Structure of the
Visiting Nursing System
in JapanJapan Visiting Nursing Foundation

Introduction
Medical care in Japan has been provided via a universal insurance system since 1961. All
citizens pay insurance premiums and are enrolled in various types of health insurance
plans. Insurance certificate holders can freely choose any hospital or clinic to receive
medical care, and they pay a co-payment of 10-30% of the cost of their medical care.
In addition, in 2000, the Long-Term Care Insurance System was implemented,
which was available to most elderly individuals aged 65 years and older. Premiums
are paid to the municipalities running the long-term care insurance system, and if
required, individuals can undergo screening to obtain a Certification for Long-term
Care Need, enabling them to access long-term care services depending on their levelof required care, etc. and within the scope of the standard payment limits. Long-termcare can be accessed with a co-payment of 10-30% of the cost of their care.
The visiting nursing system, which can be accessed under health insurance or longterm care insurance depending on the patient’s condition, plays an important role in
the lives of individuals who are affected by chronic conditions or disabilities and arerecuperating at home.
In Japan, organizations that provide visiting nursing services mainly consist of
hospitals, clinics, and visiting nursing stations. This brochure focuses on visiting
nursing stations, which are the providers of more than 90% of visiting nursing services.
An introduction to the history of the visiting nursing system and the system itself will
be given, as well as the realities of the system and future perspectives.
March 2021

2

Structure of the Visiting Nursing System in Japan

Ⅰ

Background to the Visiting Nursing
System in Japan

It is predicted that the population-aging rate in Japan will be as much as 38.4% in 2065. The number of elderly citizens
in Japan is increasing sharply at a globally unprecedented rate. In contrast, there is an ever-declining birthrate, with areduction in the working-age population of 15-64 years. Communities are experiencing an increase in at-home elderly
who require nursing or long-term care, and due to greater efficiencies in inpatient treatment and shorter hospitalization
times, visiting nursing services are increasingly required, regardless of age or condition.

The Establishment of Visiting Nursing Stations
1

Background to the Establishment of Visiting Nursing Stations
In Japan, prior to the 1920s, acute communicable diseases such as typhoid and cholera were prevalent,
leading to the construction of isolation hospitals. The privately run Jizen (Charitable) Nurses Association
dispatched nurses to hospitals and homes to care for patients with acute communicable disease.
From the latter half of the 1920s, nurses from the Japan Red Cross Hospital and St Luke’s International
Hospital provided visiting nursing services to mothers, children, and disaster victims on a volunteer basis.
From around 1960, the social problem of bedridden elderly emerged (due to delayed effects of strokes,etc.) which led to home-visit nurses providing health counseling and nursing for bedridden elderly.
Based on the Health and Medical Service Law for the Elderly enacted in 1982, hospital reimbursementof medical fees under health insurance for visiting nursing services for discharged patients was firstrecognized from 1983.
This was extended to cover visiting nursing/health counseling for psychiatric patients in 1986, and forpatients recuperating at home from cancer/refractory diseases in 1988. It thereby became possible for
medical fees to be reimbursed to hospitals for visiting nursing/health counseling, for not only the elderly
but for anyone in need.
It should be noted that in 2006 the name of the Health and Medical Service Law for the Elderly waschanged to the Act on Assurance of Medical Care for Elderly People, and a healthcare system for older
senior citizens (aged 75 and over) was established, so that the benefits would be provided by eachprefecture’s Association of Medical Care Services for Older Senior Citizens.

Commencement of Model Projects for Improvement of
the Integrated Home Health Care System including Visiting Nursing
The Ministry of Health, Labour and Welfare implemented model projects for four years to improve nursing
in home health care situations. They included (1) an investigation of the practice and structure of visiting
nursing services including medical treatments and (2) standardized training at the prefecture level. Nursing
Associations in 17 prefectures with municipalities designated as model project implementation regions
held ‘Visiting Nurse Training Workshops (programs of 120 hours)’ for nurses and others who were not
employed, in which they were trained as visiting nurses.

Background to the Visiting Nursing System in Japan

3

Background to the Visiting Nursing System in Japan2

Establishment of a Designated Visiting Nursing System for the Elderly(under Health Insurance)
Following implementation of the Model Projects for Improvement of the Integrated Home Health Care
System including Visiting Nursing, in 1991 the Health and Medical Service Law for the Elderly and otherlaws were partially revised, and the Designated Visiting Nursing System for the elderly was established.
From April 1992, Visiting Nursing services provided by visiting nursing stations commenced. In addition,with a partial revision to the Health Insurance Act in 1994, the Designated Visiting Nursing System wasestablished, enabling visiting nursing services to also be provided to individuals recuperating at home
(in addition to the elderly).

3

Establishment of a Designated Visiting Nursing System under LongTerm Care Insurance
The Long-Term Care Insurance Act enacted in 1997 was implemented from April 2000. The Long-term
Care Insurance system is designed so that even if a person requires care, a care manager will formulate acare plan to form the basis for comprehensive access to any required medical services including welfare
services, visiting nurses and rehabilitation, to allow the individual to, if possible, live an independent life in
the home they are familiar with. Many of those who utilize services under the Long-term Care Insurance
Act are ‘a person requiring support’ or ‘a person requiring long-term care’ for diseases or disabilities
requiring care over the long term, and monitoring of diseases and disabilities, etc. as well as appropriate
nursing interventions provided by visiting nurses are extremely important. As members of the care team,visiting nurses fully utilize that special feature of nursing – its coverage of both medical treatment andnursing care – and they can be counted on to provide a service that enhances the collective strength ofteam care, from nursing care/disease prevention nursing to end-of-life care.

4

Designated standards
From April 2000 onward, visiting nursing stations had to be appointed under the law as designated inhome service providers based on the Long-Term Care Insurance Act, which takes precedence over the
Health Insurance Act. Designated service providers under the Long-Term Care Insurance Act are deemed
to be designated home-visit nursing providers under health insurance, allowing them to provide visiting
nursing services under health insurance. An explanation of the designated and operational criteria follows.

Founder
A founder holds corporate status as a business corporation, medical corporation, or social welfare corporation,and is a designated home-visit nursing provider, appointed by the prefectural governor, etc. in accordance with
the Long-Term Care Insurance Act. (If appointment as a designated in-home service provider under the LongTerm Care Insurance Act is obtained, the organization is deemed to be a designated home-visit nursing provider
under the Health Insurance Act.)Manager
A Manager is a full-time public health nurse or nurse able to undertake the appropriate operational managementof a home-visit nursing provider.

4

Structure of the Visiting Nursing System in Japan

Visiting Nursing Station Employees
The full-time equivalent of 2.5 nursing professionals is employed (including public health nurses, midwives (onlyunder health insurance), nurses, and assistant nurses).
The placement of physical therapists, occupational therapists and speech-language-hearing therapists is also
implemented as required. Administration staff are also employed.

Visiting Nursing Station Facilities, Equipment, Fixtures
These include, for example, the necessary officespace depending on the number of visiting nursing
employees, car and bicycle parking (for visitors),
office equipment, cabinetry, visiting nurse uniforms/
instruments/equipment, infection control equipment/
consumables, records.

5

Inside a visiting nursing station

Provision of Visiting Nursing Services
Potential users can apply through their primary care physician or directly with a visiting nursing station,and if the primary care physician recognizes that a visiting nursing service is required, they will issue an‘Order for visiting nursing.’ A visiting nurse will then visit the client, assess their condition, and ascertain
their wishes. Visiting nursing services will then be provided based on the creation of a care plan. The
visiting nurse will regularly report to and closely liaise with the primary care physician.
Under the long-term care insurance system, nursing is carried out using a visiting nursing plan inaccordance with a care plan from a long-term care support specialist (care manager). However, if
necessary, care plans can be changed (number of nursing visits, timing, specific services, etc.) throughconsultation, so that the necessary nursing services can be provided.

Long-Term Care Insurance System

Care Manager ofHome-Care
Assistance Center
Public Health Nurse, etc.
at Community-Based
Integrated Support Center

Performance
Reporting

Request for Care Plan

Application

Client(User)
Visiting Nursing
Services

Application

Communication/
Coordination

Service Provision Schedule

Visiting Nursing
Station

Medical
Direction
Regular
ReportingPhysician Home Visit

Application

Primary
Care Physician

Background to the Visiting Nursing System in Japan

5

Ⅱ
1

Details of Visiting Nursing operations
Visiting Nursing Station statistics
There are over 12,000 visiting nursing stations in Japan from which visiting nursing services are provided.
On average, there are approximately 7 full-time-equivalent employees at each visiting nursing station(including around 5 nursing professionals).

2

Visiting Nursing Station services
Visiting nursing stations provide services that include visiting inpatients so that they can provide
collaborative health counseling upon discharge, and then at home, they carry out an assessment of theclient and form a plan depending on the client’s wishes. After this is implemented, reviews are carriedout so that visiting nursing services can be provided in accordance with changes in needs.
Services include observation of health conditions, recovery guidance for the client, rehabilitation,
nursing guidance/support for family members, assistance for daily living (e.g., care to maintaincleanliness), medication management, support for those with dementia/mental disabilities, toileting
control/support, prevention of bedsores, etc./wound treatment, etc. Emergency assistance (including
at night) accounts for less than 10% of services, and at-home end-of-life care accounts for only around
2% of services.

Implementation Process of Visiting Nursing

・Plan Revisions to Support
Changes in Need・Self-Management/Promotion of
Independence・Care System Adjustments
・User Satisfaction
・Promotion of Social
Contact/Participation
Consideration for・Checks for Anxiety
and Confirmation of
Improvements/Plan
Wishes
Revisions

Reviews/Checks

With regards to issues anticipated inassessments and matters arising in thenursing plan, regular reviews arecarried out for 'Improvements,''Becoming Stable,' 'Maintenance of
Wellbeing,' 'New Conditions,' and'Deterioration.'

6

Structure of the Visiting Nursing System in Japan・Assessments (Physical/Mental Wellbeing,
Health Conditions, Recovery Status, Lifestyle
Rhythms, Communication Skills, Cognition,
Interpersonal Relationships, Motivation
Status of Caregiving by Family Members,
etc., Living Environment, Financial Situation,
Social Situation,
Utilization of
Resources, etc.)
Assessments and・Client Wishes/
Nursing Plan
Opinions
Creation

Implementation ofVisiting Nursing
Services・In order to achieve the goals, theservices are implemented in cooperation
with the client and their family.
・The services are implemented
comprehensively so that they
complement other professional
services.

3

Numbers of visiting nursing users and the cost
A single visiting nursing station has an average of about 70 users, with each user receiving around 6-8
visits per month. The cost per visiting nurse visit is ¥7,500-11,000 (this differs depending on whether it
is covered under long-term care insurance or health insurance).

4

Visiting Nursing Station operational status
Each visiting nursing station employee makes around 70-80 visits per month, and the average revenueof one visiting nursing station is around ¥4.5-5 million per month.
Payments for visiting nursing services account for 99% of the visiting nursing station’s revenue(nursing and medical treatment payments), with revenue depending on the number of visiting nursing
users and their frequency of visits. Approximately 80% of expenditures go toward personnel costs.

Visiting Nursing Station Operational Model

Visiting Nurses

Users
Approx. 500 Visits/
MonthApprox.
Full-Time Equivalent Employees:(Including

7

5 Nurses and 2 Physical Therapists or Other Professionals)

70 Users

Users under Long-Term Care Insurance:
Users under Health Insurance:

50

20

Revenue:¥4,500,000 (Payments for Visiting Nursing Services, User Fees, Other)

Expenditure:¥4,300,000 (Personnel Costs: ¥3,500,000; Office Costs: ¥800,000)

Profit:¥200,000

Details of Visiting Nursing operations

7

Ⅲ
1

Future Issues
Securing staff for visiting nursing services and improving quality
Given the social need for visiting nursing services, it is calculated that by 2025, 120,000 visiting nurses
will be required. Looking at the placement of nursing professionals according to location, only 2.5%
(about 60,000) nurses work at visiting nursing stations. The improvement of this situation will require
proactive measures for personnel recruitment, improvements to working environments in order toenhance the motivation of nursing professionals for their visiting nursing occupation, and evaluations of
their work to lead to new career opportunities as well as improvements to their status.
Furthermore, initiatives are necessary so that visiting nurses can feel secure in their work, including
working to improve compensation and creating attractive workplaces for a good work-life balance.
Other challenges include implementing initiatives to enhance public relations advertising targeted at
local residents.

2

Service streamlining with ICT
In 2020, the novel coronavirus infection was declared a pandemic, which resulted in many workplaces,
including visiting nursing stations, establishing infection control systems including the provision of
infection control equipment, utilizing video chatting services and holding care conferences online. In
future, there is a need to further promote productivity through ICT-enabled streamlining.

3

Improving the quality of visiting nursing services
Visiting nursing stations undertake evaluations to improve the quality of their services, as well as tocontinue and develop their operations. Self-evaluation is mandatory under the Visiting Nursing System,
but there are also user evaluations, third-party evaluations, performance evaluations, etc.
User evaluations are a source of evaluation information relating to nursing services and the individual
qualities of the visiting nurses, including matters not easily expressed directly to the nurses themselves,or information on certain needs that are difficult to convey.
In third-party evaluations, structure, processes, and output are evaluated to improve quality. In orderto evaluate the outcomes/efficacy of visiting nursing services, outcomes are assessed in terms of theprovision of evidence-based nursing using objective assessments and assessment scales, as well as the
expected improvement or maintenance of physical/mental condition or treatment environment, or evena comforting end-of-life experience.
These outcomes are difficult to evaluate, given that various factors can influence the outcome aside
from the nursing. Experimental initiatives are carried out with a view to the PDCA cycle.

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Structure of the Visiting Nursing System in Japan

4

From a community-based integrated care system to the realization of acommunity inclusive society

The formation of

a community-based integrated care system by 2025
The ‘post-war baby boom generation’ born between 1947 and 1949 followed the defeat of Japan in the second
world war in 1945, and Japan entered a period of growth in the younger population with a total fertility rate ofaround 4.3. With a target of 2025, when this generation will be aged 75 or older, there is an urgent need to create
a community-based integrated care system so that these people can live their own lives in the communities they
are familiar with, until breathing their last.
In 2040, when this same generation will be aged 90 or older and their children,s generation will be aged 65 orolder, it is anticipated that Japan will reach a peak in its low birthrate/aged society with high mortality.
At present, each region must place urgency on forming a community-based integrated care system in order to
comfortably overcome the issue that will become pronounced in 2025. Visiting nursing is a service that spans
both the health insurance system and the long-term care insurance system, and is considered the cornerstone ofcommunity-based integrated care.
Given that each region has certain characteristics, such as varying population structures by age, varying levelsof social resources such as health, medical, welfare and long-term care services, differing
industries and cultures, it is difficult to realize community-based integrated care systems
only through implementing uniform measures throughout the country such as revisions
to the long-term care insurance system or to the health insurance system, controlling
benefits via payment revisions, or additions for improvement of benefits of nursing staff.
For that reason, community-based integrated care systems are being created by eachmunicipality or prefecture in accordance with the characteristics of the region and basedon its autonomy and independence.

The realization of

a community inclusive society in 2040
In the Japan of old, there were support functions embedded in daily life – in the community and in the household– including mutual cooperation within communities and assistance between families. However, with theprogression of the aging society and the decrease in the population, that base is weakening. The goal is therefore
the realization of a community-inclusive society in which by 2040, connections between people will be rebuilt,
people will support each other in times of difficulty and will continue to live their lives without loneliness.
In order to achieve this community-inclusive society in which all ages can live together, an integrated support
network will be required, in which healthcare, nursing, and long-term care/welfare
is available in the community. Nursing support is becoming even more important sothat people can, as much as possible, achieve their potential, maintain their health andprevent the deterioration of chronic diseases so that they can live well until their end.
Visiting nursing stations not only have placements of nursing professionals, but havealso made progress in the placement of physical therapists, occupational therapists andspeech therapists, and these services will be relied upon as an essential social resource
for the realization of a community-inclusive society.

Future Issues

9Future Issues

Community-Based Integrated Care System Model
The Community-Based Integrated Care System is based on residential areas inwhich the necessary services are able to be accessed/provided within around30

minutes of travel(specifically, based on junior high school districts).
To Enjoy an Active, Healthy Life for as Long as Possible

When Long-Term Care
Becomes Necessary…

In Case of Illness…

Long-Term Care

Visiting Nursing Station

Healthcare

Visiting Nursing Services underLong-Term Care Insurance

Visits for Long-Term Care,
Nursing, and Healthcare

Visiting Nursing Services Not
under Long-Term Care Insurance

Visiting nursing stations are staffed by professionals who can provide nursing services andrehabilitation according to users’ needs, whether users require long-term care or healthcare due
to illness, etc. As guardians of health in the community, they offer health consultations, long-termcare prevention, and even at-home end-of-life care depending on the client’s wishes, supporting
the ability of clients to live in the community (home) they are familiar with until their end.

10

Structure of the Visiting Nursing System in Japan

Ⅳ

Example of a Visiting Nursing

Client ‘A’ was bedridden, but has managed to return to an independent lifestyle
Name of injury/disease, etc.:

Residual pulmonary tuberculosis, chronic respiratory failure

Level of long-term care:

Requiring Long-Term Care 1

Progress of in-home recovery:

Client ‘A’ experienced acute exacerbation of chronic respiratory failure as aresult of the sequelae of tuberculosis, whereupon in-home oxygen therapy was
introduced, and the client became largely bedridden. On the recommendation ofa concerned home-helper, the client became a user of visiting nursing services.
Then, upon the recommendation of the visiting nurse, the client was examinedin a respiratory specialist hospital and received the appropriate treatment andrehabilitation, resulting in the in-home oxygen therapy no longer being needed.
Furthermore, the client recovered to the point where they could live a normal
daily life and even go on outings, as a result of the respiratory rehabilitationand lifestyle counseling provided by the visiting nurse. Currently, the client has
achieved self-management and is continuing to live an independent life without
further exacerbation of their respiratory condition.

Family composition:

Living alone

Services being accessed:• Visiting nurse: once every two weeks• Paid helper: once a month• Visiting caregiver: once a week

• Consultation at a specialist hospital:
once every six weeks• Day service care (4 hours):
once a week

• Attending physician consultation:
once a month

Features of the visiting
nursing services provided:

A detailed physical assessment (in particular, observation of the client’s
respiratory status)
Senior citizens often do not notice fevers, dehydration or low oxygen saturation
until their condition becomes serious. It is an important part of visiting nursing,even with a low frequency of visits, to conduct preventive work such as noticing
condition changes, early discovery of abnormalities and support for prevention of
exacerbation.

Support for activities of daily living
In the case of chronic respiratory failure, it is important to provide not only medical
treatment in the form of respiratory rehabilitation, but also to provide guidance on
physical movement within the activities of daily living. Support can be provided
for comfortable breathing during simple activities such as eating a meal, going to
the toilet, getting dressed, taking a bath, walking around or climbing/going down
stairs, so that, as much as possible, the patient will not become bedridden again.

Mental support
Our core messages are that we will enable clients to attain their potential, that wewill support them to realize that life is worth living, and that we will watch out forthem as nursing professionals.

Emergency measures
Respiratory difficulties can feel life-threatening, and if a client lives alone, itis necessary to consider what steps to take if their condition exacerbates orchanges rapidly. Nursing services are available 24 hours a day, 365 days a year, inorder to respond in times of emergency.

Future Issues/Example of a Visiting Nursing

11

Japan Visiting Nursing Foundation
5th Floor, Japan Nursing Association Building, 5-8-2 Jingumae,
Shibuya City, Tokyo 150-0001
Official website: https://www.jvnf.or.jp/