保健医療科学

2021

Vol.70 No.1 p.45－53

Topics: Recent topics in public health in Japan 2021

＜ Review ＞
Current topics in residences for elderly people with services in JapanKAKINUMA Tomohiro, MORIYAMA Yoko, KOBAYASHI Kenichi
Department of Health and Welfare Services, National Institute of Public Health

Abstract
In Japan, housing for older people is becoming an issue. This comes against the backdrop of a declining
and aging population with a declining birthrate, and expected future increases in older single-person households and the demand for medical care for people aged 75 and over.
In Japan, there are several types of housing that cater to the condition of users, such as welfare facilities
for the elderly requiring long-term care, fee-based homes for the elderly, and residences for elderly people
with services, which have been increasing in recent years.
The residences for elderly people with services system was launched in October 2011, but with the remarkable increase in the number of such facilities, there is a need to evaluate their quality.
This paper summarizes residences for elderly people with services from the perspectives of living environment, functions, supply and location, improvement and assurance of service quality, appropriateness ofservice use, and future perspectives.
It is necessary to evaluate the quality of the functions of residences for elderly people with services.
There are perspectives of structure, process, and outcome, and it will be important to establish a databasefor individuals to evaluate which kind of service is needed for which kind of residents and the results ofmatching them.
keywords: residences for elderly people with services, residence, function, quality, evaluation(accepted for publication, December 22, 2020)

I. Introduction
Japan is one of the countries with an aging population anddeclining birthrate. Changes in the composition of households and people’s attitudes toward retirement are becoming clearer. Specifically, the generation accounting for thelargest part of the population, the baby boomers born between 1947 and 1949, will all be 75 years or older in 2025.
In addition, it is estimated that the number of people aged
85 and over will also increase in the future. The number ofpeople aged 75 and over will show a marked increase until
around 2030.
Although the number of households is estimated to peakout in 2025, the number of older single-person households
will continue to increase[1]. From the 2030s to the 2040s,

the demand for acute care will gradually decrease, and carethat supports people’s lives while providing housing will be
required. However, in the current situation, many people
wish to live in their familiar communities for as long as possible.
According to the Ministry of Internal Affairs and Communications, the percentage of owner-occupied houses
among households with older people aged 65 and over is
82.1%, which is higher than the 61.2% of owner-occupied
houses among the total number of households, and many ofthese are detached houses[2]. Comparing the percentagesof those aged 65 and over, 75 and over, and 85 and over who
are certified as needing long-term care, it is found that thepercentage of people who are certified as needing long-termcare increases significantly as they get older. The certifica-

Corresponding author: KAKINUMA Tomohiro
2-3-6 Minami, Wako, Saitama 351-0197, Japan.
Tel: 048-458-6161
E-mail: kakinuma.t.aa@niph.go.jp

J. Natl. Inst. Public Health, 70 (1) : 2021

45

KAKINUMA Tomohiro, MORIYAMA Yoko, KOBAYASHI Kenichition rate for those aged 65 and over is 18.6%, for those aged
75 and over it is 32.1%, and for those aged 85 and over it is60.6%[3]. There are not enough human resources in Japanto support the future number of older people who will needlong-term care living in detached houses scattered throughout the community.
Japan is also characterized by an increase in the numberof older people who will need support in the future, especially those with frailty and dementia, diversifying their careneeds, and a lack of housing for low-income people. Against
this background, the future of housing for older people has
become an issue. This paper summarizes the situation andthe future challenges of residences for elderly people withservices, which has seen remarkable development in recent
years.

II. Residences for elderly people with services
from the perspective of living environment
Currently, there are several services in Japan that provide housing for the older.
The main ones are welfare facilities for the elderly requiring long-term care, fee-based homes for the elderly, andresidences for elderly people with services. In 2020, there
will be approximately 620,000 users of welfare facilities forthe elderly requiring long-term care, 540,000 users of feebased homes for the elderly, and 248,000 users of residenc-

es for elderly people with services[4]. Among these, residences for elderly people with services are rapidly being
developed.
1. Types of housing for elderly people in JapanAs the name implies, residences for elderly people withservices are simply “houses” for individual residents, andare places where they can live permanently.
There are many different types of homes for older people
who need long-term care services. The table below compares welfare facilities for the elderly requiring long-termcare, fee-based homes for the elderly, and residences for
elderly people with services in terms of facility standards
related to living environment, such as room area, corridor
width, capacity per room, and room requirements.
This section describes the positioning of the three kindsof residential facilities for older people shown in the table.
Welfare facilities for elderly people requiring long-termcare are facilities under the long-term care insurance system that provide daily care such as bathing, meals, andexcretion, as well as functional training and medical care to
those who need care. At present, they house older people
who require level 3 or higher long-term care. In the past,facilities with architectural designs similar to hospitals,
mainly four-bed rooms (multi-bed rooms), were the mainstream, and group care was the norm for efficient care.
However, with the institutionalization of private room unit-

Table1 Comparison of residential facilities for the older
Welfare facilities for the elderly requiring Fee-based homes for the elderly
long-term care (unit type)

Residences for elderly people with services

Overview

Facilities for the purpose of admitting and Facilities that admit older people and Housing for older people that provides
protecting older people aged 65 and over provide care like assistance with bathing, situational awareness services, lifestyle
who require constant care and have diffi- excretion, meals, provision of meals, consultation services, and welfare serculty receiving care at home.
housekeeping or health care, etc., but are vices necessary for daily living.
not welfare facilities for the older, grouphomes, etc.

Establisher

Local governments, social welfare corpo- Social welfare corporations, medical cor- Social welfare corporations, medical corrations, etc.
porations, private companies, etc. (indi- porations, private companies, individuals,
viduals are not acceptable)
etc.

TargetOlder people aged 65 and over with level No regulations (in case of specified facil- Older persons aged 60 and over, and per3 or higher long-term care needs
ities, those who meet the criteria of the sons under 60 who are certified as requiring support or carespecified facilities)

Capacity

No regulations (29 or fewer in case of No regulations (29 or fewer in case of No regulations
community-based)
community-based)

Room Fixer

1 person (or 2 if deemed necessary)

Room area

10.65 m2 or more (excluding the lavatory) 13 m2 or more
Double occupancy 21.3 m2 or more

Corridor width

1.8 m or more in single-sided corridor 1.8 m or more in single-sided corridor No regulations
type
type
More than 2.7 m in corridor on both sides More than 2.7 m in corridor on both sides
room
room

1 person (or 2 people)

No regulations
25 m2 or more
18m2 or more (if there is a shared livingroom, dining room, kitchen, etc.)

Required rooms In each unit: Rooms, common living Nursing care room, functional training Each dwelling unit shall be equipped withroom, washroom, and lavatory
room, cafeteria, bathrooms, restrooms, a kitchen, a flush toilet, storage facilities,
In the facility: Bathroom, doctor’s office, face washing facilities, medical room, con- washroom facilities, and a bathroom
cooking room, laundry room, waste dis- versation room, office room, etc.
(however, if there is a kitchen, storage faposal room, etc.
cilities, and a bathroom in a common area,
they do not need to be in each dwellingunit).

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Current topics in residences for elderly people with services in Japan
type facilities in 2002, architectural design based on small
units accommodating approximately 10 people is now recommended, and the quality of the homes is being improved.
Fee-based homes for the elderly are mainly managed byprivate companies and can be classified into two main types:
care type and residential type.
The care type is a fee-based homes for the elderly thathas been designated to provide daily life care for elderly
people in specific facility under the long-term care insurance system. The staff in the facility take care of bathing,meals, and excretion. With the revision of the Long-TermCare Insurance Act in 2005, local governments can now restrict the opening of a new care type to avoid an increased
burden on the long-term care insurance.
The residential type provides barrier-free housing, meals,
and daily life support services. It differs from the care typein that care services are provided by staff from outside
the facility, rather than by staff employed by the facility. In
addition, due to the revision of the Act on Securement of
Stable Supply of Elderly Persons’ Housing, a registration
system for residences for elderly people with services waslaunched in 2011, whereby even fee-based homes for theelderly are registered if they meet the criteria. If a facility isregistered as a residences for elderly people with services,
it is no longer required to submit notification as a fee-based
home for the elderly.
Residences for elderly people with services are available
for seniors aged 60 years and over, and people aged under
60 years who are certified as needing support or care. They
can move in by signing a lease contract. It is mandatory toprovide safety confirmation and life consultation services.
Many of these are managed by joint stock companies, accounting for more than 60% of the total[5].
Residences for elderly people with services provide
housing for older people where they can continue to live
to some extent even if they need long-term care, and theroom area standard is wide, ranging from 18 to 25 m2. Whilelong-term care welfare facilities are designed for older people who require heavy long-term care, these residences aremostly for older people who require light long-term care.
Residents use such long-term care services, etc. as needed, so the residences for elderly people with services canprovide an environment similar to that of a long-term careinsurance facility for residents with light care needs.
Although there is some overlap in the target population
for residences for elderly people with services and feebased home for the elderly, the facility standards are different as described above, and setting of usage fees, subsidies,and tax treatment are also different. In 2020, a policy wasannounced to strengthen information coordination between
prefectures and municipalities regarding the developmentof residences for elderly people with services and fee-based
home for the elderly. This is to ensure that those who require long-term care living in residences for elderly people
with services can use the long-term care insurance services
in the area.
2. Actual conditions of housing with services for elderly people
According to a survey[5], the actual distribution of room
size is 21.9% for 25 m2 or more, with a volume zone of 18
m2 or more but less than 20 m2, which is close to the minimum area standard, which is the most common. This isa level comparable to that of studio apartments and othergeneral housing for single persons, and it is thought thatsuch an area is necessary for relatively healthy older people
to live with their own furniture.
The rooms often do not have a bathroom, kitchen area, orother water facilities inside the room itself. This is probably
to reduce the construction costs of providing water facilities in each room, and these facilities are therefore often
installed in common areas.
In terms of building size, 26.7% of respondents reported
between 20 and 30 units, followed by 20.6% with between
30 and 40 units, and 65.9% of the respondents reported
between 10 and 40 units, while 70% of the respondents reported three or fewer floors.

III. Functions of residences for elderly people
with services
Residential functions, including residences for elderly
people with services, are expected to play a role in two
aspects: community-based care and integrated care. In addition to the residential function, the main functions of residences for elderly people with services are care function,
nursing function, life support function, support function at
the time of admission to and discharge from hospital, endof-life care function, and community development function.
As for the care function, nursing function, and life support
function, many long-term care service offices are located in
the same building as the residences for elderly people withservices. Approximately 80% of them have some kind ofcare service in the same building[5]. In particular, day services, home-help care services, care management services,and home-nursing services are often provided. In otherwords, residences for elderly people with services support
the management function of services, including nursing
functions and care management functions. It is also possible
for staff of attached services to serve concurrently, whichmakes it possible to provide efficient services from the perspective of information sharing and staff management, and

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47

KAKINUMA Tomohiro, MORIYAMA Yoko, KOBAYASHI Kenichialso provides residents peace of mind.
As for the support function at the time of admission toand discharge from hospital, for example, it plays an important role as a discharge destination when an acute phase hospital needs to discharge patients. This is because prolonged
unnecessary hospitalization is known to impact activities
of daily living (ADL). Since there is a shortage of housing
for low-income people, it is also a valuable discharge destination for people from low-income groups, also because
shortening of the average length of stay is one of the mostimportant management indicators for acute care hospitals inJapan.
It also plays the role of providing appropriate information
on a resident when the resident needs to be hospitalized.
Many older people who require long-term care are repeatedly admitted to and discharged from hospitals. Since there
are financial incentives for hospitalization and discharge
support and end-of-life care on the long-term care insurance, the residential function can have continuity with the
medical and long-term care functions.
End-of-life care function is included because the numberof hospital beds will decrease in the future and there has
also been an increase in the number of deaths outside thehospitals in recent years. According to a survey conducted by the Cabinet Office, a majority of people aged 60 andover of 51.0% answered that they would like to spend their
final days at home if they would become terminally ill[6].
The breakdown of the place of death in 2019 was 71.3%
in hospital and 13.6% at home[7]. Looking at the annual
trends, the percentage of people who die at home is gradually increasing. Considering that the ratio of discharges
from residences for elderly people with services is contract
termination due to death at approximately a third[3] andthat the percentage of residences for elderly people withservices providing end-of-life care is increasing at 22.4% in
FY2018[8], it is assumed that they will continue to play alarger role.
One of the important functions of residences for elderly
people with services is to improve the QOL (quality of life),
not only of residents but also of citizens in the community
by collaborating with local non-care insurance services andthe community. Since a residence for elderly people withservices is a place to live, it is required to not only provide
medical and long-term care, but also lifestyle support functions.
The challenge is how to foster community functions thatmake it easier for all, from infants to older people, to live
there, rather than only attracting older people in a society
with a declining population.

48

IV. Efforts and future perspectives to improve
the quality of residences for elderly people
with services.
As mentioned above, the supply of residences for elderly
people with services has steadily been progressing as ahome for elderly people. Efforts have been made to improve
the quality. Considering the evaluation of the quality of residences for elderly people with services in this chapter.
1. Situation of supply and location
The supply of residences for elderly people with services
is steadily increasing nationwide, although there are variations depending on the region[9]. There is also a problem
with their location: approximately 30% is located outside
urban areas[9]. Some residences for elderly people withservices are in areas with poor access to public transport
or medical settings. Older persons have to be able to obtain
medical and long-term care services needed in the future.
The following efforts have been taken to establish therequired amount of residences for elderly people with services in appropriate locations.
The plans and supply policies for residences for elderly
people with services must be set depending on the local
situation such as an increase/decrease in the number ofolder people by municipality[10]. It is also indispensable tocooperate with the long-term care policy to supply housing
for older people. However, it was difficult to collaborate
because the jurisdictions were different; municipalities,
owned the long-term care insurance administration while
prefectures owned the plan for securing stable housing for
elderly people. Therefore, municipalities have also beenable to formulate plans to secure stable housing for elderly
people in consultation with prefectures due to the 2016
amendment of the Act on Securement of a Stable Supply
of Elderly Persons’ Housing[11]. Municipalities will also
be notified and can grasp the registration of residences for
elderly people with services, if the prefecture accepts theregistration[12]. It is, more over, required to formulate andwrite the situation of installation of residences for elderly
people with services locally, and the plan considering thissituation on the Prefectural Insured Long-Term Care Service Plan and Municipal Insured Long-Term Care Service
Plan from 2020[13], because the role of residences for elderly people with services and the required number of themdiffers depending on the region.
The location of residences for elderly people with services, should preferably be in areas with easy access topublic transportation and medical institutions. It is therefore necessary to incorporate the location guidance policy
for residences for elderly people with services on a regional

J. Natl. Inst. Public Health, 70 (1) : 2021

Current topics in residences for elderly people with services in Japanbasis and to plan supply[11]. In some municipalities, a residential guidance area has been created, and the tax reduction rate has been sharpened inside and outside that area toensure the proper location of residences for elderly people
with services[12].
2. Ensuring/improving the quality of services
Two services: safety confirmation and life consultation
services are essential in residences for elderly people withservices as mentioned above. The staff who reside in theresidences for elderly people with services are required
to grasp the situation of the residents daily, respond to
consultations on daily life, and provide support to receive
medical and long-term care services if necessary. Qualification holders must be stationed 365 days during the day
when providing 2 essential services, from the perspectiveof ensuring the safety and security of residents[14]. There
are large variations, however, in the number of staff during
the day as well as the qualifications of staff in the system
for safety confirmation and life consultation services[9]. Approximately 24% of the residences for elderly people withservices have fewer than 4 employees per 50 residents
during the day, while approximately 36% have 10 or more
employees[9]. In addition, approximately 8% of businesses
are providing safety confirmation and life consultation services by staff who do not have certain qualifications[9]. The
qualifications, number and resident status of staff will be
examined in the future, while education such as training for
employees and efficient service provision using ICT should
also be considered simultaneously.
In addition, the staff of residences for elderly people withservices often double as long-term care service providers,making it difficult for residents to know whether they areusing life support services as a service of the residences
for elderly people with service or as a long-term care service. This can lead to problems with costs[15]. There wasa website called, “Information service for residences for
elderly people with services” where people can search forresidences for elderly people with services in their desiredarea, the services provided and the costs. They also started
providing operational information on two essential services:safety confirmation and life consultation service from May
2017[16]. They added information such as resident information, common life support service, optional life support service, features of the building, support status of long-termcare and medical services, and items showing the management policy of the office[16]. The information system has
been improved so that older people can select residences
for elderly people with services according to their needs.

3. Optimizing the use of long-term care services
As for the co-location of care services within the samebuilding site, some residences for elderly people with services only allow residents to use services of the same corporation or provide more services than are necessary[10].
Residents should be respected for their free choice and useof external long-term care services.
Therefore, appropriate management and supervision of
local governments was promoted. A guidebook was created
and disseminated for proper utilization of external services
by business associations[10]. The long-term care fee is also
subtracted when providing services to users in the samebuilding site because the time and cost required for travel
are less than when services are provided to separate homeuser[17].
4. Future perspectives in residences for elderly people
with services
Residences for elderly people with services are fulfillinga certain role as a residence for older people. The next
thing we need to do is evaluating the quality of residences
for elderly people with services effectively.
Donabedian a researcher from the U.S. proposed evaluating the quality of medical care from the three aspectsof “structure,” “process,” and “outcome”[18,19]. The
three-element approach he advocated is widely used in theevaluation of quality in the fields of medical care, healthcare and welfare policy.
The efforts addressing the above-mentioned issues
mostly involve structure including location, manpower andqualifications, and process including enhancement of theinformation system, according to Donabedian. Outcome,referring to the condition of the user resulting from theuse of health and medical welfare services, should be evaluated, but the quality of residences for elderly people withservices has not systematically been evaluated yet. It isnecessary to assess how to maintain/change the conditionof residents, not only physical aspects including the severity of the disease, ADL (Activities of Daily Living), but also
psychological and social aspects such as QOL (quality oflife), satisfaction, well-being when the quality of residences
for elderly people with services is evaluated. Alternatively,
it would be worthwhile to evaluate perspectives such associal participation or contact with society. Life functions
related to activity and participation can be measured by
WHO-DAS2.0[20,21] established by WHO (World HealthOrganization) applying the biopsychosocial model based ICF(International Classification of Functioning, Disability and
Health), or SCRQoL (social care-related QOL) can be measured by ASCOT (the Adult Social Care Outcomes Toolkit)[22,23,24]. It is possible to conduct a new survey that in-

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49

KAKINUMA Tomohiro, MORIYAMA Yoko, KOBAYASHI Kenichi
cludes the items needed for evaluation, or if that is difficult,it is possible to perform a secondary analysis of existingdata such as home care survey, daily needs survey, longterm care certification data and long-term care claims data.
The amount of service used by residents, care need-level,
ADL, and the degree of independence of older people withdementia in their daily life can be evaluated with these data.
There are, however, few data available to track residents
individually and analyze the details overtime. Residences
for elderly people with services are not performed under
the long-term care insurance system unless the services
are designated to provide daily life care for elderly people
in specific facilities, so these do not appear in the longterm care claims data. Whether it is reflected properly is
not clear, even if the data appear in the claims data, because
there are no rules regarding the input of data related tolong-term care certification[25].
Future efforts are necessary to improve the quality ofresidences for elderly people with services based on theevaluation of the outcomes of residents using well-organized data, and to design incentives for improving the care.

[4]

[5]

Acknowledgment
This work was supported by JSPS KAKENHI Grant
Number JP 16K21309.

[6]

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Current topics in residences for elderly people with services in Japan＜総説＞
サービス付き高齢者向け住宅の現状と今後の展望
柿沼倫弘，森山葉子，小林健一
国立保健医療科学院医療・福祉サービス研究部

抄録
日本において，高齢者の住まいのあり方が課題となっている．これは，人口減少と少子高齢化，高齢の単身世帯の今後の増加，75歳以上の医療介護需要の増加が見込まれていることを背景にしている．
日本には，介護老人福祉施設，介護型の有料老人ホーム，住宅型の有料老人ホーム，近年増加しているサービス付き高齢者向け住宅といった利用者の状態に応じた住宅がある．サービス付き高齢者向け住宅は，2011年の10月に始まった制度であるが，著しく増加してきているなかで質の評価の必要性が生じている．
本稿では，サービス付き高齢者向け住宅について，居住環境，機能，供給と立地，サービスの質の向上と確保，サービスの利用の適切さ，今後の展望といった観点から整理を行なった．
サービス付き高齢者向け住宅の有する機能について，質の評価が求められる．ストラクチャー，プ
ロセス，アウトカムの視点があるが，どのような入居者にどのようなサービスが必要になって，何が得られれたのかを個人が紐付けされたデータベースを構築した上でアウトカム評価をすることが必要である．
キーワード：サービス付き高齢者向け住宅，居住，機能，質，評価

J. Natl. Inst. Public Health, 70 (1) : 2021

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