Introduction ofdementia care modelin Japan
10:30-12:00, 18th May 2015
Miharu Nakanishi
Tokyo Metropolitan Institute ofMedical Science01

Key points
Japanese dementia care model• Health and social care system• Transition in care
• Dementia care coordination• Housing options till end of life care
• Advocacy and safeguarding

02

Health care system in Japan
Universal health care insurance coverage• Variety of insurers– For employees– For self-employed, farmers and pensioners– For people aged 75 and overOutpatient care and hospital care
• No registration system of general practitioners (GPs)• Free access03

Adult social care in Japan
Older adults• Public long-term care insurance (LTCI) program for elderly carein local authorities• In case of protection: Public tax-funded services for person
who is 65 years old and over

Younger adults with disabilities• Public tax-funded care services for people with disabilities inlocal authorities
04

Social care systems by age
Age

Older adults

Younger with disabilities

Finance - Governance

Finance - Governance

0-17

Tax fund - Local authority

18-39

Tax fund - Local authority

40-64

Insurance - Local authority

65Tax fund - Local authority• Care for people with dementia may involve all of thesesystems, except for children.
05

Certification of LTCI care level
40-64 years oldwith specific diseases

65 years oldand overResidents in local authority

Application for use of services under LTCI

Local authority
Investigation

First
judgment

Physician’s opinion

Certification Committee of Needed Long-Term Care
Independent

Needed support

Community general support centre

06

Other services(not coveredby LTCI)

Preventive home
Preventivecommunity-basedSecondjudgmentCare level 1-5

Certification

Care manager

Care plan

Home careCommunitybased care

Residential care

Benefit scheme for LTCI
Government

Formulate universal benefit schedule for LTCI
services once every 3 years

Formulate Local LTCI plan once every 3 years

Prefecture (state)

Local authority

Designate home andresidential careservices

Care provider

Designate community-based careservicesa

Claim payment
Audit claims
Payment

Federation of National Health
Insurance Associationba Community-based care service is introduced in 2006. It includes group homes.
b “National Health Insurance” is a healthcare insurance scheme for self-employed07

and pensioners.

Transition in dementia careCommunity
generalsupport centre

Community
based care

Preventive care

Care manager
Home careIntermediate care

DoctorOutpatient/outreachDoctorHospitalSpecial
nursing home
Residential careLong-term care insurance
08(Local Authority)

Inpatient care
Health care insurance(Insurer)Dementia care coordination
Initial-Phase Intensive
Community
SupportTeam
generalsupport centre

Dementia
coordinator

Community
based care

Preventive care

Care manager
Home careIntermediate care

Medical Centre
for Dementia
DoctorOutpatient/outreachDoctor
HospitalSpecialnursing home
Residential careLong-term care insurance09(Local Authority)

Inpatient care
Health insurance(Insurer)

Coordination - Scotland
Community Mental
Health Service

LinkWorker

General Practitioner
Home care

Primary care

Social Work Officer
Integrated Authority?

Specialist

Hospital
Care home
Residential care
Adult social care10(Local Authority)

Intermediate care
Secondary care
National Health Service(Health Board)Discharge planning in Japan
DoctorHospital• Hospital-based implementation

Home (LTCI home care)

11

DoctorCommunity
generalsupport centre

Care manager

LTCI residential care

Discharge planning in England
DoctorLocal authority

Hospital• Single assessment process

Home (social home care)

Care homeIntermediate care

NHS Continuing Healthcare
12

Registered Nursing Care Contribution (RNCC)

Housing for older adults
Long-term care insurance

SpecialnursinghomeSanatorium Intermediate
bedcareCongregate housingGroup
homeFee-based
home forelderly

Senior housewith services
6000004000002000000

Number of residents at 30 September / 1 October 201313

Dementia in care homes
Percentage of residents with diagnosis of dementia
100%
80%
60%
40%20%0%England

National statistics at 201314

ScotlandAustralia

Japan

Residential relocations• Care transitions may occur
because of unavailable
permanent residence option
for people who suffer withmedical deterioration(Nakanishi et al., 2014 JAMDA)

15

Residents in care homes
Permanent residence per 1000 elderly population
80
70
60
50
40
30
20
100England

ScotlandNational statistics at 201316

Denmark

SwedenAustralia

JapanDementia in psychiatric beds
Inpatients by primary diagnosis (1,000 persons)
350

Other

300
250
200

Vascular and
other

150

Alzheimer's

100
Schizophrenic

50019961999National Patient Survey
1720022005

2008

2011

Discharge from psychiatry
Psychiatric patients with primary diagnosis of dementia

0%

20%

40%

60%

Cohabitance with family

Living alone

Other hospitalIntermediate care

Special nursing home

Other facility

Death

Other

Re-analysis of National Patient Survey 2008
18

80%

100%

Discharge from care homes
Discharge distribution, excluding short staySpecial nursing
homeGroup homeFee-based
home/senior house
0%

20%

60%

80%

100%

Own home

Hospital

LTCI residential

Other facility

Death at facility

Death at hospital

Death, other

Other, unspecified

National Statistics and other reports
1940%

End of life care
Place of death
100%
Other

80%
60%

Hospital

40%

Care home

20%

Own home

0%EnglandWales

National statistics at 2013
20FranceJapan

End of life care in dementia
Place of death, 65 years and over100%
Hospice80%60%

Hospital

40%

Care home

20%

Own home

0%

Belguim

TheEngland
Netherlands

Houttekier et al (2010) JAGS
21

Wales

ScotlandEnd of life care in Japan
Place of death, by leading cause of death
100%
Other

80%
60%

Hospital

40%

Care home

20%
Own home

0%

Alzheimer's

National statistics at 201322Vascularand otherTotal

Advocacy and safeguarding
Scotland• Adults With Incapacity Act 2000
• Adult Support and Protection Act 2007

Japan
• Adult guardianship under Civil Law• Elder Abuse Prevention and Caregiver Support Law• Act on Prevention of Maltreatment of Persons with Disabilities

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Family caregivers
Older adults by type of household composition
100%

Other

80%
60%

With
children40%

Two (withpartner)

20%

Alone

0%

Denmark (2013)

Sweden (2013)

National statistics at 201324

Japan (2010)

Mistreatment by family carers
Japan: National statistics in 2013
• 97.6% (16140/16542) of substantiated cases were identified atdomestic settings• 8071 (48.8%) victims had any symptoms of dementia• 41.0% of domestic abusers (family) were sons; 19.2% werehusbands

Referrals per 100000 population• Japan had 85 per 100000 population (+65)• It may be relatively low: England had 246 per population (+18)
25Systems for safeguarding
Local authorities• A small number of reports/substantiated cases was related topoor system development in the local authority (Nakanishi et al.,2013 JASP)

Community general support centre• Delegated by local authorities: a first access point• 71.7% of centres were operated by private sector in 2013
• Private centres found more difficulties in addressing elder
abuse cases rather than public centres (Nakanishi et al., 2014
JEAN)
26

Challenges in Japan (1)Decision making process• There is no legislation on advanced care planning[Example]• Percutaneous endoscopic gastrostomy (PEG) tubes wereplaced in people with advanced dementia regardless ofexpectation of improvement in QOL (Nakanishi and Hattori, 2014
JNHA)

• Even when nursing home residents documented their end oflife care preferences, their preferences regarding place ofdeath were not known (Nakanishi and Miyamoto, in press EJPCH)
27

Challenges in Japan (2)Place of (end-of-life) care
• The majority of group homes did not provide end of life careto residents with dementia (Nakanishi and Honda, 2009 AGG)
•There is a long waiting list for nursing home placement• Nursing homes sometimes rejected applicants withchallenging behaviors because of their facility’s inability toaddress challenging behaviors (Nakanishi et al., 2012 JAMDA)• Intermediate care facilities serve as a place of residence forolder adults with unavailable permanent residence option(Nakanishi et al., in press Ageing Int)28

To be continued afternoon
International comparison of dementia plans• Dementia care pathways• Palliative care contents in national dementia plans

Discussion• Coordination or one-stop service (packaged care)?
• Coordination by public or private sector?
• Where to obtain end-of-life care for dementia?

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