Comprehensive Community

Care System

Mitsugi General Hospital

October 2011

(point)

Mitsugi General Hospital （as of 2011）Philosophy :Establish comprehensive community health/care system

with hospital for community and its citizensSystem : ○ Under public corporation law

○ Directly run by National Health InsuranceBeds : ２４０Annexed : Comprehensive health/welfare facilities including geriatricfacility health facility) ３１７ beds

Total ５５７ bedsDepartments : ２２ departmentsPopulation ：Approx.. 70,000No. of staffs ：６３７ including temporary staff (No. of MD ２９)Features : ○ Regional core hospital with advanced medicine (secondary ER ）

○ Rehabilitation ward and palliative care ward○ Comprehensive community care system with hospital and health

and welfare center→ Liaison office for comprehensive community health care

○ Home care with bed-bound free campaign○ Coordination and integration of health, medicine and welfare○ Designated teaching hospital certified by academic societies○ Accredited by JCQHC○ Certified for Ningen Dock and health check ups○ Certified palliative care facility○ Certified comprehensive community health and care facility

Comprehensive Community Careat Mitsugi General Hospital Today

Acute Medical Care

Comprehensive Health and Medical CareHealth care,Rehabilitation,Palliative care

Home care（Visiting nurse station)

Rehab wards,Integrated health and welfare

facilities（Care facilities)

Comprehensive community support center,

Care prevention center

Health and Welfare Center（Health management center）Care prevention center

（Comprehensive community care

liaison office)

Other institutions

between hospitals

between hospitals and clinics

240 hospital beds, 22 departments, 317 institution beds,catchment area of 70,000 people

Comprehensive Community Care○ Improves QOL by providing continuous comprehensive medical care in the community, taking social factors into consideration and by assuring that people keep living in their familiar environment

○ Comprehensive care aims at holistic medicine (and care) by providing not only cure but also health service (health promotion), home care, rehabilitation and takes community and normalization into perspectives through coordination of care at home and in the facilities and citizens’ participation.

○ Community is not a simple geographical area but organic area of living.

（by Noboru YAMAGUCHI）

Comprehensive Community Care System

１）System of collaboration among health, medical and social care

２）System of collaboration between institutional (medical, care and social)

services and home care

○ Collaboration between palliative care ward and home palliative care

○ Collaboration between rehabilitation ward and community (home)

rehabilitation

○ Collaboration between (geriatric health) care facility and home care

３）Network of local government, professionals and citizens

Comprehensive care system involving all community components

three dimensional collaboration

Comprehensive Community Care System（Integration of health, medical, care and welfare services)

Comprehensive Facilities

Geriatric Health Facility（General Ward, Dementia Ward）

Skilled Nursing Home

Home Care Support Office

Day Service Center

Rehabilitation Center (Clinic)

Regional Rehabilitation

Support Center

Care House (assisted living)

Group Home

Senile Dementia Center

Welfare Human Resource

Center

Aid Facility

National Health Insurance Clinics and Care Facilities

Local GovernmentOmi Regional Office, Hiroshima

Public Health Center

Acute Care Ward（ICU）Sub-acute Care WardPalliative Care WardRehabilitation WardChronic Care Ward

Regional Center for High Level

Brain Functions

Mitsugi General Hospital

Medical and Dental Associations

Other HospitalsSocial Welfare Council

Day Service for the Disabled

Visiting Nurse StationsHome Care SupportOfficeHome Help Station

Citizens

Com

prehensive Com

munity

Support Center

Health Welfare CenterDental Health CenterCare Prevention Center（Exercise, diet, oral care)

Home

（Institu

tion

）

Local government

Community-based service

Volunteers

Palliative care ward

Care prevention center

Geriatric health facility

Hospitals

Clinics

Skilled nursing home

Visiting care

Day care

Respite care

Wide area community rehab support center

Welfare office

Welfare center

Comprehensive community support center

(Home care support center)

Home care support office

Convalescence ward

Rehabilitationward for recovery

Concept of Comprehensive Community Care（Welfare and care） （Health and medicine）

（Institu

tion

）

(Hom

e)

(Hom

e)

Public healthcenterHealth centerHealth managementcenter

New residential arrangement

Assisted living apartment

Group home

Citizens(Clients)(Home)

Visiting nurse(station)Visiting rehabHome palliative care

Concept of Comprehensive Community Care System

（Buildings）

（programs）

（System）

Health (welfare) centerHealth management Center(ComprehensiveHealth Facility)

Hospitals

Clinics

Long-term care

insurance facility

Care house etc

Disability welfare facility etc

Primary prevention

Secondary prevention

Tertiary prevention

EmergencyTreatment(primary, secondary, tertiary)Rehabilitation(acute,recovery)(maintenance, community)Home medical care(terminal care)Training of new doctors

Care-Care managementCare prevention (new allowance for prevention,community support business)

Comprehens i ve communi ty care sys tem

Home careCare managementVisiting serviceDay service

Health

（Health Japan 21）（Health Frontier

project）

WelfareMedicineMedical law revisionHealth care system reformHealth care plan

Care Long-term care insurance lawCare insurance system reform etc.

Welfare for the disabled(IndependenceSupport Law)Welfare for the elderlyWelfare for the children etc.

（ Citizen participation） （ Citizen participation (Volunteers)

“point” to “line”, “line” to “plane” (Community Collaboration)

Community-wide comprehensive care system（Mitsugi General Hospital）

C i t i z e n s ( U s e r s )City Health CenterPublic Health Center

Health PromotionPrevention of Life-Style Related DiseaseHealthy Japan 21

GP (Clinic)Hospitals (Different roles)

A Hospital B Hospital C Hospital(Cancer) (Cardiovascular) (Stroke)

Primary Care (Early)

Cure

(Secondary, Tertiary)

Social Welfare CouncilWelfare Office

Acute care Ward

Recovery Ward(Rehab)/Palliative Ward Rehabilitation

Home Medical Care

Home Care

Long-care (Medical)

(Care)

Long-Term Care Insurance Facility

Image of Comprehensive Community Care~ Functions, Roles and Collaboration ~

Visiting Nurse / Help Stations

Citizen Volunteers

Welfare Facility

Health

Medical

Care

Welfare

HealthMedicine

Life

Welfare Care

Comprehensive Community Care System～ Medicine as a core ～

（by Noboru Yamaguchi)

[５ elements of comprehensive community care]① Strong collaboration with health care ②Improvement of care service③ Promotion of prevention ④ Advocacy and diverse life support services such as watching, meal on the wheel and shopping ⑤ Development of barrier-free housing forelderly citizens (MLIT)

Care

Prevention

Living support

Housing

Daily life zone（within 30 minutes distance)

Comprehensive Community Care System（MHLW）

Medicine

～ Care as a core ～

Network of Comprehensive Community Care (System)-System of collaboration, point to line, line to plane-

Citizens（consumers

） CitizensVolunteersHealth and welfarecommitteeHealth guidePrivate /NPOs

HealthMedicineWelfareCare

GovernmentHealth and welfare centerHealth management centerComprehensive community support center

InsurersNational Health InsuranceAssociationInsurers’ Council Professionals

（Facilities）（Collaboration）

L i n e a r C o l l a b o r a t i o nP l a n e r ( O r g a n i c )C o l l a b o r a t i o n

Comprehensive Community Care Network～ “Point”to“Line”, “Line”to“Plane”～

（Sufficient Multiple“ lines”）

（Medical)

（Medical）

（Medical）

（Care and Welfare）

Citizens' OrganizationsVolunteers

（Government ）Health and Welfare CenterComprehensive

Community Support Center

“Point”

“Line”

quasi “Plane”

“ Plane ”

（Medical）

（Medical ）

Clinic/hospital, hospital/hospital collaboration

（Hospital）（Clinic） （Clinic）

（Clinic） （Care/welfare)

（Hospital)

（Citizens）

（Noboru Yamaguchi）

Locally Self-sufficient Comprehensive Community Care System

○ Service provision (buildings and programs) and system

integration of health, medicine, rehabilitation, care and welfare are

in place in the community

○ Service provision appropriate for specific conditions is possible

○ Identification of roles (functions) and collaboration among health care

institutions

○ Collaboration between medical and care facilities

○ Collaboration between institutional care and home care

(home, residential institutions)○ Point to line, line to plane

Network building

○ Health, medicine, care and welfare to meet the needs of citizens in the community

Types of Comprehensive Community Care System

○ Rural village type (Mountain type)

○ Urban type

○ Mega-city type

○ Housing complex type

Outcome of CCC SystemHealth promotion（Health project）Bed-bound free campaignHome care（Comprehensive and integrated service provision)Planer collaboration (regional collaboration)Seamless service provision

Health management center (Health/welfare center)（restructuring)Care prevention centerComprehensive health and welfare facilityHospital as a community hub

Know

-how

Facilities

Fewer bed-bound pts.

Slower increase in health

care expenditure

Economic effects

Community vitalization

(Town planning)

Changes in the number of the elderly staying home and that of those bedridden at home in

Mitsugi Town

year

persons％ Bar chart: elderly staying at homeLine chart: ratio of the elderly bedridden at home

Graph1

19801980

19811981

19821982

19831983

19841984

19851985

19861986

19871987

19881988

19891989

19901990

19911991

19921992

19931993

19941994

19951995

19961996

19971997

19981998

19991999

20002000

20012001

20022002

20032003

20042004

20052005

20062006

20072007

20082008

20092009

寝たきり老人の割合

在宅老人数

3.8

1479

3.4

1450

3.3

1484

2.8

1516

1.8

1513

1.1

1564

1

1587

0.9

1625

1.1

1676

0.9

1740

1

1814

0.8

1841

1

1867

1

1965

0.9

2040

0.8

2070

0.6

2136

0.8

2181

1

2209

0.7

2240

0.8

2247

1

2281

1

2301

1

2348

1

2332

1

2343

1.1

2340

1.2

2359

1

2345

1

2325

Sheet1

198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009

寝たきり老人の割合3.83.43.32.81.81.11.00.91.10.91.00.81.01.00.90.80.60.81.00.70.81.01.01.01.01.01.11.21.01.0

在宅老人数1,4791,4501,4841,5161,5131,5641,5871,6251,6761,7401,8141,8411,8671,9652,0402,0702,1362,1812,2092,2402,2472,2812,3012,3482,33223432340235923452325

(National Health Insurance)Expenditure for an Elderly in Mitsugi Town

(Mitsugi General Hospital)amount

Graph1

19851985

19881988

19911991

19931993

19951995

19971997

19981998

19991999

20002000

20012001

20022002

20032003

20042004

Expenditure in Mitsugi

Average in Hiroshima

562014

523491

557584

590304

610654

638758

653886

680289

668895

699546

676120

733585

660518

740154

714384

760754

631991

725707

642995

732133

628529

704341

647548

714457

664371

737137

Sheet1

1985198819911993199519971998199920002001200220032004

Expenditure in Mitsugi562,014557,584610,654653,886668,895676,120660,518714,384631,991642,995628,529647,548664,371

Average in Hiroshima523,491590,304638,758680,289699,546733,585740,154760,754725,707732,133704,341714,457737,137

Comprehensive Community Care System: Issues

○ “Human” and “financial "resources

○ Seamless service provision（Collaboration between health and care, institutional care and

home care services）

○ Understanding of and support by mayors

and citizens

Seamless Health/Care Collaboration（Part 1）

○ Acute medical Primarycare Secondary

Tertiary○ From medical care to social care

rehabilitationMedical home care

long-term rehabilitationinstitutional care (care facility)

○ Planer collaboration ＋ seamless services

Seamless Health/Care Collaboration （Part 2）

○ Services needed are provided anywhere at any time ○ Planer collaboration with seamles service provision

Government

ProfessionalsInstitutions

Citizens

Seamlessness

Seamless Health/Care Collaboration（Part 3）

MedicineRehabCare

Home care

Medical care & rehab

RehabCare

Home care

discontinued

ER

Discharge

Medical care and rehab discontinued

（Case of discontinued medical care and rehabilitation)

（Case of seamless service）

ER

Rehabilitation

(acute) CareM

edicine

Collaboration

Maintenance

Recovery

Rehab

Care

Inst.H

ome

Care

Bedbound

CareRehab

(re)started

Continued

Discharge

Difficulty in MaintainingHuman Resources (inclu. MDs)（１）MD shortage

（２）Nurse shortage

（３）Care staff maintenance

（４）Rehab staff maintenance

MD Shortage（Report by Japan Economic Training Center）（ Medical wave 2009）

○ Approx. 77,000 MDs in short in 2016○ Largest number of MDs per 1,000 pts. in Kyoto (42 MDs)○ Serious problem in Aomori, Mie and Hiroshima○ Increase in patients will surpass increase in doctors in Mie,

Hiroshima, Kagawa and Kumamoto in 2025 and 2030→ Increase in medical students will not be enough

○ Measures with immediate effects needed→ △ Allied professionals to take some MD roles

△ Support female MDs returning to workforce△ Participation of GPs in emergency care

Factors and Issues of MD shortage ① Long-lasting shortage in rural mountainous areas② Specialization requires more MDs③ Increase in specialists who lack primary care expertise④ Insufficient use of female MDs⑤ Becomes apparent with new residency system⑥ Fewer MDs staying at local universities

→ Fewer MDs wishing to take PhD→ Universities incapable of sending MDs to the field

⑦ Uneven distribution of MDs（Concentration to big cities,specific departments, avoiding high risk associated depts.)

⑧ Increase in GPs and decrease in hospital MDs⑨ Effects of intensive allocation of doctors

→ Lack of support to rural mountainous areas⑩ Geographical discrepancy and uneven distribution among

departments not taken care of→ Free choice of MDs at present

How to Cope with MD shortage○ Increase number of doctors○ Allocation by geographical areas, departments and working

system→ Quota system（UK, Germany）

○ Compulsory service in rural areas for certain period duringthe first 10 years after MD qualification

○ Training in and establishment (system) of general medicine(Department of General Medicine)

○ Fare and adequate fee structure○ Develop sense of mission among doctors

→ Review of medical school education, retraining of MDs○ Use of allied professionals (advanced practice nurses etc.)for part of MD roles, utilization of midwifery clinic ○ Region-oriented health care plan

→ Different plan for urban cities and rural mountain areas

（Proposal to national government)

Image of Concentration of Doctors at Hub Hospitals

Cooperating hospital

ＡＢ

Ｃ

Ｄ

Hub Hospital

Ｅ

Clinic

Small-scalehospital

Clinic

Cooperating hospital

Cooperating hospital

Cooperating hospital

Cooperating

hospital（community hub）

Treatment and diagnostics Ⅰ（Buildings）（Facilities / equipment） T & DⅡ（Programs）

PhilosophyHuman resourcesTeam medicine, quality of careInformed consentMedical safetyCollaboration between hospital and clinic or facilities and between hospitalsRehabilitation and palliative medicine

Operation and managementManagementHR evaluationOrdering systemE-chartE-receiptsUtilization of IT’s

Functions to meet local needs

Comprehensive health / welfare facilityHome careCollaboration of health and welfareEstablishment of comprehensive community care system Collaboration with community services and roles of comprehensive community liaison officeNetwork building (two dimensional collaboration)

T&D Ⅲ（Quality of science and clinical service）

Patient service

Improvement of meals, environment and amenity

（ Noboru Yamaguchi ）

Hospital (Clinic) Functions

※ Challenges：How to secure “human” and “financial "resources

（％）

Improved educational environment and diverse learning opportunities

Good health, medical and welfare services

Good for the elderly and the disabled

Improved amenity in habitat

Low risk in disaster damages

Good telecommunication infrastructure

Convenient transportation including road system

Environmentally friendly with harmonization with nature

Desirable environment for children to grow

Active town with attractive urban space

Active international tourism and exchange

Vital town with active industries

Active citizen activities

Others

Culture-orientation with active art and cultural exchange

Cultural landscape and beautiful streets

Interview on the town after amalgamation

（Onomichi City・Mitsugi Town and Mukaijima Town)

Graph1

0.7

4

25.2

4.8

7.2

10.9

9.5

10.9

28.7

32.3

14.1

15.2

5.7

19.3

29.9

56

東京

Sheet1

東京0.74.025.24.87.210.99.510.928.732.314.115.25.719.329.956.0

New System for Doctor Training （ Philosophy of Training ）

To nurture good quality and personality as doctors and to let them acquire fundamental clinical competency (attitude, skill and knowledge) for primary care so that they are prepared to respond adequately and appropriately to diseases and pathologies they frequently encounter in their daily practice with accurate recognition of social needs for medicine and healthcare, irrespective of their future specialties.

(MHLW)

Background for Community Care Training（New training for doctors）

○ Health care trend From Cure to CareFrom Hospital Care to Home Care

○ Change in demographics and advancement in medicine and medical technologies○ Problems of specialization / compartmentalization○ Importance in comprehensive community healthcare○ Distinction and relationship between medicine and care（continuity）

Creation of long-term care insurance system○ Priority in primary care○ Specialist and generalist model（Comprehensive healthcare）○ Experience in specific healthcare settings

emergency medicine, preventive medicine, community health and medicine,perinatal, pediatric and developmental medicine, psychiatry, palliative andend-of-life medicine

○ Healthcare to respond to the people’s needs

“Town Planning” in the Aging SocietyCollaboration of health, medicine, care and welfare and daily life

○ Environment,Architecture, Education

○ Housing for the Elderly3-generation house

○ Community CenterSchool/Nursery schoolShopping Center

○ Employment

Skilled Nursing HomeNursing Home

○ Assisted LivingGroup HomeNursing Home

○ Social Welfare Council

Citizens’ ParticipationCitizens’ OrganizationHealth and Welfare

Welfare OfficeComprehensive Welfare Center

Citizens’ Participation

・Visiting Nurse Station・Home Care Support Center・Geriatric Health

Facility・Hospice・Comprehensive

Community Support Center

Health Promotion CenterHealth and Welfare Center（Health Management Center）

Public Health Center

Hospital

Clinic

GeneralLong - termPsychiatryTB

Health（Health motion）

Life

Medicine Care/welfare

○ Health is more than medical treatment○ Necessity of comprehensive medicine○ Bed-bound free campaign○ Establishment of comprehensive community care

→ Collaboration of health, medicine, care and welfare:team health care

○ Ｓcience （Knowledge）Art （Skill）Ｈumanity（Holistic health care）

○ From disease (organ) oriented medicine to holistic health care (QOL)○ Care is beyond simple help

→ Holistic care including living environment

Holistic Health and Care（by Noboru Yamaguchi）

スライド番号 1スライド番号 2スライド番号 3スライド番号 4スライド番号 5スライド番号 6スライド番号 7Concept of Comprehensive Community Care Systemスライド番号 9スライド番号 10スライド番号 11Network of Comprehensive Community Care (System) �-System of collaboration, point to line, line to plane-Comprehensive Community Care Network�～ “Point”to“Line”, “Line”to“Plane”～Locally Self-sufficient Comprehensive Community Care Systemスライド番号 15スライド番号 16スライド番号 17(National Health Insurance)�Expenditure for an Elderly in Mitsugi Town� (Mitsugi General Hospital)スライド番号 19スライド番号 20スライド番号 21スライド番号 22スライド番号 23スライド番号 24スライド番号 25スライド番号 26Image of Concentration of Doctors at Hub Hospitalsスライド番号 28スライド番号 29New System for Doctor Training Background for Community Care Training� （New training for doctors）スライド番号 32スライド番号 33