Introduction of dementia care model in Japan

10:30-12:00, 18th May 2015 Miharu Nakanishi Tokyo Metropolitan Institute of Medical Science

01

Key points Japanese dementia care model

• Health and social care system

• Transition in care

• Dementia care coordination

• Housing options till end of life care

• Advocacy and safeguarding

02

Health care system in Japan Universal health care insurance coverage

• Variety of insurers

– For employees

– For self-employed, farmers and pensioners

– For people aged 75 and over

Outpatient care and hospital care

• No registration system of general practitioners (GPs)

• Free access

03

Adult social care in Japan Older adults

• Public long-term care insurance (LTCI) program for elderly care in local authorities

• In case of protection: Public tax-funded services for person who is 65 years old and over

Younger adults with disabilities

• Public tax-funded care services for people with disabilities in local authorities

04

Social care systems by age

05

Older adults Younger with disabilities

Age Finance - Governance Finance - Governance

0-17 Tax fund - Local authority

18-39 Tax fund - Local authority

40-64 Insurance - Local authority

65-

Tax fund - Local authority

• Care for people with dementia may involve all of these systems, except for children.

Certification of LTCI care level

06

Care level 1-5 Needed support Independent

Certification Committee of Needed Long-Term Care

Residents in local authority

Application for use of services under LTCI

Local authority

Investigation Physician’s opinion

65 years old and over

40-64 years old with specific diseases

Community general support centre

Home care

First judgment

Second judgment

Residential care Preventive home Other services (not covered by LTCI)

Certification

Care manager

Preventive community-based

Community- based care

Care plan

Benefit scheme for LTCI

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Care provider

Prefecture (state) Local authority

Designate home and residential care services

Claim payment

Formulate Local LTCI plan once every 3 years

Government Formulate universal benefit schedule for LTCI services once every 3 years

Federation of National Health Insurance Associationb

a Community-based care service is introduced in 2006. It includes group homes. b “National Health Insurance” is a healthcare insurance scheme for self-employed

and pensioners.

Designate community-based care servicesa

Audit claims Payment

Preventive care

Transition in dementia care

Inpatient care

Outpatient/ outreach

Residential care

Home care

Hospital

Special nursing home

Intermediate care

Doctor

Doctor

Long-term care insurance (Local Authority)

Health care insurance (Insurer) 08

Communitybased care

Care manager

Community general

support centre

Dementia care coordination

Inpatient care

Outpatient/ outreach

Residential care

Hospital

Special nursing home

Intermediate care

Doctor

Doctor

Long-term care insurance (Local Authority)

Health insurance (Insurer)

Medical Centre for Dementia

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Home care

Care manager

Preventive care Community

based care

Community general

support centre

Initial-Phase Intensive Support Team

Dementia coordinator

Coordination - Scotland

Secondary care

Primary care

Residential care

Home care

Hospital

Care home Intermediate care

General Practitioner

Specialist

Adult social care (Local Authority)

National Health Service (Health Board)

Community Mental Health Service

Link Worker

Integrated Authority?

Social Work Officer

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• Hospital-based implementation

Discharge planning in Japan

Hospital

LTCI residential care

Doctor Doctor

11

Home (LTCI home care)

Care manager

Community general

support centre

• Single assessment process

Discharge planning in England

Hospital

Doctor

12

Local authority

Home (social home care) Care home Intermediate care

NHS Continuing Healthcare

Registered Nursing Care Contribution (RNCC)

Housing for older adults Long-term care insurance Congregate housing

Number of residents at 30 September / 1 October 2013

Special nursing home

Sanatorium bed

Intermediate care

Group home

Fee-based home for elderly

Senior house with services

0

200000

400000

600000

13

Dementia in care homes Percentage of residents with diagnosis of dementia

National statistics at 2013

0%

20%

40%

60%

80%

100%

England Scotland Australia Japan

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Residential relocations • Care transitions may occur

because of unavailable

permanent residence option

for people who suffer with

medical deterioration

(Nakanishi et al., 2014 JAMDA)

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Residents in care homes Permanent residence per 1000 elderly population

National statistics at 2013

0

10

20

30

40

50

60

70

80

England Scotland Denmark Sweden Australia Japan

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Dementia in psychiatric beds Inpatients by primary diagnosis (1,000 persons)

National Patient Survey

0

50

100

150

200

250

300

350

1996 1999 2002 2005 2008 2011

Other

Vascular andother

Alzheimer's

Schizophrenic

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Discharge from psychiatry Psychiatric patients with primary diagnosis of dementia

Re-analysis of National Patient Survey 2008

0% 20% 40% 60% 80% 100%

Cohabitance with family Living alone Other hospitalIntermediate care Special nursing home Other facilityDeath Other

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Discharge from care homes Discharge distribution, excluding short stay

National Statistics and other reports

0% 20% 40% 60% 80% 100%

Fee-basedhome/senior house

Group home

Special nursinghome

Own home Hospital LTCI residentialOther facility Death at facility Death at hospitalDeath, other Other, unspecified

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End of life care Place of death

National statistics at 2013

0%

20%

40%

60%

80%

100%

England Wales France Japan

Other

Hospital

Care home

Own home

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End of life care in dementia Place of death, 65 years and over

Houttekier et al (2010) JAGS

0%

20%

40%

60%

80%

100%

Belguim TheNetherlands

England Wales Scotland

Hospice

Hospital

Care home

Own home

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End of life care in Japan Place of death, by leading cause of death

National statistics at 2013

0%

20%

40%

60%

80%

100%

Alzheimer's Vascularand other

Total

Other

Hospital

Care home

Own home

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Advocacy and safeguarding Scotland

• Adults With Incapacity Act 2000

• Adult Support and Protection Act 2007

Japan

• Adult guardianship under Civil Law

• Elder Abuse Prevention and Caregiver Support Law

• Act on Prevention of Maltreatment of Persons with Disabilities

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Family caregivers Older adults by type of household composition

National statistics at 2013

0%

20%

40%

60%

80%

100%

Denmark (2013) Sweden (2013) Japan (2010)

Other

Withchildren

Two (withpartner)

Alone

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Mistreatment by family carers Japan: National statistics in 2013 • 97.6% (16140/16542) of substantiated cases were identified at

domestic settings

• 8071 (48.8%) victims had any symptoms of dementia

• 41.0% of domestic abusers (family) were sons; 19.2% were husbands

Referrals per 100000 population • Japan had 85 per 100000 population (+65)

• It may be relatively low: England had 246 per population (+18)

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Systems for safeguarding Local authorities

• A small number of reports/substantiated cases was related to poor system development in the local authority (Nakanishi et al., 2013 JASP)

Community general support centre

• Delegated by local authorities: a first access point

• 71.7% of centres were operated by private sector in 2013

• Private centres found more difficulties in addressing elder abuse cases rather than public centres (Nakanishi et al., 2014 JEAN)

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Challenges in Japan (1) Decision making process

• There is no legislation on advanced care planning

[Example]

• Percutaneous endoscopic gastrostomy (PEG) tubes were placed in people with advanced dementia regardless of expectation of improvement in QOL (Nakanishi and Hattori, 2014 JNHA)

• Even when nursing home residents documented their end of life care preferences, their preferences regarding place of death were not known (Nakanishi and Miyamoto, in press EJPCH)

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Challenges in Japan (2) Place of (end-of-life) care

• The majority of group homes did not provide end of life care to residents with dementia (Nakanishi and Honda, 2009 AGG)

• There is a long waiting list for nursing home placement

• Nursing homes sometimes rejected applicants with challenging behaviors because of their facility’s inability to address challenging behaviors (Nakanishi et al., 2012 JAMDA)

• Intermediate care facilities serve as a place of residence for older adults with unavailable permanent residence option (Nakanishi et al., in press Ageing Int)

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To be continued afternoon International comparison of dementia plans

• Dementia care pathways

• Palliative care contents in national dementia plans

Discussion

• Coordination or one-stop service (packaged care)?

• Coordination by public or private sector?

• Where to obtain end-of-life care for dementia?

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