Current Conditions and Issues for Home Care Support Clinics

Introduction

Spreading and promoting home care supporting patients through the end of their lives is an extremely urgent issue in Japan’s super-aging society, where one in every three people is expected to be elderly in the near future. By 1992, the concept of visiting care, not just the traditional home visits, had emerged, with the patient’s home as the medical care delivery point. Visiting care consists of regular visits based on a medical treatment plan tailored to the patient’s illness, contrary to home visit at the patient and family request. It can be seen as a kind of ward round. A visiting nurse system for the elderly was established in 1992 under the Law on Health and Medical Services for the Elderly, and Visiting Nurse Stations began to be set up, so that this year became known as the birth of home care.

Two years later, in 1994, the revised medical fee system made 24-hour emergency home visits eligible for insurance coverage, and medical fees for home care, such as visiting care, were assessed as being more advantageous. However, home care was not actively promoted. In 2000, a nursing care insurance system that aims to have society fill the gaps in home nursing, which had previously depended on families, went into effect. This upheld the integrated delivery of medical care and nursing services as the basic concept behind the program, and further raised the importance of home care. However, home care did not earn civic rights as the national government expected. Accordingly, in 2006 home care support clinics came under the rubric of medical fees, with home care increasingly seen as beneficial. As a result, home care was no longer a burden for clinic management, and we even saw the emergence of home care specialist clinics without outpatient functions.

What Is a Home Care Support Clinic?

Home care support clinics are those clinics with acclaimed home care support functions available 24 hours a day until the patient dies, regardless of specialties such as internal medicine and surgery. The notification requirements (Table 1) must be met, and indicates the importance of collaboration. In addition, the visiting nurse station that is collaborating has incentives to make visits at the request of the support clinics. In 2012, enhanced home care support clinics were institutionalized (Table 2). If multiple support clinics that met the conditions strengthened their ties and provided 24-hour support through end-of-life, additional medical fees would be eligible for coverage. In 2008, hospitals with functions similar to support clinics were positioned as home care support hospitals in the medical fee system.

Table 1.

Requirements for home care support clinics

(As of July 1, 2010.) 

○The clinic has physicians or nurses who can be contacted 24 hours a day.

○The clinic has a system in place enabling 24-hour home visits at the patient’s request, or has ties with doctors at other health institutions authorized to treat patients with health insurance coverage that ensure availability for 24-hour home visits, with the clinic taking the central role.

○The clinic has a system enabling it to provide 24-hour visiting nurses based on the clinic physician’s instructions at the request of the patient, or has ties with nurses at other health institutions authorized to treat patients with health insurance coverage or visiting nurse stations to ensure this.

○A system is in place ensuring that home care patients can be hospitalized in the event of an emergency at the clinic or at another health institutions authorized to treat patients with health insurance coverage with which it has an affiliation.

○The clinic has ties with nursing support experts (care managers), etc. in charge of coordinating medical services and nursing services.

Table 2.

Facility standards for enhanced home care support clinics

(Ministry of Health, Labour and Welfare: Quoted and altered from Fiscal 2012 materials 1. from briefing on home care collaborative base operations held on July 11, 2012.)
(1)	The following was added to the previous requirements for home care support clinics and hospitals:
	A.	More than 3 full-time doctors appointed
	B.	More than five cases in the past year of emergency home visits
	C.	More than two cases of end-of-life care in the past year
(2)	Several medical institutions can work together to meet the requirements in (1), but the following requirements must be met when collaborating:
	A.	Point of contact for patients with emergencies is centralized.
	B.	The collaborating medical institutions regularly hold conferences more than once a month to share information on patient care.
	C.	Less than 10 institutions collaborate
	D.	Hospitals collaborating must have less than 200 beds.

Currently, society’s expectations for home care, which form a crucial part of comprehensive community care system, are on the rise.

Current Conditions at Home Care Support Clinics (Figs. 1,2,3)

Fig. 1.

Number of filings for status as home care support clinic (as of July 1, 2010)

Fig. 2.

Achievements of home care support clinics (as of July 1, 2010)

Fig. 3.

Number of home deaths per home care support clinic (with more than one end-of-life patient at home) (as of July 1, 2010)

A study by the Ministry of Health, Labour and Welfare shows that 12,487 clinics have filed for approval as support clinics (as of July 1, 2010).

However, of these, 6,046 clinics did not actually provide palliative care to home patients, and instead general clinics are currently providing support through end-of-life. Moreover, the standards at which home care support clinics are equipped and maintained differ depending on the municipality. As such, support clinics face many issues to solve.

Future for Home Care Support Clinics

The history of home care as a third form of medical care, together with hospitalization and outpatient service, is brief, and Home Care Net was organized to work on spreading and promoting home care while resolving these issues at the same time.

An excerpt from the Association’s charter reads as follows: A new form of medical care in which patients are treated at home through inter-professional cooperation is difficult to conceptualize with any specificity in the medical world. Moreover, medical academic societies, community physician societies and university medical departments would likely have difficulty supporting the activities of home care support clinics.

Accordingly, we have organized an association of home care support clinics on a national scale so that we can join together with the aim of enhancing the home care system while working diligently together to spread and develop home care in Japan.

Through our association, we hope to endeavor to meet the wishes of our fellow citizens who want to be treated with their families in the community they are accustomed to and end their days at home.

Any physician interested in home care can participate in the National Association of Home Care Support Clinics. An active dialogue is carried out on mailing list. Please refer to the web site for details (http://www.zaitakuiryo.or.jp/).

Conclusion

An ultra-aged society is also a society characterized by many deaths, and with 1,700,000 deaths annually anticipated, the number of citizens wanting intensive medical intervention is on the decline when disease treatment cannot be expected. While changes in the disease structure resulting from the aging society and progress in medicine mean that lives difficult to save with the previous standard of care can be rescued, secondary diseases such as paralysis and dementia as well as frailty mean that the elderly end their lives after a period in which they cannot survive without some kind of social support. We must face this reality. At present, the majority of physicians in private practice specialize in a specific internal organ or disease, but for many patients, all they want of their family physicians is to be able to end their lives in their own homes. With a major shift away from “health care for treatment” to “health care for support,” a health care system relying on hospitals is changing to comprehensive community care. And high expectations are placed on home care support clinics. We are now in an era in which Japan’s medical culture is changing as a matter of pride for private physicians.