Interprofessional Carefor Elderly in Japan
Hirotaka Onishi MD, MHPE, PhD
Department of International Cooperation for Medical Education
International Research Center for Medical Education
Graduate School of Medicine,
The University of Tokyo

The Story of My Aunt (1)94yo, in Tokyo #1 Alzheimer’s disease, #2 Sjögren syn.
#3 Generalized anxiety disorder Divorced, one daughter Until late 80s living with the daughter but
moved to Geriatric Health Services facility(Roken) and lived there for 2 years
The Story of My Aunt (2)I think it will be difficultfor her to move back tothe facility but does
she need gastrostomy?
I am a medical socialworker. I will explain how
your mother will dischargeYour mother was in long-term carefacility but suffered from aspiration
pneumonia 3 days ago for hospitalization. Since her swallowing is not
good, so the Dr suggested
gastrostomy for her future nutrition.

I am a daughter.
Nice to meet you.
Oh, my…

The Story of My Aunt (3)Hospital beds are full... She
should get out of the ward!

Nurses’ information is that the amountof oral intake was not enough yesterday.
If you don’t like gastrostomy, she can go
to a long-term type hospital withintravenous hyperalimentation!
If you intend to take care of her athome with oral intake, she candischarge next week!

I cannot take care of her athome due to my work…
What should I do?!

The only pleasure for my mom
was eating. I helped her eat
supper last night, and she
mostly ate it. I don’t think sheneeds gastrostomy right now!
I don’t think she can go backto the previous long-term carefacility but could you try oral
intake one more time?

Age55
19501955
19601965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065

Trend and Estimate ofLife Expectancy in Japan95

900yo M

850yo F

80

75

70

65

60

Year

Changes in the % Population Over Age 65
45%40%
35%30%

India
Taiwan
Korea
Malaysia
UK
Germany

China
Japan
Indonesia
SwedenFranceUSA

25%20%15%10%0%

1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100

5%

Age
25

10
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065

Trend and Estimate ofLife Expectancy at 65yo
3065yo M
65yo F

2015

Year

Characteristics of Super
Aging Society of Japan
Life expectancy is one of the highestcountries.
 % of senior people is highest globally.
 In 2040s % of senior people will beplateau.
 Life expectancy at 65yo is also
elevating (risk of too long life…).
Whole Picture of Community-based
Integrated Care System (CBICS) Model

地域包括ケアシステム

Medicalcare

Medical care/serviceprovision

Housing
Outpatient/
InpatientCommunity
comprehensive
support center/
Care manager
Participating incommunity/volunteer

Nursingcare

Ambulatory/Residence
Provision ofnursing care/service

Provision of activity
settings

Lifesupport,Keeping
activeCommunity-based Integrated
Care System (CBICS) Model
Senior people can continuously live in theirhouse in the community.
 Medical/nursing care will be the support when
they become ill/frail/dementia.
 They can have active life in the community
with the support by friends/neighbors.
 Community comprehensive support centers
are portal for any issues.
Number of Senior People Certified
for Long-term Care Insurance
7000

1000 people

6000
5000
4000
3000
2000

Year

Family with Senior Person
million people

OthersParent with single child
Living alone

Three-generation
Only couple% of family with senior member

3050%

2540%

2030%

1520%

10
510%

00%

1980

1985

1990

1995

2000

2005

2010

2015

Year

How Should We Support
Senior People?
Long-term care insurance is the key to provide
supportive care. 65yo< people (also 40yo< withspecific diseases) are eligible to apply for thecertificate of long-term care insurance.
 City/town/village office will decide the care need level
after the client applies. The higher care need level,
the more clients can use the care services but theunit price of care will be more expensive.
 Clients must tell which service they like to use to acare manager. He/she will contact service providers
to decide which service they use.
Keys to Better Clinical
Decision Making
Several points of clinical conflictFramework of EBM

Sackett DL, et al. BMJ 1996;312(7023):71-72
Patients
Values andPreferences

ClinicalJudgment

Relevant
ScientificEvidenceLong-term survival rates are
not improved in pts withadvanced dementia whounderwent percutaneousendoscopic gastrostomy(PEG) for dysphagia(Goldberg. Clin Interv Aging.
2014:14;9:1733-9

How Do We Make Clinical
Decisions?
Information from History + Physical + Testing Diagnosis  Plan for therapy/Management
 EBM: Optimizing clinical decision making by
best available evidence from clinical studies
 Conference: Gather knowledge/experiencesfrom different members, professionals, etc.
 Shared decision making (SDM): Lead to
optimal decision making by sharing logic/
values between patient and healthcare sides.
VBP Mapping
Mutual Respect for
Differences of Values
Clinicalskills

Awareness

Relationships in Person-centered practice
VBP
Science& VBP

Two-feetprinciple

Knowledge

Reasoning

Communicationskills

Multidisciplinary teamwork

Squeaky-wheel
principle

Dissensus

PremiseScience-driven
principle

Process

Partnership

Balanced Decision-making within a
Framework of Shared Values

PointClinical Skills
1. Awareness to the values of self and others
2. Reasoning: case-based reasoning withreflection on values of self and others
3. Knowledge: search for information aboutvalues
4. Communication skills: ICE-StAR

Negative values: idea, concern, expectations
Positive values: strengths, aspirations, resources

Relationships in VBP
5. Person-values-centered practiceIncluding not only patient but healthy person,
client, etc.

6. Multidisciplinary teamwork
Each professional has its own role for information
gathering and decision making

Science and VBP
7. Two-feet principle: When you think about
evidence, think of values too.
8. Squeaky-wheel principle: When you think
about values, do not forget evidences.
9. Science-driven principle: In high-edge areaof medicine, integration of evidences andvalues is important.

Dissensus
10. Partnership
Formulate partnership through “agreeing todisagree”
 Dissensus: Do not pursue 100% agreement
for all the parties. Getting to “consensus”
might be a power game.
Geriatric Swiss Cheese Model
A tool for case information gathering tooverview wide area of geriatrics
 Developed in Florida Univ. and utilized inpracticum in Geriatric Dept, Univ Hawaii
 Participants seek for the information for eachdomain, analyze it, and list which information
they need further.
SOCIALECONOMICAL

Seven Domains

ENVIRONMENTAL
MEDICAL

Social ACTIVE
EconomyPSYCHI/PSYCHO
 Environmental
 Medical
 Nutritional
 Active
 Psychi/psycho
NUTRITIONALSeven Domains: Details
SocialFamily, relative, key person, family role/task, family, caretaker, welfare services

EconomyBalance, property, family support, medical/nursing carepayment with insurance

Environmental

Public transportation, shopping sites, clinic, hospital, carefacility, house environment

MedicalDiagnosis, hearing/visual acuity, pain, decubitus ulcer,
airway clearance, use of devices/catheters…

Nutritional
ActiveDental, swallowing, appetite, cooking, bowel movement

Psychi/psycho

Calculation, reading, talking, sleep, anxiety, depression,motivation, memory, dementia, BPSD

ADL、IADL、social participation

ADL: activities of daily living, IADL: instrumental ADL
BPSD: behavioral and psychological symptoms of dementia

Points for the Case ofMy Aunt
Whether she should be hospitalized or not
was not an important issue.
 Hospitalization may cause delirium andphysical restraint. There was a risk to hurt thedignity/QOL of the patient.
 What should be the goal of her care?
Longer life? Better QOL? Better death for herself?
Better death her daughter or family?

Physical Restraint

If VBP Is Used…
Values are more important than evidences.
 The hospital had a value to limit the numberof hospitalization periods. The main doctor
just asked MSW to make hard decision withthe daughter.
 The daughter was sometimes difficult tomake decision, but it was her first experience
to do. It cannot be helped.
 As a strength, the daughter was diligent andindependent to do her best.
Simulated Interprofessional
Conference (Tamai, et al, 2018)
This educational strategy was used in homecare physician development project in U Tokyo.
 Each professional is provided common andspecific scenarios. Discussion starts frominformation sharing from each professionalrole. One who plays a role different from daily
work can behave like its professional role
sharing his/her own information.
VBP Workshop(Nomura, et al, 2018)
Simulated interprofessional conference.
stnd Half: Decision making
 1 Half: Planning  2DR

Hp
NsOTDRHp
Ns

OTMSW

HmNsCMMSWHmNs

CMPt

Points for Discussion
1. Concept of complexity
2. Strengths model/positive approach
3. Clinical reasoning model for diagnosis,
therapy/management, and monitoring
4. Values of each professional and power
imbalance
5. Relationship with normative ethics

1. Cynefin Framework(Snowden, 1999)



Cynefin is Wales language of habitat
Snowden used system theory to connect people with theirtribe/religion/geology, etc, to tackle with complicate problemsCynefin FrameworkSimple: sense–categorize–respondComplicated: sense–analyze–respond

Experts’ experience/analysis is needed to solveproblems.

Complex: probe–sense–respond

Rule-based problem solving is easy.

Difficult to analyze. Overview, make some actions tofind the clue

Chaotic: act–sense–respond“Act and see” approach is necessary. Find/feel thestable part and move it back to “Complex” level.

2. Strengths ModelCharles A Rapp, Professor of Social Welfare atKansas University, proposed this in 1997 (TheStrengths Model. 1st Ed. Oxford Univ. Press).
 Until then, healthcare support was using analytic
and problem-solving approach. However, if someproblems are persist, such an approach will notwork very well.
 Strengths model focuses on the strengths of thepatient/client/person to construct supportive care.
Recovery Phase of a Person in the Lifeand Support Process by Nurses
EmpowermentStrengths
Major
CrisisPowerless
Phase

Resilience

Acute phase
support to raise
resilience

Continuous
support using
strengths modelICE-StAR
One of the goals of communication in VBP is
to make clear ICE-StAR values．
 ICE：Negative valuesIdeas
 Concerns
 Expectations


StAR：Positive values
Strengths
 Aspirations
 Resources

Leading toStrengths model!

Related Concepts 1
Salutogenesis
Antonovsky’s theories rejected traditional medicalmodel dichotomy separating health and illness.
 His studies were pursuing how people manage
stress and stay well, so he made the term from“salus” = health and “genesis” = origin.
 People feel stress, some people is able to manage
it. Those people can predict and understand thesituations, get away with them, and feel the meaningof life in hard situations and days. They are called as“sense of coherence.”Related Concepts 2Positive psychology
Martin Seligman, who is famous for learned
helplessness, thought that positive thinking is thekey for happiness. He proposed positive
psychology in American Psychology Association.
 The same terminology was used by Abraham
Maslow in 1954, and so on.
 Seligman suggests five factors for well-being as(1) positive emotion, (2) engagement, (3) positiverelationship, (4) meaning, and (5) achievement.
3. Clinical reasoning model for
diagnosis, therapy/management,and monitoring
HealthProblems of aPatientSolution/
Stabilization of
HealthProblems

Information
Gatheringfrom thepatient
Identifying Process for
Points for Intervention

Decision
Making forIntervention

SettingDiagnostic
Hypotheses

Validating
Diagnostic
Hypotheses

Decision Making Process for Intervention

Decision Making
for Continuation/
Change ofIntervention

Listing up
Options ofIntervention

Setting Goals
forIntervention

Implementing and Evaluating Process for Intervention

Implementing
Intervention

Monitoring ofResults fromIntervention

Identifying
Points forIntervention(Eg. Diagnosis)

Judgment of
Success/
Failure ofIntervention

Diagnostic Reasoning
Health Problemsof a Patient

Information
Gathering fromthe patientSolution/
Stabilization of
Health Problems

Identifying Process for
Points for Intervention
SettingDiagnostic
Hypotheses

Differential diagnosis. If thisframe does not include correct
diagnosis reasoning will be fail.

Validating
Diagnostic
Hypotheses
Identifying Points
for Intervention (Eg.
Diagnosis)

Therapeutic Reasoning
Identifying
Points forIntervention (Eg.
Diagnosis)

Decision
Making forIntervention

Listing up
Options ofIntervention

Setting Goals
for Intervention

If goal setting is not stable,
option list and decision making
is heavily affected.

Advance Care Planning (ACP)In palliative care stage, the goal ofintervention can be longer life, better life, orbetter death (for whom?). If the goal is notstable, decision making might not go well.
 In my aunt case, the cousin did not have
ACP discussion with the mother. However,this is quite difficult discussion for values.
4. Values of Each Professionaland Power Imbalance
General tendency…
 Hospital physician: diagnosis, therapy, evidence Nurses: patients’ life, comfortable care
 MSW： better welfare, management of hospital bed PT/OT： functional recover for activity/participation
 Care manager： needs of patient/family
 Patient: avoiding fear/pain/death or annoyance tohis/her family
 Family: the patient’s interest/preference/QOL,
his/her own life, household budgetPower Imbalance
For flight, if a captain and a copilot have toomuch up/down relationship, the copilot will be
too intimidated to make advise and suchsituation will be the cause of the accident.
 Such relationship might be happening
between physician and other healthprofessionals because physicians normally
make orders to other professionals.
How to Decrease Such
Imbalance
Why• Imbalance ofknowledge,understanding,information• Age, gender,
physical features• Social statusDecreasing• Skills• Greetings, equal way of speech toeverybody• Active listening, respect for otherprofessionals• Attitude• Non-judgmental• Interest in the differences insituational and historical viewpoints

5. Relationship with
Normative Ethics


Utilitarianism


DeontologySum of whole utilities among all the concerned
people should be maximized.
How should we act? What are duties/rules?

Virtue ethics


How should I become a person with virtue?

Ethics, Evidence and Values
In clinical ethics, information is list up but
sometimes no one knows the exit.
 In EBM, health professionals sometimes do nothave any clear suggestion for the patient if there isno evidence.
 In VBP, different health professionals may havedifferent opinion but it is positively accepted for thediscussion (similar to open dialogue).
 When such fundamental discussion was held,normative ethics might be useful to find the exit.
SummaryIn Japan CBICS becomes the fundamental
system for health/medical/welfare care.
 We disseminated VBP and developed its
workshop to upgrade Japanese care system.
 There are several related concepts with VBP
to improve CBICS.
