Research on case management system in the geriatric health services facility【Abstracts】[Background]
Changes in function in the elderly during and after discharge from geriatric healthservices facilities (Roken) was studied in the former research project, "Research
Project on Factors Concerning the Elderly, Who Require Nursing Care, to Continue
Living at Home, after Returning from the Facility", conducted in FY2013. This
study showed improvement in most of functions such as "mobility and ADLs","cognitive functions" and "diet and self-care" during the stay at the Roken. However,functional decline started after they returned home except in the area of socialparticipation. This was measured using the ICF staging, but the period of follow-up
was limited to 3 months. Therefore it was required to measure the long-term
trajectory of functional decline after 3 months to design services to maintain elderlyfunctioning. In addition, this study could not determine the factors related tofunctional decline. Adequate intervention, such as case-management based on therisk management might be effective, however, this also remained to be studied.
In order for the facilities care management to fully operate, it is desirable thatcase-management both at home and at facility, medical support, rehabilitation
management and nutrition management are provided integrally while being awareof the patient's functional changes over time. However, the question of whether thecurrent care management was able to provide those things still remained.
Further, regarding nutritional care management, not only management bynutritionists, but oral dysphagia rehabilitation from the perspective ofrehabilitation was also necessary to be concurrently provided for effective care.
[Purpose]
The main purposes of this project was to realize care planning based on
multidisciplinary collaborations and taking the changes in the patients andprevention of deterioration into account.
Therefore we looked at the followings;
1. Examine the pattern of changes in the patients after discharge as the basic
material to understand their their changes in function.
2. Propose a nutritional dysphagia care plan from the perspectives of bothnutrition care management and dysphagia rehabilitation.Verify the effects ofrisk management.
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3. Propose a system which makes it possible to integrally provide caremanagement, rehabilitation management, and dysphagia rehabilitation
management while taking the change of the patients into consideration.
[Methods]
1.Examine the pattern of changes in the patients after discharge as the basic
material to understand their changes in function.
To understand the changes in both physical functions and living environments, thesurvey continuously measured each patient at 6 set times. (On admission, just after
returning from the facility, after one week, one month, three months and about one
year after returning home). In addition to ICF Staging, new survey items, such asIADL, motivation index, pain evaluation items and IADL were included. While
gaining an understanding of the trend of functional change using average value, thegeneralized linear model (GLM) was used to test the significance of the changes offunction after discharge.
2.Propose a nutritional dysphagia care plan from the perspectives of bothnutritional care management and dysphagia rehabilitation.
The programs for nutritional care management and dysphagia rehabilitation wereexamined to standardized dysphagia and nutritional management. After examining
necessary items of both nutritional care management and rehabilitation, thestandard rehabilitation program was created by an expert panel. The necessary
items were fed back and added to the form mentioned in section 4, which describes
the creation of the care management form.
3.Verification of the risk management effects.
In an earlier project in FY 2014, the occurrence of undesirable events such as fall
and aspiration pneumonia were studied from 2 perspectives. (1) The effect of risk
management, and (2) the effect of assigning a risk manager. After intervention, theprocess of the risk management was improved. However it was not evident whether
the outcome such as the effect on the occurrence of undesirable events remained tobe studied. It was possible that we had stratified the target population using theprevious history of such events. Therefore, the data used in FY2014 wasre-analyzed to show the effect of risk-management on the occurrence of undesirable
outcomes.

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4.Development of a standard form for care management at the time of admission
to the facility, short-term stay or day-care while taking into consideration thechanges in the patient’s circumstances.
After understanding the above matters and adding the necessary items from theperspective of dysphagia and nutrition rehabilitation, and risk management, adraft of the multidisciplinary collaborative care management form which makes it
possible to see the changes in the patients was created by the multidisciplinary
panel. The forms were actually used for admission rehabilitation and outpatient
rehabilitation at the geriatric health services facility, and some corrections weremade. Finally the multidisciplinary panel made a revision and a final version wasdraughted.
[Results]
1.Examine the pattern of changes in the patients after discharge as the basic
material to understand their changes in function.
The examination was made based on the 7 abstract indexes (the adding scale,motivation index and IADL based on ICF Staging, motivation and IADL). The
pattern of changes in the elderly patients functioning from admission through todischarge and after their home return was similar to the results from last year,
confirming the reproducibility of the data.
As a result, the functions of the patients were significantly improved during thefacility stay in all of the indexes. Although their state is maintained after 3 monthsof their returning home, a trend of deterioration was observed in the survey
conducted approximately one year after. Regarding their social participation, theelderly patients who returned home maintained participation for a relatively longtime. The IADL functions were low during the stay at the facility and remained lowat home. The Index of motivation improved at the facility, however, it dropped 3months after returning home down to the level at the time of admission to thefacility and the level continued to dropped.
2.Propose a nutritional dysphagia care plan from the perspectives of bothnutritional care management and dysphagia rehabilitation.
Through the findings of the previous surveys and discussion by the experts,
necessary items of assessment for nutritional dysphagia care management wereselected. Based on those items, a standardized plan of nutrition and dysphagia
3rehabilitation were developed using BMI and oral functioning index.
3.Verification of the risk management effects.
The significant differences were not clearly recognized in the survey involving theentire subject patients in 2014. However, in the survey targeting only the patients
who had a high-risk anamnestic history, the occurrence of aspiration pneumonia
and decubitus was reduced by about ½ after implementation of the care plan. On
the other hand, the interventions effect against falls, fractures, fever anddehydration were not observed.
4. Development of a standard form for care management at the time of admission
to the facility, short-term stay or day-care while taking into consideration thechanges in the patient’s circumstances.
The major changes to the draft were as follows;
1. Similar items were put together on the same sheets. The first sheet contains theitems of social worker, medical, nursing and risk management. The second sheet,the items related to rehabilitation. The third sheet, the items related to nutritional
dysphagia.
2. Since Zarit burden interviews cannot be used for care management, it wasdeleted from the form. Instead, the information regarding intake interviews
requested from the offices was included to be entered on the form.
3. Instead of creating a plan for each small item, it was decided to make a plan toitemize categories..
[Conclusion]
Previous care management systems for the elderly had been created with the ideathat care should be given as services to compensate for a loss of functions. However,in the concept of comprehensive and integrated community care, care should aim at
helping the elderly to continuously live with dignity in the community they are used
to living in. Living with dignity means, not only maintaining functions, but also
maintaining their participation in society, such as leisure and social interaction, etc.
The results of this research showed that although various functions and socialparticipations of the elderly improved through admission to the facility, after
returning home, their functions began to deteriorate except for social participation,
and after 3-6 months, returned to the same state as at the time of admission, andabout one year later,was worse than the state at time of admission. On the other4

hand, their social participation showed a tendency to be maintained throughout theperiod of their living at home.
According to the results, even during the period of their living at home, day-carerehabilitation or other rehabilitation, or intensive rehabilitation by re-admission in
the short-term could be seen as desirable.
In addition, known factors of functional deterioration in the elderly are fractures,
aspiration pneumonia, dehydration, decubitus and others. Care- management of thepatients using the history of undesirable events, (high-risk individuals), is very
effective to prevent aspiration pneumonia and decubitus. On the other hand, theeffect of the management couldn’t be clearly seen in regard to falls, dehydration orfever. Thus, explanations to the patients will differ according to the type of event.
For example, fall, fever and dehydration may not be prevented, and aspiration
pneumonia and decubitus may be reduced, but not eliminated. Also, in the future, it
might be necessary to re-examine the care management methods for preventing fall
and fractures. In the meantime, it is desirable to disseminate the knowledge that
falls and fever are not preventable to the agencies that provided care services.
Moreover, through use of the form for multidisciplinary performing diet, nutritionand dysphagia rehabilitation, standardized programs in these areas became
possible.
The main achievement of this study is the development of a standard form for caremanagement taking into consideration the changes in the patient’s circumstances.
It not only incorporates the assessment items to maintain their function but also
the items necessary to maintain the social participation of the elderly in caremanagement. Regarding features of ICF Staging, leisure and social interactions
were added to the indexes for the system to measure the social participation of theelderly. Furthermore, this time, risk indexes, which may become more important in
the future, and the concepts of diet, nutrition and dysphagia care management forstandardized services was incorporated in the care management.
In this research project the care management method was re-examined based on
the Geriatric Health Services Facility in Japan’s R4 system. Through thisre-examination, a new multidisciplinary method was proposed that enables themonitoring of changes in the patients and to achieve social participation throughrehabilitation. Also, this system is recommended to be used after the elderly
patients return home and change the way they receive the services.
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