Background:
There seems to be a lack of consistency of maintenance/community-based rehabilitation through long-term care insurance. We aimed to clarify whether consistent rehabilitation can be performed through long-term care insurance by questionnaires.
Materials and Methods:
This study was a cross-sectional study in a nationwide survey among rehabilitation staff and care recipients who completed disease-specific rehabilitation and required maintenance/community-based rehabilitation through long-term care insurance. Consistency of rehabilitation was compared using Fisher’s exact tests. The concordance of the rehabilitation evaluation and treatment conducted under medical and long-term care insurance was assessed using the κ coefficient.
Results:
Six hundred questionnaires from care recipients and staff were analyzed. Of the rehabilitation staff, 264 (44%) obtained rehabilitation plans from medical institutions. There was a significant difference between the responses of “referral from the same medical corporation” and “obtaining the rehabilitation plan” by Fisher’s exact test (odds ratio: 3.242; P<0.001). Most rehabilitation treatments under medical insurance comprised walking or training with parallel rods/canes [498 patients (83%)], and 454 patients (76%) received stretching and range-of-motion training for the limbs and spine for long-term care insurance. Muscle strength evaluation was the most frequently conducted under medical and long-term care insurance [383 (73%) and 487 (83%), respectively]. The concordance of the evaluation and treatment content, except for disease-specific evaluation, was low (κ coefficient≤0.6).
Conclusions:
The rate of provision of rehabilitation plans was low, and evaluation and treatment content under medical and long-term care insurance was inconsistent. Our results draw attention to the need for consistent rehabilitation plans between disease-specific and maintenance/community-based rehabilitation.
Keywords: aged, community health services, questionnaires, rehabilitation medicine, surveys
Highlights
Long-term care insurance (LTCI) for rehabilitation is increasing in Japan.
Whether consistent rehabilitation can be performed was assessed by a questionnaire.
The implementation rate of a rehabilitation program was low.
Consistency in receiving rehabilitation could not be implemented.
It is necessary to develop and ensure consistent rehabilitation program.
Introduction
Community-based rehabilitation (CBR) involves collaboration between individuals with disabilities, families, and communities for appropriate health, education, vocational, and social services1. Japan has an aging rate of 28.4%, which is predicted to reach 37.7% by 2050, with one in 2.6 people aged 65 years and above2. To respond to the increase in older people requiring long-term care over an extended period, a LTCI system was established in 20003,4, and many patients have received outpatient and home-visit rehabilitation using long-term care services5.
In Japan, disease-specific rehabilitation is a medical fee-based system that uses medical insurance under the direction of a doctor, and the medical fee and the maximum number of days for rehabilitation differ depending on the disease. During rehabilitation by LTCI, doctors’ instructions are required before starting rehabilitation through LTCI. In Japan, LTCI helps in the seamless transition between treatments from acute to chronic phases to improve and maintain functional activity of patients6. Disease-specific rehabilitation in each clinical department is widely recognized7 and has been established in Japan8–10. Scarce evidence is available for successful rehabilitation using LTCI as opposed to medical insurance; however, success has been reported in different patients, including those with reduced dementia symptoms11, improved cognitive function12, and reduced fall risk and improved mobility13,14. The number of deaths from acute heart failure can be reduced by home-visit rehabilitation after hospitalization and increasing the number of physiotherapists in nursing homes15,16. Regarding the transition from disease-specific to CBR through LTCI, ∼36% of patients are stroke patients17.
While devising a new CBR program, we first need to perform a “situation analysis” for examining community status and needs and to explain the choices for rehabilitation collectively for all diseases at the national level1. In Japan, as of 31 March 2019, CBR through medical insurance was revised, which established a shift to rehabilitation through LTCI-paid programs after disease-specific rehabilitation using a rehabilitation plan including. However, there are few reports on rehabilitation received through public LTCI and no reports on the effectiveness of public LTCI18, and the status of consistency in rehabilitation from medical insurance to LTCI is unknown in Japan.
In this study, we administered a questionnaire to two focus groups: (i) patients requiring long-term care who had completed disease-specific rehabilitation through medical insurance and (ii) the CBR staff who worked in long-term care facilities to evaluate the contribution of the First Step of the CBR Management Cycle1 in Japan. Investigating rehabilitation plans and differences in the evaluation and treatment content of rehabilitation between medical insurance and LTCI allows to clarify whether the consistency of rehabilitation from the hospital to the community is possible. We hypothesized that the rate of obtaining rehabilitation plans from medical insurance was low, with differences in the implementation of evaluation and treatment content between medical insurance and LTCI.
Materials and methods
This was a cross-sectional survey (UIN: 8378, https://www.researchregistry.com/register-now#user-researchregistry/registerresearchdetails/633a7ca2e71d14002339063d/) on the rehabilitation content in long-term healthcare and medical facilities that conduct outpatient (day-care, day-service) and/or home-visit rehabilitation. This study was approved by the Research Ethics Committee of Wakayama Medical University and was performed according to the Declaration of Helsinki (Approval number: 2938). This cross-sectional study is reported in line with the STROCSS Guidelines19 (Supplemental Digital Content 1, http://links.lww.com/MS9/A13).
Participants
Individuals requiring long-term care (care recipients) who started CBR in long-term care health facilities or outpatient rehabilitation and home-visit rehabilitation in medical facilities were included in the study. To be eligible, care recipients must have completed their disease-specific rehabilitation through medical insurance within 3 months. A questionnaire was also distributed to the rehabilitation staff (physiotherapists, occupational therapists, speech therapists) in charge of the care recipients.
Survey method and questionnaire content
We mailed 1300 questionnaires to long-term healthcare facilities and outpatient rehabilitation or home-visit rehabilitation services of medical facilities nationwide from the beginning of November 2020, with a response deadline of January 2021. The sample size was estimated according to a previous report20. The required sample size was 384 with an expected response rate of 30%. The questionnaire was developed by a physiatrist (rehabilitation physician), registered therapist, nurse, and medical statistics specialist based on the aim of the study. The questionnaire used in this study was developed particularly for this study. We prepared a questionnaire through multiple online meetings attended by authors. Before administering the questionnaire, it was distributed to multiple physiatrists other than the authors and its contents were verified. Care recipients were asked to complete the survey but could be assisted by family members or staff. Care recipients were asked to describe rehabilitation treatment (“type of rehabilitation treatment under medical insurance,” “rehabilitation treatment under long-term care insurance”); rehabilitation staff were asked to describe rehabilitation evaluation (“the evaluation item that was performed through medical insurance,” “the evaluation item that is performed through LTCI”). We included questions to investigate “whether the rehabilitation evaluation/treatment through medical insurance and LTCI are consistent” and “whether information about the rehabilitation is transmitted smoothly.” We classified “the main illnesses and injuries that required long-term care” in the questionnaire for care recipients based on definitions of rehabilitation medicine provided by the Japanese Association of Rehabilitation Medicine.
Data analysis
Basic information on care recipients and rehabilitation evaluation and treatment content of medical insurance and LTCI were tabulated. The Fisher’s exact test was used to compare the responses between “whether the referral was from the same medical corporation or a related medical institution” and “whether the rehabilitation plan was obtained from the same medical institution” from the staff questionnaire. Furthermore, the degree of correspondence of the rehabilitation treatment content between the two insurance groups was evaluated using the κ coefficient21. We used IBM SPSS Statistics 27 (IBM Japan, Tokyo, Japan) for the statistical analyses, and the significance was set at P-value less than 0.05.
Results
Response rate and demographic variables
Among the 601 questionnaires that were returned, one patient aged less than 40 was excluded because younger than the age covered by LTCI; thus, 600 questionnaires were analyzed. The median age of the care recipients was 79.0 years (interquartile range: 72.0–85.0); with 242 males (41%), 349 females (59%), and nine (0.02%) participants without information on sex. Among the five care levels for long-term care, 40 (7%), 67 (11%), 86 (14%), 105 (18%), and 109 (18%) patients were listed for care levels 5, 4, 3, 2, and 1, respectively. Outpatient facilities (day-care and day-service) were the most common facilities under LTCI currently in use [388 patients (65%)], followed by home-visit rehabilitation for the elderly [197 (33%)], and healthcare facilities for the elderly (Roken) [85 (14%)].
Questionnaire content
Answers from care recipients
Cerebrovascular disease and brain injury were the most common reasons for care [235 patients (39%)], followed by bone and joint diseases and trauma [223 (37%)], cardiovascular disease [20 (3%)], neuromuscular disease [20 (3%)], respiratory disease [19 (3%)], spinal cord injury [8 (1%)], prevention/recovery of perioperative physical function [6 (1%)], cancer [5 (0.8%)], renal disease [5 (0.8%)], rheumatic disease [4 (0.7%)], amputation [trauma/circulatory deficit/tumor; 2 (0.3%)], diabetes [2 (0.3%)], and osteoporosis/burns [1 (0.3%)]. Difficulty in classification was encountered in 32 patients (5%), and 17 (3%) were unlisted. Hypertension was the most common disease currently treated [182 patients (30%)], followed by heart disease [heart failure, angina; 42 (7%)]; 214 patients (36) were not treated for any disease at the time of the study.
The last facility where rehabilitation under medical insurance was received was the convalescent ward (303 patients, 50%), followed by the general (81 patients, 14%) and acute (75 patients, 12%) wards. The frequency of rehabilitation (average number of times per week) under the medical insurance was the highest at seven times a week (238 patients, 40%), while it was twice a week (236 patients, 39%) under the LTCI. The most common rehabilitation duration (average daily duration) under medical insurance was 120–139 min (110 patients, 18%) and under LTCI was 20–39 min (202 patients, 34%).
Most rehabilitation treatments under medical insurance comprised walking or training with parallel rods and canes in 498 patients (83%). Under LTCI, stretching and range-of-motion training for the limbs and spine was provided to 454 (76%) patients. Details are shown in Table 1.
Table 1.
Responses from care recipients (rehabilitation treatment)
| Treatment contents | Medical insurance | Long-term care insurance |
|---|---|---|
| Massage | 312 (52) | 311 (52) |
| Physical agents | 101 (17) | 91 (15) |
| Stretching and range-of-motion training for limbs and spine | 482 (80) | 454 (76) |
| Sitting/standing training | 475 (79) | 393 (66) |
| Walking training with parallel rods and canes | 498 (83) | 402 (67) |
| Aerobic exercise with rowing/foot rowing bicycle | 177 (30) | 181 (30) |
| Walking/aerobic exercise with running machine | 60 (10) | 181 (30) |
| Extremities/body trunk strength training | 337 (56) | 371 (62) |
| Sit on a chair and work on the table | 200 (33) | 97 (16) |
| ADL training | 345 (58% | 191 (32) |
| IADL movement training | 87 (15) | 57 (9) |
| Training considering reinstatement/work | 79 (3) | 22 (4) |
| Recreation activities | 113 (19) | 122 (20) |
| Speech language therapy training | 171 (29) | 52 (9) |
| Swallowing training | 102 (17) | 29 (5) |
| Breathing training | 43 (7) | 30 (5) |
| Prosthetic leg/hand training | 7 (1) | 4 (1) |
| Training related to spinal cord injury or limb paralysis | 26 (4) | 11 (2) |
| Home renovation and home training | 123 (21) | 102 (17) |
| Not listed | 18 (3) | 14 (2) |
ADL, activities of daily living; IADL, instrumental activities of daily living.
Staff responses
Rehabilitation staff worked mainly in outpatient facilities (day-care and day-service; 286 individuals, 48%), followed by home-visit rehabilitation (162 individuals, 27%) and long-term care facilities (126 individuals, 21%). Regarding the referral of patients requiring long-term care, 400 staffs (67%) were referred from the same medical corporation or related medical institutions, and 354 staff (59%) responded that medical information could be obtained when needed via electronic medical records. Overall, 264 staff (44%) received a rehabilitation plan from a medical institution.
When performing rehabilitation under LTCI, those who considered the content of disease-specific rehabilitation obtained through medical insurance was 426 (71%). The rehabilitation classification by disease among the referred care recipients was 183 patients (36%) for cerebrovascular rehabilitation and 158 (30%) for musculoskeletal rehabilitation. In addition, 144 staff members (28%) answered that they did not know the disease classification.
For disease-specific rehabilitation, 527 (88%) staff members answered “yes” to the question “do you know if you received disease-specific rehabilitation until the latest registration (within about 3 mo)?”
Muscle strength evaluation was performed in 383 patients (73%). The evaluation items for LTCI included 558 (93%) patients who answered “yes” to the question “do you regularly and quantitatively evaluate LTCI rehabilitation?” Under LTCI, muscle strength was evaluated in 487 patients (83%), range of motion in 412 (74%). Details are shown in Table 2.
Table 2.
Responses from staff (rehabilitation evaluation)
| Evaluation items | Medical insurance | Long-term care insurance |
|---|---|---|
| Disease-specific evaluation | ||
| Brunnstrom stage | 130 (21) | 100 (16) |
| The Hoehn and Yahr score | 28 (4) | 27 (4) |
| JOA hip score | 26 (4) | 25 (4) |
| Knee JOA score | 24 (4) | 24 (4) |
| Frankel score | 26 (4) | 22 (3) |
| New York Heart Association (NYHA) classification | 25 (4) | 25 (4) |
| Not listed | 454 (75) | 488 (81) |
| Body functions and structures | ||
| Muscle strength | 388 (64) | 489 (81) |
| Sensory | 274 (45) | 269 (44) |
| Range of motion | 379 (63) | 413 (68) |
| Pain | 315 (52) | 358 (59) |
| Swallowing | 141 (23) | 130 (21) |
| Executive function | 178 (29) | 148 (24) |
| Aphasia dysfunction | 157 (26) | 139 (23) |
| Not listed | 198 (33) | 77 (12) |
| Activities | ||
| Sitting | 264 (44) | 229 (38) |
| Standing | 284 (47) | 290 (48) |
| 6-min walking test | 131 (21) | 128 (21) |
| Timed Up & Go Test | 170 (28) | 301 (50) |
| MMSE | 169 (28) | 156 (26) |
| HDS-R | 173 (28) | 262 (43) |
| Communication ability | 153 (25) | 143 (23) |
| Not listed | 241 (40) | 117 (19) |
| ADL | ||
| FIM | 325 (54) | 247 (41) |
| Barthel Index | 176 (29) | 352 (58) |
| Not listed | 228 (38) | 161 (26) |
| IADL | ||
| Frenchay Activities Index | 42 (7) | 99 (16) |
| Life Space Assessment | 28 (4) | 70 (11) |
| Gerontology Index of Competence | 33 (5) | 66 (11) |
| Preparing and cleaning up meals | 73 (12) | 136 (22) |
| Washing | 69 (11) | 130 (21) |
| Cleaning and tidying | 68 (11) | 137 (22) |
| Shopping | 58 (9) | 151 (25) |
| Going out | 83 (13) | 185 (30) |
| Outdoor walking | 119 (19) | 207 (34) |
| Hobbies | 64 (10) | 143 (23) |
| Traveling | 42 (7) | 95 (15) |
| Reading | 41 (6) | 95 (15) |
| Work | 49 (8) | 89 (14) |
| Not listed | 442 (73) | 326 (54) |
ADL, activities of daily living; FIM, FunctionaI Independence Measure; IADL, instrumental activities of daily living; HDS-R, Hierarchic Dementia Scale-Revised; JOA, Japanese Orthopaedic Association; MMSE, Mini-Mental State Examination.
Consistency between disease-specific rehabilitation and community-based rehabilitation in long-term care insurance
When comparing results for the questions, “whether the referral was from the same medical corporation or a related medical institution” and “whether the rehabilitation plan was obtained from the same medical institution” for the rehabilitation staff, the Fisher’s exact test showed a significant difference (odds ratio: 3.242; 95% confidence interval: 2.205–4.766; P<0.001).
We analyzed 563 patients that responded to “the main illnesses and injuries that required long-term care,” “type of rehabilitation treatment under medical insurance,” and “rehabilitation treatment under long-term care insurance” in care recipients, and the 406 that staff members responding to “The rehabilitation classification by disease among the referred care recipients,” “the evaluation item that was performed through medical insurance.” and “the evaluation item that is performed through LTCI.” Tables 3–5 demonstrate the rehabilitation evaluation and treatment. The κ coefficient for all treatment and evaluation items, except the disease-specific evaluation, was 0.6 or less, and the index score was “moderately consistent” or lower. The κ coefficient for disease-specific evaluation ranged from 0.656 (Brunnstrom stage) to 0.737 (Japanese Orthopedic Association hip score). The implementation rate of disease-specific evaluations was low for both medical insurance and LTCI.
Table 3.
Type of rehabilitation treatment under medical insurance versus long-term care insurance
| Treatment contents | κ coefficient | 95% CI |
|---|---|---|
| Massage | 0.550 | 0.481–0.619 |
| Physical agents | 0.302 | 0.200–0.404 |
| Stretching and range-of-motion training for limbs and spine | 0.292 | 0.198–0.386 |
| Sitting/standing training | 0.323 | 0.241–0.405 |
| Walking training with parallel rods and canes | 0.340 | 0.260–0.420 |
| Aerobic exercise with rowing/foot rowing bicycle | 0.329 | 0.245–0.413 |
| Walking/aerobic exercise with running machine | 0.357 | 0.237–0.477 |
| Extremities/body trunk strength training | 0.459 | 0.385–0.533 |
| Sit on a chair and work on the table | 0.306 | 0.227–0.384 |
| ADL training | 0.232 | 0.165–0.299 |
| IADL movement training | 0.234 | 0.126–0.342 |
| Training considering reinstatement/work | 0.549 | 0.359–0.739 |
| Recreation activities | 0.391 | 0.297–0.485 |
| Speech language therapy training | 0.262 | 0.183–0.340 |
| Swallowing training | 0.220 | 0.122–0.318 |
| Breathing training | 0.459 | 0.312–0.606 |
| Prosthetic leg/hand training | 0.541 | 0.184–0.898 |
| Training related to spinal cord injury or limb paralysis | 0.373 | 0.171–0.575 |
| Home renovation and home training | 0.288 | 0.192–0.384 |
For the κ coefficient, the responses of “type of rehabilitation treatment under medical insurance” and “rehabilitation treatment under long-term care insurance” of care recipients are cross-tabulated by rehabilitation treatment to see how well the treatments between medical and long-term care insurance match.
ADL, activities of daily living; CI, confidence interval; IADL, instrumental activities of daily living.
Table 5.
Rehabilitation evaluation through medical insurance versus LTCI (activities, ADL and IADL)
| Evaluation items | κ coefficient | 95% CI |
|---|---|---|
| Activities | ||
| Sitting | 0.429 | 0.343–0.515 |
| Standing | 0.418 | 0.328–0.509 |
| 6-min walking test | 0.480 | 0.382–0.579 |
| Timed Up & Go Test | 0.333 | 0.245–0.422 |
| MMSE | 0.344 | 0.247–0.442 |
| HDS-R | 0.275 | 0.180–0.371 |
| Communication ability | 0.478 | 0.383–0.573 |
| ADL | ||
| FIM | 0.262 | 0.179–0.346 |
| Barthel Index | 0.287 | 0.206–0.368 |
| IADL | ||
| Frenchay Activities Index | 0.479 | 0.365–0.594 |
| Life Space Assessment | 0.499 | 0.364–0.634 |
| Gerontology Index of Competence | 0.514 | 0.378–0.650 |
| Preparing and cleaning up meals | 0.504 | 0.403–0.606 |
| Washing | 0.490 | 0.386–0.594 |
| Cleaning and tidying | 0.445 | 0.342–0.549 |
| Shopping | 0.419 | 0.318–0.519 |
| Going out | 0.433 | 0.342–0.524 |
| Outdoor walking | 0.442 | 0.354–0.531 |
| Hobbies | 0.435 | 0.334–0.536 |
| Traveling | 0.534 | 0.414–0.653 |
| Reading | 0.541 | 0.422–0.660 |
| Work | 0.573 | 0.457–0.690 |
For the κ coefficient, the responses of “the evaluation item that was performed through medical insurance” and “ the evaluation item that is performed through LTCI” of rehabilitation staff are cross-tabulated by rehabilitation treatment to see how well the treatments between medical and long-term care insurance match.
ADL, activities of daily living; CI, confidence interval; FIM, FunctionaI Independence Measure; IADL, instrumental activities of daily living; HDS-R, Hierarchic Dementia Scale-Revised; JOA, Japanese Orthopaedic Association; LTCI, long-term care insurance; MMSE, Mini-Mental State Examination.
Table 4.
Rehabilitation evaluation through medical insurance versus LTCI (disease-specific evaluation and body functions and structures)
| Evaluation items | κ coefficient | 95% CI |
|---|---|---|
| Disease-specific evaluation | ||
| Brunnstrom stage | 0.656 | 0.568–0.743 |
| The Hoehn and Yahr score | 0.680 | 0.517–0.844 |
| JOA hip score | 0.737 | 0.581–0.893 |
| Knee JOA score | 0.703 | 0.537–0.87 |
| Frankel score | 0.671 | 0.489–0.853 |
| New York Heart Association (NYHA) classification | 0.668 | 0.492–0.844 |
| Body functions and structures | ||
| Muscle strength | 0.074 | −0.034 to 0.182 |
| Sensory | 0.378 | 0.288–0.468 |
| Range of motion | 0.219 | 0.111–0.328 |
| Pain | 0.339 | 0.241–0.436 |
| Swallowing | 0.505 | 0.408–0.601 |
| Executive function | 0.445 | 0.354–0.536 |
| Aphasia dysfunction | 0.496 | 0.404–0.589 |
For the κ coefficient, the responses of “the evaluation item that was performed through medical insurance” and “ the evaluation item that is performed through LTCI” of rehabilitation staff are cross-tabulated by rehabilitation treatment to see how well the treatments between medical and long-term care insurance match.
CI, confidence interval; JOA, Japanese Orthopaedic Association; LTCI, long-term care insurance.
Discussion
This nationwide survey on whether CBR under LTCI is consistent with disease-specific rehabilitation for patients requiring long-term care clarified that, under LTCI, the implementation rate of rehabilitation treatment and instrumental activities of daily living (ADL) evaluation was low. The probability that the same corporation could obtain a rehabilitation plan is higher, and there was discrepancy in the rehabilitation treatment/evaluation content between medical insurance and LTCI.
Among the rehabilitation staff in long-term care, 264 (44%) participants obtained a rehabilitation plan from a medical institution, while more than half did not. The probability of obtaining a rehabilitation plan increased if referrals were made from the same medical corporation or a related medical institution. Further, CBR could not be performed for disease-specific rehabilitation using the current rehabilitation plan. Although the study targeted patients requiring long-term care within 3 months of completing disease-specific rehabilitation, some patients also require long-term care when they start rehabilitation under LTCI. Therefore, the total amount of CBR that can be performed based on the rehabilitation plan may be smaller than that reported in this study.
Convalescent rehabilitation within the same medical corporation improved physical function and ADL among postoperative patients with heart disease22. However, under the Japanese system, long-term care services cannot be provided to all long-term care recipients within the same corporation. Therefore, in addition to standardizing the format of the rehabilitation plan, an information-sharing system should be built for cooperation within the same corporation. A database for long-term care information (LIFE: Long-term care Information system For Evidence) was developed in Japan23, and the management of rehabilitation plans using this database is being promoted24.
Regarding the degree of agreement between the rehabilitation evaluation of the two insurance types, all κ coefficients, except the disease-specific evaluation, were 0.6 or less. A previous study indicated that physiotherapists working in home care settings were more likely to use any outcome measures than those who were working in the acute care settings25. Conversely, in Germany, more physiotherapists use device-based evaluations when providing physiotherapy treatment to inpatients26. The evaluation implementation rate varied depending on the insurance system and implementation time in each country. In Japan, there has been survey performed on rehabilitation evaluation covered by medical insurance and subsequently LTCI, so this study can act as an index for the evaluation content of rehabilitation in Japan.
In the ADL evaluation items, the implementation rate for medical insurance and LTCI is low for both FunctionaI Independence Measure (FIM) and the Barthel Index, confirming that consistent evaluation was not implemented. In the 2016 revision of medical fees in Japan, the rehabilitation performance index based on FIM was evaluated in the convalescent rehabilitation period; therefore, the FIM implementation rate under medical insurance is higher than that under LTCI. In contrast, the Barthel Index, which is often used in the LTCI field, including rehabilitation, correlates with the degree of support/need under LTCI27. The use of home-visit care maintains the Barthel Index for frail older individuals28, and the implementation rate of this index is higher than that of FIM under LTCI.
The ADL and instrumental ADL evaluations in care recipients depend on the number of chronic illnesses and the risk of ADL and instrumental ADL disorders increase with two or more chronic illnesses29, thus, rehabilitation under LTCI may require a whole-body evaluation. Among the care recipients in this study, 65% presented concomitant diseases other than the one requiring long-term care. However, the evaluation implementation rate of measures other than the Barthel Index, muscle strength, range of motion, and pain was less than 50%, suggesting that sufficient evaluation was not performed in older people with multiple diseases. Furthermore, the implementation of aerobic exercise in LTCI, expected to be effective against multiple diseases30, was only 11% (walking/running machine) and 30% (rowing/treadmill), and it is possible that effective CBR for older patients has not been performed sufficiently.
A limitation of this study is that the questionnaire was unevenly distributed nationwide and centered on facilities related to the authors; thus, our results may not be generalizable to all of Japan. Validity has not been evaluated other than the number of responses. We did not consider the content validity of the questionnaires31 for the Japanese population. In addition, as this was a cross-sectional study, it is uncertain whether consistent rehabilitation treatment can be implemented from medical insurance to LTCI by enhancing rehabilitation plans. In addition, although the questionnaire was distributed to rehabilitation professionals, the type of job and years of experience were not queried, and the results of rehabilitation evaluation may differ depending on the years of experience. In the supply and demand survey of rehabilitation professionals in Japan, all physiotherapists, occupational therapists, and speech therapists who worked in LTCI facilities are in their 20s, so younger than those covered by medical insurance field32. In addition, the recommended ratio of home-visit and outpatient facility rehabilitation was slightly different from rehabilitation receivers in the government’s long-term care service protocol announced by the Ministry of Health, Labour and Welfare in Japan5. Furthermore, 67% of the referrals were from the same corporation or related medical institutions, and many establishments were able to conduct consistent rehabilitation from disease-specific to CBR. We did not conduct an analysis to clarify significant differences between medical insurance and LTCI. Therefore, a limitation of this study was that we did not perform a power analysis. We interviewed care recipients and staff and did not directly acquire information on treatment details and evaluation items from facilities that perform disease-specific rehabilitation. Furthermore, self-management exercises can prevent the requirement for long-term care from occurring33, therefore, self-care may also contribute to the development of LTCI rehabilitation treatment by the therapists targeted in this study. Thus, the cognitive bias of participants may have a strong influence on the results. Finally, we did not fully investigate dementia, with 2% of patients reporting treatment for dementia. Day-care users with risk factors such as diabetes, hypertension, and obesity could have reduced risk of exacerbation of dementia for 1 year compared with that of home caregivers34. Thus, dementia in the consistent implementation of LTCI rehabilitation is a topic of interest for future studies. Last, this research was a survey on rehabilitation within LTCI specific to Japan, and those results cannot be generalized to CBR in all countries.
The major findings of this study were as follows: (i) the implementation rate of the rehabilitation plan was low and was affected by referrals from the same medical corporation and related medical institutions, (ii) a low degree of agreement existed in the evaluation and treatment content between medical insurance and LTCI, and (iii) consistency in rehabilitation from disease-specific rehabilitation to CBR could not be implemented. The reasons for the lack of consistency may be attributed to the lack of unified evaluation and treatment in both the insurances programs. Thus, unified information sharing is requiring in Japan to improve the quality of long-term care by introducing evidence into the long-term care field23. The Japanese Ministry aims to standardize the contents of the rehabilitation plan and implement consistent rehabilitation treatment regardless of the type of insurance provided. Other clinical implications from this study include the recommendation for objective indicators regarding the condition and rehabilitation treatment effect of the care recipient. This study, which clarified the actual condition of evaluation and treatment content of CBR in Japan, will help guide the development policies to promote long-term care based on objective results.
Provenance and peer review
Not commissioned, externally peer reviewed.
Ethical approval
This study was approved by the Research Ethics Committee of Wakayama Medical University and was performed according to the Declaration of Helsinki (Approval number: 2938). Patients provided informed consent for study participation by answering and returning the written questionnaire. All study methods were performed in accordance with the relevant guidelines and regulations.
Sources of funding
This work was supported by the Ministry of Health, Labour and Welfare, Health Labour Sciences Research Grant (20GA1001).
Authors’ contribution
M.A. was a major contributor in writing the manuscript. Yukio M., Y.N., T.S., H.S., T.K., K.K., H.O., H.U., R.K., Yasuo M., F.T., and T.K. were involved in the study design and data interpretation. Yukio M., Y.N., H.S., T.K., K.K., T.O., H.O., H.U., and Yasuo M. collected the data. M.A., Yukio M., T.S., and H.S. were involved in the data analysis.
Conflicts of interest disclosure
Y.N. received the Ministry of Health, Labour and Welfare, Health Labour Sciences Research Grant (20GA1002). The remaining authors declare that they have no financial conflict of interest with regard to the content of this report.
Research registration unique identifying number (UIN)
researchregistry8373.
Guarantor
Yukio Mikami.
Supplementary Material
Acknowledgements
The authors thank the members of Rehabilitation Medicine, Wakayama Medical University, for distributing and collecting questionnaires.
Footnotes
Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's website, www.annalsjournal.com.
Published online 27 January 2023
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Hiroyasu Uenishi, Email: h-uenishi@tumh.ac.jp.
Rumi Kuroda, Email: rumikuro@fmu.ac.jp.
Yasuo Mikami, Email: mikami@koto.kpu-m.ac.jp.
Fumihiro Tajima, Email: tajibun@gmail.com.
Toshikazu Kubo, Email: tkubo@koto.kpu-m.ac.jp.
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