平成 21 年度 老人保健事業推進費等補助金（老人保健健康増進等事業）

地域包括ケア推進のための地域診断に関する調査等事業報告書

平成 22 年 3 月
財団法人

長寿社会開発センター

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第１部

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日常生活圏域高齢者ニーズ調査モデル事業

報告書

はじめに ······································································· 9
第１章

日常生活圏域高齢者ニーズ調査概要 ······································· 11

１．日常生活圏域高齢者ニーズ調査の概要 ········································· 13（１）日常生活圏域高齢者ニーズ調査の意義 ······································· 13①日常生活圏域の課題の明確化 ················································· 13②介護保険事業計画の客観的基礎データの整備 ··································· 13③個人への生活アドバイス表の送付による普及啓発効果 ··························· 14（２）日常生活圏域高齢者ニーズ調査の実施方法 ··································· 15①調査票の作成（準備） ······················································· 15②調査票の発送・回収 ························································· 15③調査結果の集計・分析 ······················································· 16④調査結果の個人返却 ························································· 16⑤事業の費用・効果 ··························································· 16（３）日常生活圏域高齢者ニーズ調査の実施結果 ··································· 17（４）日常生活圏域高齢者ニーズ調査に関する考察 ································· 17①日常生活圏域高齢者ニーズ調査の必要性 ······································· 17②住民参加と個人情報保護 ····················································· 18③第 5 期介護保険事業計画策定に向けた実施体制 ································· 18
第２章

モデル事業の実施結果 ··················································· 21１．日常生活圏域高齢者ニーズ調査の実施概要 ····································· 23（１）目的 ····································································· 23（２）調査概要 ································································· 23（３）回収結果 ································································· 25（４）有効回収者の属性 ························································· 25（５）郵送未回答者の傾向等 ····················································· 26２．調査結果の概要 ····························································· 27（１）生活機能 ································································· 27（２）閉じこもりの状況 ························································· 29（３）転倒リスク ······························································· 30（４）低栄養状態リスク ························································· 32（５）その他のリスク ··························································· 33（６）基本チェックリスト判定結果 ··············································· 353（７）認定者、一般・特定高齢者を通じた指標 ····································· 37（８）健康・疾病状況 ··························································· 38（９）地域ごとの高齢者の状況 ··················································· 44３．調査結果の活用 ····························································· 47（１）介護保険事業計画の作成 ··················································· 47①介護サービスニーズ ························································· 47②地域支援事業（介護予防事業・特定高齢者施策） ······························· 48③権利擁護・見守り事業 ······················································· 49④高齢者専用賃貸住宅 ························································· 49（２）支援が必要な高齢者の把握・フォロー ······································· 50（３）介護予防事業の実施 ······················································· 52①特定高齢者の教室誘導 ······················································· 52②アセスメント時の活用 ······················································· 52

第２部日常生活圏域ニーズ調査票作成検討委員会

報告書

はじめに ······································································· 55
１．検討経過 ··································································· 57（１）日常生活圏域ニーズ調査に関する調査票作成検討委員会の設置 ················· 57（２）検討委員会の構成 ························································· 57（３）検討委員会の開催状況及び論点 ············································· 58
２．日常生活圏域ニーズ調査票案の作成 ··········································· 59（１）日常生活圏域ニーズ調査

調査票案 ········································· 60

３．日常生活圏域ニーズ調査における生活機能判定 ································· 68（１）日常生活圏域ニーズ調査

第３部

生活機能判定の概要 ······························· 69

地域ケア会議の機能と実施拡大策に関する調査研究

報告書

はじめに ······································································· 75
第１章

地域ケア会議の実施拡大に向けた検討結果 ································· 77

１．地域ケア会議とは何か ～理論・方法論の整理～ ································ 79（１）地域ケア会議の目的 ······················································· 79（２）地域ケア会議の実施方法 ··················································· 79①メンバーの選定・招集 ······················································· 79②地域ケア会議の実施頻度・実施時間等 ········································· 81③地域ケア会議の事前準備等 ··················································· 82④地域ケア会議の実際 ························································· 85（３）地域ケア会議の意義 ······················································· 88
4①市町村（保険者）の理念の共有 ··············································· 88②サービス等の充実・整備 ····················································· 89③関係者の力量形成（人材育成）
・ケアプランの質の向上 ·························· 89④生活機能の改善・重度化予防 ················································· 91
２．地域ケア会議の実施拡大に向けた課題整理 ····································· 94（１）妙高市の事例に基づく課題整理 ············································· 94（２）琴浦町の事例に基づく課題整理 ············································· 97
第２章

地域包括ケア実現に向けての考察 ········································· 103

１．地域ケア会議の必要性・課題等に関する考察 ··································· 105（１）市町村（保険者）の責務 ··················································· 105（２）地域ケア会議の必要性 ····················································· 106（３）評価の必要性 ····························································· 107（４）地域ケア会議の可能性 ····················································· 108（５）地域ケア会議の質を高めるには ············································· 109
２．第 5 期介護保険事業計画作成に向けての考察 ··································· 110

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