medical Service Law designated homes as a place for medical care delivery. In the 1994 Health Insurance Act, home care was made eligible for medical insurance coverage.

Home care, previously called “home visits,” was often employed as an emergency measure for patients who were bedridden due to a serious illness and patients whose condition had suddenly worsened, but in recent years, home care has been provided to patients who are in the convalescent stage after the completion of acute therapy as well as patients with chronic conditions requiring regular treatment.

Subsequently, when the medical fee program was revised in 1998, the 24-hour collaborative system for comprehensive home care for bed-ridden elderly was added to coverage. In 2006 and 2008, home care support clinics and home care support hospitals were established as systems eligible for insurance coverage.

Thirty years have passed since the national government took up home care as a policy issue. However, as we stated above, home care itself is still not being delivered to those who really need it. To address this, the Ministry of Health, Labour and Welfare initiated many operations nationwide in 2012, designating it the year in which home care and nursing would be stabilized.¹ The Ministry put 2.3 billion yen (ca. 20 million US$) into the establishment of bases serving as home care support centers (home care collaboration bases) and 109 million yen (ca. one million US$) on training home care physicians.

The 2012 medical fee revisions added 150 billion yen (ca. 1.3 billion US$) to strengthen affiliations between medical care and nursing care and to augment home care. In the nursing fee revisions, resources were allocated with an emphasis on comprehensive community care, starting with the establishment of a new menu that included visiting nurses for 24-hour regular house rounds and on-demand visits.

When the medical plan was revised in 2012, home care was designated as a pillar alongside the “five diseases and five medical systems” for major challenges, with the establishment of the “Guidelines for Developing a Home Care System.”

Initiatives to Promote Home Care at National Center for Geriatrics and Gerontology

Figure 1 shows the initiatives taken thus far by the National Center for Geriatrics and Gerontology to promote home care. The National Center invited members of groups, research organizations and academic societies related to home care in Japan to establish the Home Care Promotion Conference. Since 2007, conferences have been held to take opinions of stakeholders on policies to promote home care through end-of-life in Japan.

Fig. 1.

Main home care-related programs run by National Center for Geriatrics and Gerontology

One of the activities of the Home Care Promotion Conference was to form a working committee to review national studies on home care and policies on staff training. As part of this, in 2008 the Home Care Net was set up, and symposiums such as forums to promote home care were held in the respective regions. In the same year, the Home Care Promotion Office was established to actively promote home care as a national policy.

In these conditions, a model hospital ward intended to form seamless affiliations with home care physicians were set up in April 2009 (home care support hospital wards) and carried out specific activities aimed at revitalizing community home care services. It has been reported that with the active involvement of hospitals in home care support as a community base, the reversion rate from hospital to home and the rate of end-of-life care at home increased, and that the involvement of hospitals in promoting home care is important.

Future Approach to Home Care

Expansion of home care collaboration bases programs

Home care collaboration bases programs were initiated throughout Japan, primarily in 2012, the year designated for stabilizing home care and nursing.

There were 10 programs nationwide in fiscal 2011, but 105 in fiscal 2012. In these programs, the institutions offering home care services were served as centers to build a support system for home care through inter-professional collaboration. And they carried out activities aimed at providing comprehensive and ongoing home care in communities in collaboration between medical care and nursing. The bases work to overcome obstacles at the municipal level, and ultimately must promote collaboration between governments, medical associations, home care support clinics and hospitals, visiting nurse stations and nursing organizations so that the program is deployed from single points to the greater population.

This operation is expected to contribute to the development of the comprehensive community care system currently promoted following revisions to the Nursing Insurance Act. Since fiscal 2013, it has been sustained as an official prefectural project with emergency grants for the revitalization of community health care, and more than 500 bases were set up nationwide. This is equivalent to almost one-third of the approximately 1,700 local municipal governments nationwide, thus bringing bases for home care close to most residents.

Contributions to the comprehensive community care system by medical and nursing collaborations

According to the Comprehensive Community Care Research Society (Fiscal 2008 Health Services and Health Promotion Services for the Elderly)² the definition of community care is “a community system which enables the appropriate delivery of services that support daily life in a variety of ways, including medical and nursing services, as well as welfare services, within their daily sphere to ensure safe, secure and healthy lives with the basic assumption being that homes should be provided based on needs.” The comprehensive community care sphere is defined as, ideally an area that could be covered within 30 minutes—specifically, this would be equivalent to the boundaries for junior high-school district.

In providing comprehensive community care in the regions, the comprehensive community support center plays the leading role on the nursing side, but forming collaborations with physicians were difficult because of a sense of awkwardness about working with physicians. The health care collaboration bases are important as, within their activities, physicians approach the nursing side and build collaborations.

Conclusion

Comprehensive community care systems based on residences and lifestyle support services will continue to be promoted. This concept is called “Aging in Place,”³ which is the same concept as the program promoted overseas enabling the elderly to live in their customary community.

Japan will experience a super-aging society unprecedented in the world, and we will be judged for our success in creating communities that are gentle on the elderly and preserve interaction between the generations throughout Japan.

We believe that home care collaboration bases, together with comprehensive community support centers, will play an important role as bases to promote collaboration with community home care and nursing. In addition, training physicians and nurses who understand both hospital and home care, seamless collaboration between hospitals and home care facilities and collaboration between clinics and facilities, establishing information and communication technology (ICT) for use in inter-professional collaboration and intervention tailored to community’s actual conditions to couple the actual work of comprehensive community care (social inclusion) to community development in anticipation of an ultra-aged society are necessary.