ISSN 1342-7482

Journal of Social Policyand

Social WorkJ S P S W

MARCH 2011

Japan College of Social Work

J S P

S W　　　  N

umber 15　

2011 　

Japan College of Social W

ork

Journal of Social Policy and Social WorkNumber 15

Contents

Foreword

Ken-ichi Nakashima　 �  � 1

Papers

Societal Changes and Establishment of Local Comprehensive Care System in Japan　 �   5–Reform of the long-term care insurance program and future of elderly welfare services

Hirokazu MurakawaMiyuki Murata

Reforms of Elderly Long-Term Care Insurance System in Germany and Japan　 �  �25–Focused on the Development of Community Services for the Elderly with Consulting and Support Functions –

Hirokazu MurakawaKaori Yasumura

Multiple Regression Analysis of Compassion Fatigue/ Satisfaction Questionnaires, 　 �  �39and Correlation between these Questionnaires and Care Providers’ Behavior (FR behavior) in Japanese Child Welfare Facilities.

Takashi Fujioka

A Study of Methods of Model Formulation and assessment to Construct Models　 �  �59of Effective Program Implementation Based on a Nationwide Survey of Support Providers

Noriyasu KosazaIwao OshimaHisao Sato

March 2011

No 15

ISSN 1342-7482

Journal of Social Policyand

Social WorkJ S P S W

MARCH 2011

Japan College of Social Work

J S P

S W　　　  N

umber 15　

2011 　

Japan College of Social W

ork

Journal of Social Policy and Social WorkNumber 15

Contents

Foreword

Ken-ichi Nakashima　 �  � 1

Papers

Societal Changes and Establishment of Local Comprehensive Care System in Japan　 �   5–Reform of the long-term care insurance program and future of elderly welfare services

Hirokazu MurakawaMiyuki Murata

Reforms of Elderly Long-Term Care Insurance System in Germany and Japan　 �  �25–Focused on the Development of Community Services for the Elderly with Consulting and Support Functions –

Hirokazu MurakawaKaori Yasumura

Multiple Regression Analysis of Compassion Fatigue/ Satisfaction Questionnaires, 　 �  �39and Correlation between these Questionnaires and Care Providers’ Behavior (FR behavior) in Japanese Child Welfare Facilities.

Takashi Fujioka

A Study of Methods of Model Formulation and assessment to Construct Models　 �  �59of Effective Program Implementation Based on a Nationwide Survey of Support Providers

Noriyasu KosazaIwao OshimaHisao Sato

March 2011

No 15

Journal of Social Policy and Social Work No.15（ J S P S W）

Eighth Issue： MARCH 2011

Editor： Helen Fujimoto

No part of this publication may be reproduced in any formwithout the prior written permission

of the copyright owner

　　　 　

ISSN 1342-7482Published by Japan College of Social Work

3-1-30 Takeoka, Kiyose-shi,TOKYO, JAPAN, 204-8555

Printed in JapanKYOSHIN Co.,Ltd.

ISSN 1342-7482

Journal of Social Policy and Social WorkNo 15

MARCH 2011

Japan College of Social Work

Foreword

Ken’ichi NakashimaDirector, Social Work Research Institute

Japan College of Social Work

Social welfare studies, when compared to other human service fields such as medicine, nursing and

psychology, is a discipline which is closely linked to national politics, economy, legislation, social systems

and policies. The question of poverty, homelessness or NEETs is strongly influenced by politics and economy.

However, ways to support disabled people’s independence and to care for the elderly are also problems

which are to be discussed in connection with legislation and social systems rather than purely academically.

We need to grasp bullying and truancy among school children and child abuse too as problems of social

structure exceeding mere characteristics of individuals. In short, we can say that while social welfare studies

is a discipline always influenced by national tendencies, it is also one which can counterinfluence them

through carrying out research. In this sense, we should not limit our discussion to the extent of a framework

set up by us taking current legislation, social systems or policies as prescribed factors. Instead, researchers

of social welfare are expected to have a perspective according to which all can be changed and to compare

ideal and actual conditions, hence study and advocate directions for progress.

At present, actions are being taken to revise the international definition of social work and a proposal

for an Asian definition is also under consideration. What is well-being? What is social justice? What is

independence? What is a social network? Finally, what is the definition of “living” to be supported to begin

with? Rather than to produce a definition consisting of a few lines as a conclusion to several discussions

between researchers from different countries with various backgrounds, answering to expectations, it is

of even greater significance that the role of social welfare and social work is going to be redefined from a

universal perspective.

In this edition, some of the researches conducted at the Japan College of Social Work are published

in an English journal format. We hope that it can contribute to the further establishment of universal social

welfare and long-term care studies.

Journal of Social Policy and Social WorkNumber 15

March 2011

Contents

Foreword

Ken-ichi Nakashima …………………………………………………………………………  1

Papers

Societal Changes and Establishment of Local Comprehensive Care System in Japan

-Reform of the long-term care insurance program and future of elderly welfare services

Hirokazu Murakawa ………………………………………………………………………… 5Miyuki Murata

Reforms of Elderly Long-Term Care Insurance System in Germany and Japan

-Focused on the Development of Community Services for the Elderly with Consulting and Support

Functions -

Hirokazu Murakawa ………………………………………………………………………… 25Kaori Yasumura

Multiple Regression Analysis of Compassion Fatigue/ Satisfaction Questionnaires, and Correlation

between these Questionnaires and Care Providers’ Behavior (FR behavior) in Japanese Child Welfare

Facilities.

Takashi Fujioka ……………………………………………………………………………… 39

A Study of Methods of Model Formulation and assessment to Construct Models of Effective Program

Implementation Based on a Nationwide Survey of Support Providers

Noriyasu Kosaza …………………………………………………………………………… 59

Iwao Oshima

Hisao Sato

5

Societal Changes and Establishment of Local Comprehensive Care System in Japan - Reform of the long-term care insurance program and future of elderly welfare service

Hirokazu MURAKAWA Miyuki MURATA

Introduction

As ageing population has been progressing on the global scale, situations surrounding ageing society

are posing the most serious problem in the social life in Japan as well as in foreign nations. With the

society getting matured and ageing population further progressing, how should elderly people spend their

longer life in their old age? In addition, various problems are piling up, such as increased nuclear families

in Japan’s depopulating society, solitude of elderly people, and an increase in frail elderly people and those

requiring health,medical and social care services.

In the development process of elderly welfare services in Japan, charity services by voluntary

gentlemen as well as elderly support services as a poor-relief program used to play central roles in the

past. Since lawmakers passed Act on Social Welfare Service for Elderly in 1963, institutional care services

provided by social welfare corporations have been playing certain roles until recently. Through submitting

Golden Plan and enacting Long-term Care Insurance Act, more emphasis is placed on the quality of

life (QOL) and self-reliance support for elderly people. In this context, at-home care services and other

services that would meet such needs are becoming necessary.

In the contemporary trend of social security structural reforms, including pension system and medical

care programs, the government started the Long-term care insurance program in 2000. It is necessary to

provide care services in line with user needs, improve service quality, and set up user-friendly, small-

size and multi-functional core facilities. As elderly people are estimated to occupy approximately 35% of

Japan’s total population in 2030s, social welfare corporations, social welfare councils, elderly people’s

volunteer activities, non-profit organizations, such as local NPOs, cooperative movement grups, and

agricultural cooperatives, as well as business sector for elderly, are becoming more important. It is the

time to strongly push ahead with developing various services and social resources in local communities.

This paper makes clear essential points of Japan’s societal changes (population, family, and local

communities) and discusses social policy-related problems with focusing on situations of elderly people in

the 2010s.

6

Chapter I. Trend surrounding aged society with declining birthrate

1-1. Shift from ageing society to aged society with declining birthrateThe term “Ageing society” has appeared on the scene for years, but it is the United Nations’ report that

points out the situations of ageing society for the first time. Ageing society means people aged 65 or over

occupy 7% or more of the total population in a nation. As Japan shifted to ageing society in 1970 and sees

further population aging thereafter, the nation falls under the situation called “Aged society” and suffers

common social problems with western advanced industrial countries. In addition, with birthrate dropping

for recent years, the social situation/term, “Ageing society with declining birthrate”, has been taking root

in Japan.

1-2. Population trend and ageing population in the worldThe overall world population stands at 6,414.75 million as of 2005 and is estimated to increase to

9,091.29 million in 2050. People aged 65 or over as a percentage to the total population have been

increasing from 5.2% in 1950 to 7.3% in 2005. In addition, the percentage is estimated to further rise

to 16.2% in 2050. Ageing population will progress rapidly in a half century ahead. Except for a large

portion of Africa, global-scale ageing population and maturation of the human society will be progressing

throughout the 21st century.

As shown in Table 1, elderly people register 20.1% of the total population in Japan, 19.7% in Italy,

17.2% in Sweden, 18.8% in Germany, and 12.3% in the United States as of 2005. Japan hits the world’s

highest figure of elderly people as a percentage to the total population.

Ageing population in Japan is characterized by its unprecedentedly high speed in the world. Elderly

population has increased from 7% to 14% of the total population only for 24 years. Ageing population in

Japan has been progressing at a much quicker pace than that in France (115 years) or Sweden (85 years).

The percentage of elderly citizens straightly indicates significant and abrupt changes for the society,

people, families, and local communities in Japan.

Analysts have long recognized that ageing population problems represent a social phenomenon

only observable in advanced industrial countries. However, as the United Nations calls our attentions

through “International Year of Older Persons” in 1999, developing countries such as China and India will

inevitably see ageing population as well from the middle to the second half in the 21st century.

7

Table 1. International comparison of ageing population rate (People aged 65 or over as a percentage to the overall population)

Nation Percentage of people aged 65 or overFuture estimate

2050Japan 2005 20.1% 39.6%The United States 2005 12.3% 20.6%The United Kingdom 2005 16.1% 23.2%Germany 2005 18.8% 28.4%France 2005 16.3% 27.1%Sweden 2005 17.2% 24.7%Italy 2005 19.7% 35.5%

(Source) Japan Center of Longevity Society, “Handbook of Elderly Care 2007,” p.3; the author has partially amended the data.

1-3. Population trend and ageing population in JapanAs of October 2007, the total population in Japan stands at 127.77 million, remaining almost flat at the

preceding year’s level. Population aged 65 or over stands at 27.46 million (11.70 million men and 15.76

million women), occupying 21.5% of the overall population (i.e., ageing rate).

Among elderly citizens, population of early-stage elderly people (aged 65-74) is 14.76 million, while

that of late-stage elderly people (aged 75 or over) stands at 12.70 million, exceeding 10 million.

In Japan, elderly citizens only occupied less than 5% of the nation’s overall population in 1950, but they

grew further than 7% in 1970 (so-called “ageing society”) and exceeded 14% in 1994, leading to rapid

progress in aged society. Population of elderly people will reach its peak at 38.63 million in 2042 and take

downturn thereafter.

Japan’s overall population started a downward trend in 2005, but ageing rate will keep rising, increasing

to 25.2% in 2013 and 40.5% in 2055 when one person out of 2.5 Japanese citizens will be older than 65.

Table 2. Trend of elderly population (1960 to 2050) (units: 1,000 / %)

Year

Population Percentage to overall population

TotalPeople aged 65

or overPeople aged 75

or overPeople aged 65

or overPeople aged 75

or overMen Women Total Men Women Total Men Women Total Men Women Total Men Women Total

1960 46,300 48,001 94,302 2,341 3,057 5,398 601 1,034 1,642 5.1 6.4 5.7 1.3 2.2 1.71975 55,091 56,849 111,940 3,838 5,028 8,865 1,119 1,722 2,841 7.0 8.8 7.9 2.0 3.0 2.51990 60,697 62,914 123,611 5,988 8,907 14,895 2,233 3,741 5,973 9.9 14.2 12.0 3.7 5.9 4.81995 61,574 63,996 125,570 7,504 10,757 16,261 2,564 4,606 7,170 12.2 16.8 14.5 4.2 7.2 5.72000 62,111 64,815 126,926 9,222 12,783 22,005 3,195 5,804 8,999 14.8 19.7 17.3 5.1 9.0 7.12005 62,349 65,419 127,768 10,923 14,838 25,761 4,308 7,331 11,639 17.5 22.7 20.2 6.9 11.2 9.12010 11,868 65,309 127,176 12,569 16,843 29,412 5,420 8,802 14,222 20.3 25.8 23.1 8.8 13.5 11.22015 60,806 64,624 125,430 14,570 19,211 33,781 6,378 10,074 16,452 24.0 29.7 26.9 10.5 15.6 13.12020 59,284 63,451 122,735 15,462 20,437 35,899 7,344 11,393 18,737 26.1 32.2 29.2 12.4 18.0 15.32025 57,406 61,864 119,270 15,562 20,792 36,354 8,617 13,050 21,667 27.0 33.7 30.5 15.0 21.1 18.22050 45,320 49,832 95,152 16,227 21,414 37,641 9,558 14,170 23,728 35.8 43.0 39.6 21.1 28.4 24.9

(Data) Statistics Bureau, Ministry of Internal Affairs and Communications, “Population Census” and “Population Estimates”; and National Institute of Population and Social Security Research, “Population Projections for Japan” (Estimated as of December 2007, medium estimate)

(Source) Japan Center of Longevity Society, “Handbook of Elderly Care 2007,” p.1, 2007

8

Out of elderly population, population of early-stage elderly citizens will gradually decrease after hitting

a peak in 2016, but late-stage elderly people aged 75 or over are estimated to keep increasing and will

exceed early-stage elderly citizens in 2017, inevitably sending up the number of elderly citizens requiring

care services because they suffer dementia or become bedridden.

On the other hand, birthrate has been taking a downward trend, resulting in lower fertility. In contrast to

increased elderly population, child population (aged 0-14) will account for a lower percentage. This will

push down Japan’s overall population in the long run, bringing down labor force population, leading to

a decrease in taxpayer population and social insurance policyholders, which will surely pose significant

impacts on Japan’s socioeconomic structure as well as on the nation’s social programs, such as pension,

medical care, welfare, and care programs.

1-4. Aged society with declining birthrate, and its factors(1) Mortality rate and longer average life expectancy

Japan’s mortality rate (the number of deaths per 1,000 citizens) decreased by half for approximately 15

years from 14.6 in 1947 because mortality rate of babies, toddlers, and young people dropped sharply due

to improved living standards, better dietary life and nutrition, and progress of medical technologies. Since

then, the mortality rate kept a gradual downward trend, hitting the record low of 6.0 in 1979. It takes a

slight upward trend for recent years, standing at 8.6% in 2006 (1,106,000 deaths). However, since stronger

health awareness among Japanese citizens as well as remarkable development of medical technologies has

resulted in lower mortality rate for patients with cerebrovascular diseases and longer life for patients of

other diseases, the mortality rate for middle-aged or older citizens has been improving.

In particular, mortality rate for elderly people aged 65 or over has been consistently taking a downward

trend since the end of WWII, falling from 71.5 in 1950 to 47.4% in 1980, and 33.8% in 2006. As for a

gender gap of mortality rate among elderly persons, mortality rate for women significantly falls short of

that for men in any age bracket.

As mortality rate gets lower, average life expectancy for Japanese people has been sharply rising

from 50.06 years for men and 53.96 years for women in 1947 to 79.00 years for men and 85.81 years for

women in 2006. Japan is the nation with the greatest longevity.

As average life expectancy at the age of 65 has been also getting longer from 10.16 years for men and

12.22 years for women in 1947 to 18.45 years for men and 23.44 years for women in 2006, both men and

women are spending longer senior life. In the future, average life expectancy will keep getting longer

to 83.67 years for men and 90.34 years for women in 2055 (according to the December 2006 medium

estimates of National Institute of Population and Social Security Research, “Population Projections for

Japan”).

(2) Progress of lower birthrate

As for the trend of new-born babies in the post-WWII era, the number of live births tends to decrease

after the peak twice in the first baby boom (1947-1949) and the second baby boom (1971-1974). As of

2005, the number of live births stands at 1,062,530, while birthrate (the number of live births per 1,000

9

persons) is 8.4.

In addition, total fertility rate (i.e., the sum of age-specific birthrate of women aged 15 to 49, which

represents the number of children that would be born to a woman over her lifetime if she were to

experience the age-specific fertility rate for her age) sharply fell down since the first baby boom. The

rate stood at 2.22 in 1956 and kept the necessary level to maintain population (2.05 to 2.10) for a while.

However, it fell to 1.91 in 1975, falling below 2.00, and decreased to 1.46 in 1993, dipping from 1.5. Total

fertility rate kept falling thereafter. As of 2006, total fertility rate stands at 1.32, rising 0.06 point from the

2005 level.

Figure 1. Annual trend of live births and total fertility rate

(Source) Japan Center of Longevity Society, “Handbook of Elderly Care 2007,” p.5, 2007

A drop of live births and birthrate in this way is attributable to multiple factors. As Japan has a relatively

small number of babies born outside of marriage, direct factors would include a rise in first-marriage age

(tendency to marry later) and an increase in people going unmarried (an increase in people staying single).

A percentage of unmarried persons started to particularly rise for men aged 25-39 and women in their

20s around 1975. The rate of remaining single for life has been taking an upward trend both for men and

women, standing at 15.96% for men and 7.25% for women in 2005, rising stronger for men than women.

First-marriage age is also rising both for men and women.

Average number of children born to a married woman takes a slight downward trend. However, married

women in younger generation tend to give birth to fewer children than those in other generations. In

addition to tendency to marry later and an increase in people staying single, if married couples give birth

to a decreased number of children, fertility rate will further drop, according to some analysts.

These population trends have resulted from several social factors, such as increased women with higher

10

education background and self-reliance attitude, a rise in women’s labor-force participation ratio, poor

child-care services for babies and toddlers, difficult balance between child-rearing and working, husband’s

poor participation in child-rearing, and a change in social awareness of marriage and child-rearing.

1-5. Ageing population in each region(1) Population trend since the 1970s: Overpopulation and underpopulation

Ageing population in Japan significantly varies region by region. Significant regional gap is

attributable to a labor force shift from rural areas to urban areas in the high-growth era from the 1960s

to the 1970s. Since industrial structural change has sent out younger labor force to urban area and has

brought about concentration of younger generations from rural areas to urban areas, underpopulation

and ageing population in rural communities or local small cities have progressed, posing serious social

problems. Urban areas have also suffered from environmental deterioration or housing problems due to

overpopulation. In this sense, overpopulation and underpopulation have brought about overwhelmingly

serious problems.

(2) Ageing population in local areas

Ageing population significantly varies among local areas. Ageing population has been particularly

progressing in Tohoku, Shikoku, and Kyushu areas, while that in Tokyo metropolitan area and Kinki area

is progressing at a slightly slower pace, but is estimated to gradually take a quicker pace in the future.

In addition, elderly citizens occupy a majority of the overall residents in some municipalities, while

ageing population is expected to progress rapidly in some prefectures in Tokyo metropolitan area, such

as Tokyo, Chiba, Saitama, and Kanagawa Prefectures in the 2020s and the 2030s. In this context, it is

important to take countermeasures on ageing population from the viewpoints of decentralization and local

social welfare services.

Chapter II. Living conditions of elderly citizens in Japan

2-1. Households with elderly peopleAs of 2006, 18.29 million households have at least one elderly person, occupying 38.5% of the overall

households (47.53 million households).

Households with elderly people consist of 4.1 million “single-person” households (22.4%), 5.4 million

“husband-wife-only” households (29.5%), 2.94 million households with “parent(s) and unmarried

child(ren) only” (16.1%) and 3.75 million “three-generation” households (20.5%), suggesting a decrease

in three-generation households and a higher percentage of “husband-wife-only” households and “single-

person” households.

11

Figure 2. Trend of households with elderly person aged 65 or over

(Source) Japan Center of Longevity Society, “Handbook of Elderly Care 2007,” p.10, 2007

As for the future trend of elderly households in Japan, the total number of households with household

head aged 65 or over (hereinafter, such households are referred as “elderly households”) is estimated to

increase approximately 1.4 times from 13.55 million in 2005 to 19.03 million in 2030. On the other hand,

the number of ordinary households will increase from 49.06 million in 2005 to 50.60 million in 2015. As

a result, elderly households as a percentage to the total number of ordinary households will increase from

27.6% in 2005 to 39.0% in 2030 (“ordinary households” means a group of persons under the common

residence and livelihood or a single person that has his/her own household).

2-2. Economic life for elderly people(1) Income

Annual income of elderly households (average income as of 2005) stands at \3.019 million, slightly

exceeding a half of the average income of all households (\5.638 million). However, as elderly households

usually have fewer household members, income per household member is \1.89 million, suggesting

almost no gap with ordinary household’s average income per household member (\2.059 million) (See

Table 4).

As for income sources for elderly households, \2.119 million come from “public pension” (70.2% of

the gross income), occupying the largest percentage, followed by “labor income” (\545,000; 18%) and

“money sent or other income” (\172,000; 5.7%).

12

Table 4. Income of elderly households

Category

Average income

Income per householdIncome per household member (average number of household members)

Elderly households

Gross income: \3.019 millionLabor income: \545,000 (18.0%)Public pension: \2.119 million (70.2%)Property income: \157,000 (5.2%)Social welfare benefits other than pension: \25,000 (0.8%)Money sent or other income: \172,000 (5.7%)

\1.89 million (1.60 persons)

All households Gross income: \5.638 million

(Source) Cabinet Office, “Annual Report on the Aging Society 2008,” Saeki Printing, p.26, 2008

According to Cabinet Office’s first survey report that focuses on elderly men and women’s economic

anxiety and their self help in their daily life (survey respondents: age 55 to 74), approximately a half of

elderly women make annual revenues less than \1.8 million. A little bit more than 20% of them spend

their life with the annual revenues less than \1.2 million. As for elderly male single persons, 10% of

unmarried male elderly persons make annual revenues of less than \600,000.

As for distribution of annual income of elderly households, the income bracket of \1 million or more

but less than \2 million controls the largest percentage of 27.1%, followed by that of \2 million or more

but less than \3 million (18.5%), \3 million or more but less than \4 million (16.9%), and less than \1

million (15.7%), and the median value stands at \2.4 million (See Figure 3). Elderly persons aged 65 or

over occupy 39.8% of the overall recipients of livelihood protection subsidy. Out of this, single-person

households controls 28.5%, and in particular, female single-person households account for 16.8%.

(2) Consumption

As for budget of households with the household head aged 65 or over, worker households with the

household head aged 65 or over have monthly disposable income of \307,983 a household, which consists

of consumption expenditures of \277,474, and savings and other surplus of \30,509. On the other hand,

non-worker households with the household head aged 65 or over have monthly disposable income of

\163,023 a household, including consumption expenditures of \203,567, which generates deficit of

\40,544. They cover this deficit by drawing down their savings.

13

Figure 3. Distribution of annual income of elderly households

(Data) Ministry of Health, Labour and Welfare, “Comprehensive Survey of Living Conditions of

the People on Health and Welfare” (2006) (Annual income in the said survey) (Note) Elderly household means a household consisting of senior citizen(s) aged 65 or over or a

household comprising senior citizen(s) aged 65 or over and unmarried person(s) younger than 18 years old.

(3) Savings

Savings on hand for Japanese citizens tend to increase as they get older. According to “Annual Report

on the Aging Society 2008,” elderly households have \24.29 million savings on hand on average as of

2006, 1.4 times of the average of all households. Almost 20% of elderly households have savings on hand

more than \40 million.

As for whether or not they think they have enough savings for their old age, 27.9% of elderly

respondents think they “have sufficient savings” (i.e., the sum of respondents answering they “have

enough savings” and “have minimum savings at least”). Respondents choosing the answer option they

have “insufficient savings” (i.e., the sum of respondents answering they “have a little bit insufficient

savings” and “have quite insufficient savings”) occupy 64.7% of the overall respondents, rising 7.6% from

57.1% in the preceding survey.

(4) Housing

In terms of housings for elderly people aged 65 or over, almost 60% (59.0%) of senior citizens live

in the same residence for 31 years or longer (some of them are living in the same house since they were

born). On the other hand, 6.5% of senior people live in the same house for “5 years or shorter,” suggesting

a downward trend of senior citizens living in the same house for a long time of 20 years or longer.

Figure 4 shows residence patterns that elderly people aged 65 or over are wishing when they get run-

down.

14

Figure 4. Residence patterns that elderly people are wishing when they get run-down (multiple answers allowed)

(Data) Cabinet Office, “Consciousness Survey on Elderly People’s Housings and Living

Environment” (2006) (Note) This survey covers male and female respondents aged 60 or over all over Japan.

(5) Increased nuclear families and lifestyle changes

Social structural changes after WWII have significantly altered local communities and family life.

Traditionally, large families consisting of three or four generations were widely observable both in urban

and rural areas. However, as nuclear families have been getting increased until recent years, the percentage

of elderly citizens living with their children takes a downward trend. In fact, 79% of elderly people lived

with their children in 1963 when lawmakers passed Act on Social Welfare Service for Elderly, but the

percentage fell to 47.1% in 2002 and sharply dropped to 43.9% in 2006.

In addition, the percentage of husband-wife-only elderly households and elderly single-person

households stands at 52.2% as of 2006, occupying more than a half of elderly persons. In particular, Japan

is characterized by an increase in elderly persons living alone. According to the estimate of National

Institute of Population and Social Security Research, Ministry of Health, Labour and Welfare, single-

person households with household head aged 65 or over will sharply increase to 6.354 million households

in 2020.

A lot of senior citizens probably would like to spend a fulfilling life for their old age by making use

of their experiences and techniques in a local community they are accustomed to. In addition, as elderly

15

people now have a variety of self-fulfillment opportunities due to changes of the times, they enjoy

increased opportunities to actively work on what they long wish to do. On the other hand, weaker mental/

physical conditions due to ageing as well as problems requiring care services would prevent them from

achieving their life images that they have envisioned.

If they face weaker mental/physical conditions or problems requiring care services, they will feel a

lot of anxieties, such as what they should do, or how they should use or take procedures for, necessary

services or programs. These mental anxieties and cost burden associated with hospital visit, hospital stay

or other issues for continuing their life should not be underestimated.

Table 5 shows what elderly citizens are worrying in their daily life. Approximately 68% of elderly

people feel “very insecure” or “a little insecure,” suggesting an example of their anxieties about care

service problems.

Table 5. Expected care service providers if elderly citizens require care services

JapanThe United

StatesSouth Korea Germany Sweden

1. Spouse or partner 46.7 36.1 40.7 41.5 44.92. Son (including adopted son) 8.1 6.8 29.4 8.6 3.63. Daughter (including adopted daughter) 9.8 22.2 7.0 20.7 9.24. Spouse or partner of son or daughter 8.7 2.7 13.5 2.1 0.75. Other family members or relatives 1.3 6.0 0.5 5.0 2.26. Friends/acquaintances 0.3 2.9 0.1 3.6 2.37. Nonprofessional service providers, such as

volunteers0.7 0.1 0.6 1.0 0.8

8. Professional service providers, such as care attendants

10.4 13.8 0.5 8.3 28.6

9. Others 1.1 1.4 0.3 1.8 0.610. No care providers available 1.4 2.1 3.7 1.4 0.611. Unknown 11.2 5.2 3.8 4.7 5.8

(Data) Director General for Comprehensive Planning Coordination, Cabinet Office, “International Comparison Survey on Elderly Citizens’ Life and Awareness (FY2000)”

(Source) Japan Center of Longevity Society, “Handbook of Elderly Care 2007,” p.27, 2007

Long-term Care Insurance Act of 1997 became fully effective in 2000. Golden Plan 21, which was

developed in 1999, aims to provide better environment for care services and expand health welfare

programs for elderly citizens. In this context, Japan has entered a new stage called “Socialization of Care

services,” shifting away from heavy dependence on family members as care service providers in the past.

With the long-term care insurance program becoming operational, a variety of care services have been

spread out, but there are still a lot of problems, including elderly persons still unable to use these services.

16

Chapter III

3-1. Historically Systematic deployment of elderly care services: Since Long-Term Care Insurance Act became effective

Table 6 describes Japan’s social policies and welfare programs for elderly citizens since the end of

WWII. After efforts through Golden Plan and New Golden Plan, lawmakers passed Long-Term Care

Insurance Act in the Diet in December 1997, which became fully effective in April 2000. To take specific

countermeasures on elderly care for the 21st century, the government aims at “socialization of care

services” by setting up comprehensive care services/programs, such as at-home care services, facility-

based services, and care support services (care management), while local governments are working on

providing better environment for care services based on their long-term care insurance project plans

and health/welfare plans for elderly residents (for more information, see section 4 of this chapter and

Chapter V). In line with launch of the long-term care insurance program, Gold Plan 21 has started, putting

emphasis on countermeasures on dementia.

In June 2005, about five years later than launch of the long-term care insurance program in FY2000,

lawmakers amended Long-term Care Insurance Act in the Diet. This amendment to Long-term Care

Insurance Act is intended at sustainable and stable program operations mainly through (1) shifting to

a prevention-based system (such as expanding care preventive services and amending how to certify

long-term care needs), (2) clearly stating dignity of elderly citizens in Article 1 of the said legislation,

(3) improving policy actions on elderly patients with dementia, (4) setting comprehensive community

services, (5) reviewing facility-based benefit programs (introducing food/housing-cost-related user charges

and supplemental benefits), and (6) improving service quality (launching a new program to disclose care

service information). This amendment became fully effective in FY2006. In addition, it is decided that

municipalities will set up local comprehensive support centers that provide comprehensive counseling

services for local elderly residents, to prevent abuses on elderly persons and provide care preventive

services.

NPOs, which are incorporated in accordance with Act on Promotion of Specified Non-profit Activities,

are working on welfare activities for elderly citizens, such as group homes for elderly patients with

dementia. As lawmakers have passed Social Welfare Act in the Diet, social welfare corporations are also

working on addressing complaints and improving service quality, aiming to provide more user-friendly

services.

In addition, as Elderly Persons' Housing Act and barrier-free new legislation are put in place to provide

appropriate environment for elderly citizens’ smoother daily life, efforts are made for solving residence/

housing problems of elderly people and improving their living environment.

By the way, as care facilities/centers have been facing a serious shortage of care service staff at once

around 2000, lawmakers unanimously passed Care Work Force Securing Act in the Diet in May 2008.

Amendment to care service fees have led to 3% rise in service fees since April 2009. These efforts have

resulted from insufficient wage level and poor welfare programs for care workers. It is necessity to secure

care service human resources and improve working conditions mainly for certified care workers in the

17

future.

As mentioned above, in line with the preparation/implementation process of the long-term care

insurance program, Omnibus Decentralization Act became fully effective to push ahead with municipality

mergers. At the same time, the government introduced the adult guardianship program by amending Civil

Code. In this context, as more than 60 years have passed since the end of WWII, Japan’s society inevitably

needs structural reforms. It is also necessary to specifically and effectively solve problems, such as an

increase in jobless people and low-income workers, and economic negative impacts on elderly pension

recipients under global-scale economic fluctuations since 2008.

Table 6. Chronology on welfare programs for elderly citizens in the modern era

Calendar year Legislations, programs, facilities, and others on welfare services for elderly people1946 The Constitution of Japan established, opening up a road to a welfare nation1950 Public Assistance Act established 1951 Social Welfare Program Act established (launching programs on welfare offices, social welfare councils, and Judical

person of social welfare)1958 National Health Insurance Act amended drastically to expand insurance coverage all over Japan1961 National Pension Act established and coming into force1963 Act on Social Welfare Service for Elderly established (special elderly nursing homes and care attendant dispatching

business, etc.)1970 Public housing preferential admission program for elderly citizens1973 The elderly medical fee benefit program (Self-pay of elderly citizens became free of charge; this program continued

until 1982)1978 Elderly person short stay program started1979 Elderly person day services started1982 Act of Health and Medical Services for the Aged established (elderly medical services, prevention, rehabilitation, etc.)1987 Housing service for Elderly (housings with care services for elderly citizens) program started 1987 Certified Social Workers and Certified Care Workers Act established1989 Ten-Year Strategy to Promote Health Care and Welfare for the Aged (Golden Plan) developed and publicly announced1990 Welfare-related eight legislations, including Act on Social Welfare Service for Elderly, amended1991 Introduction of three-stage training system for care attendants 1992 Elderly care attendant services introduced1993 Plan of municipality geriatric health care & socialwelfare services established1993 Assistive Products Act established and coming into force1994 New Ten-Year Strategy to Promote Health Care and Welfare for the Aged (New Golden Plan) developed1995 Basic Law on Measures for the Aged Society established1996 Group-home Caremodel project for elderly patients with dementia launched1997 Long-term Care Insurance Act established (Fully implemented from April 2000)1998 Act on Promotion of Non-profit Activities (NPO Act) established1999 Civil Code partially amended (introducing the adult guardianship system)1999 Golden Plan 21 formulated2000 Omnibus Decentralization Act becoming fully effective2000 Social Welfare Act (user-friendly welfare services, regional welfare plan, etc.)2000 Transportation Barrier Free Act established2001 Health Promotion Act established (Health promotion target from children to elderly people)2001 Elderly Persons' Housing Act established (elderly citizen smooth admission rental housing, quality rental housing for

elderly people, etc.)2003 Act on Advancement of Measures to Support Raising Next-Generation Children established2005 Long-term Care Insurance Act es tabl ished ( local comprehensive support centers ,Prevent ion of

care,dependent,community-based services, etc.)2005 Elderly Abuse Prevention Act established2006 Barrier-free new legislation established2007 Care Scandal by a private service provider`Comsn` revealed (Long-term Care Insurance Act partially amended in the

next year to beef up restrictions)2008 Elderly People Medical Care Act becoming effective (Act of Health and Medical Services for the Aged radically

amended;),however, new next system is scheduled to start in 2013)

(by H. Murakawa)

18

3-2. Reorganization of elderly care services, and new approaches(1) Problems surrounding the long-term care insurance program

As demand-supply relation in care services is gradually getting matured after the long-term care

insurance program was put in place, a variety of problems are emerging on a local basis. Here are the main

points of these problems.

First, while various care services are supplied, the at-home care service sector is seeing a wide variety

of new market entrants. In this context, users are facing difficulty of service choice, wondering which

service providers they should select. This is a unique problem mainly to metropolitan areas, that is, users

are actually spending way too much time and cost before finding out a satisfactory service provider. In

addition, in response to heinous service providers, including the COMSN (its scandal revealed in 2007),

the government has decided to beef up applicable restrictions by partially amending Long-term Care

Insurance Act.

Second, as mentioned in the preceding section (at-home care, facility-based care, etc.), analysts are

raising questions on care services from qualitative perspectives. As an approach to secure care service

quality, service providers will need to disclose information, while policymakers should actively push

ahead with service evaluation in objective and specific manners.

Third, users are facing urgent needs, such as their long waiting time before admission to care facilities.

They are also making requests or complaints about facility-based service menu and facility operations. In

the meantime, facility operation problems are getting improved through efforts on small-size life units (unit

care). However, as problems, such as accommodation cost burdens and non-insurance cost burdens, are

emerging, policymakers need to take fine-tuned countermeasures for low-income persons.

If the viewpoint of residence care is incorporated, policymakers should reexamine the residence

(admission to residence or facility) facility-based service structure by making clear roles of care houses or

deploying elderly housing-related policy actions.

On the other hand, cost burden for using facilities should be disclosed in an easily understandable

manner to users. In relation with reforms on elderly medical care programs, it is a high time to reset

facility usage fees with focus on the ability-to-pay principle.

To solve these problems, policymakers should reorganize care insurance and elderly welfare systems

in a sustainable program. In addition, it is also necessary to systematically train human resources, mainly

certified care workers that play central roles in providing services and to systematically push ahead with

stress management for care workers.

(2) Reorganization of elderly care, and new approaches

In relation with reviewing the long-term care insurance program, some policymakers are considering

identifying new care services and launching a new insurance benefit program by partially reorganizing the

traditional care benefit and preventive benefit programs.

The first approach is to put more emphasis on preventive care services. Specifically, it is necessary to

stay focus on disease prevention services based on health promotion concept and effectively push ahead

with preventive care services for elderly citizens requiring supports or a portion of elderly people requiring

19

care services.

In parallel with this, local rehabilitation services should be also enhanced. Specifically speaking,

appropriate services for the acute, recovery, and maintenance stages should be made available in a

mutually related manner in a local community. It is necessary to specifically designate local rehabilitation

center easily accessible to elderly citizens. One idea would be to enhance capabilities of care-related

comprehensive facilities and local core hospitals in a way that they will play specific roles as local

rehabilitation center.

The third approach is to push ahead with local comprehensive care services. The concept of local

comprehensive care services has been traditionally put in place with focus on local medical services.

From the viewpoints of enhancing collaboration between health medical treatment and social welfare, it

is necessary to set up new model of local care services, including stabilization and development of local

comprehensive support centers.

Analysts recently pay increased attentions to developing and diffusing small-scale multifunctional

care services. Paying due attentions to local characteristics, group homes, elderly housings, and so-called

elderly day care centers/salons should be put in place in an interrelated manner. In any event, policymakers

should inevitably streamline construction cost, but it is necessary to work on improving quality of life for

users (or residents) in terms of program operations, rather than simply providing “cheep welfare” services.

(3) Problems of long-term care insurance and elderly health welfare programs

As a lot of new problems are emerging in relation with elderly local residents, policymakers should

launch elderly welfare programs from new perspectives, rather than simply reexamining the long-term

care insurance program.

First, it is necessary to make use of adult guardianship program that supports daily life of elderly

dementia patients and improve/enhance local welfare human rights protection projects. In this relation,

in line with the purposes of Elderly Abuse Prevention Act of October 2005, policymakers should make

efforts to respect dignity and human rights of elderly citizens.

Second, there are problems surrounding reorganization of facility-based care services. As long-term-

care and medical facilities will be abolished in the near future, how facilities in local communities will

be reorganized? In relation with elderly citizens waiting for their admission to special elderly nursing

homes, what should facility-based care services be in the future? In addition, what are appropriate elderly

housings adjunct to facility-based care services and their supplementary services (day services, salons,

etc.)? There are a lot of problems that should be solved.

Third, since illegal business practices on housing refurbishing services or financial instruments, as well

as so-called bank transfer scams, have been spread out nationwide, a lot of elderly citizens are suffering

from fraud damages. It is absolutely necessary to drastically enhance consumer counseling services and

beef up collaboration among organizations relating such as health and welfare services.

Due to amendment to the care service fees, service fees will rise 3% in total since FY2009, aiming to

secure care service human resources. Related organizations/facilities should correctly reflect such fee hike

to the salary level of care workers. In addition, policymakers should set up a new system to secure care

20

service human resources in the medium- and long-run.

Among a variety of problematic situations, citizen’s participation (in stand-watching, supports, mutual-

help, and local network) is desired at the municipality level, while municipalities should also make

community-building efforts with participation of elderly citizens.

Chapter IV. Toward setting up local comprehensive care system

4-1. Common aspects and diversity of elderly people's needsMore than 10 years have passed since the long-term care insurance program became effective to address

care service needs of elderly people. It is necessary to set up a new framework toward the 2020-30s when

ageing population will reach its peak, in particular, toward the year 2025 in which baby boomers will all

become late-stage elderly citizens. In relation with medium-term reforms on the long-term care insurance

program, the study group on “local comprehensive care” has been examining and suggesting possible

solutions for two years of FY2008-09. [note 1]

Analysts has traditionally discussed the concept of local comprehensive care to come up with details for

network of related organizations and possible collaboration among professional staff, while making clear

the necessity of cooperation among health, medical care, and welfare sectors in systematically deploying

local medical services.

The recommendations in March 2010 and related materials call for 1) expanding sustainable care

services and setting up appropriate framework, 2) beefing up collaboration between the care service sector

and the medical sector, 3) expanding elderly housings, 4) systematically pushing ahead with dementia-

related care, 5) paying attentions to elderly citizen’s isolated deaths in local communities, 6) taking policy

actions with due considerations to low-income people, and 7) securing care service human resources and

setting up their career progression system.

4-2. Common aspects and diversity of elderly people’s needsAs of September 2010, Japan has approximately 29.44 million elderly people aged 65 or over, and

ageing rate stands at 23.1% (as announced by Ministry of Internal Affairs and Communications). In the

near future, elderly population will exceed 30 million, and ageing rate will also rise further than 25% (a

quarter of the overall population). In addition, 4.88 million people certified as requiring care services/

supports all over Japan. The nation has 826,000 persons staying in long-term care insurance-related

facilities, 2.924 million at-home service users, and 250,000 local-based service users (Ministry of Health,

Labour and Welfare, “Report on Long-term Care Insurance Program, preliminary report in May 2010”).

As the outcome of its longer-than-10-year history, the Long-term Care Insurance Program has yielded

the outcome that care services for elderly dementia patients and other elderly citizens requiring care

services have quantitatively expanded. However, problems surrounding elderly people in recent years

would firstly include elderly person’s isolated death. With increased nuclear families and single-person

households in the society, these problematic cases keep increasing, affected by weaker physical conditions

of middle-aged and elderly persons living alone and weaker family/local network connections. As a

21

lot of elderly persons older than 100 years old were identified as missing all over Japan this summer,

municipalities and case workers faced pressing works to address this problem.

By the way, under the recent “deflation and economic crisis,” the pension/benefit level for elderly

citizens is an urgent problem. From income security perspectives, it is necessary to provide job

opportunities for elderly persons and sustain/stabilize the pension programs. In addition, for elderly

citizens suffering from various diseases, it is also urgently necessary to revitalize local medical services

and to shift to and establish an alternative program to replace the late-stage elderly medical program.

Looking in this way, almost 30 million elderly people in Japan have diversified needs for their daily

life and care services. In addition, it is necessary to find out a new direction to solve problems suffered by

elderly persons and provide comprehensive supports (including their consumption life-related problems).

4-3. Principles and basic direction of local comprehensive care services“Local comprehensive care” is a keyword when establishing new elderly policy actions, such as reforms

of the current Long-term Care Insurance Act and related programs. The following three points may be

pointed out as the principles of local comprehensive care.

(1) Continuing to live a life in a local community and residence that elderly citizens are accustomed

to (i.e., comprehensive life supports are important);

(2) Making selection by the elderly person on his/her own (elderly person’s needs should be

respected); and

(3) Making use of and maintain elderly people’s abilities, are important.

As for how to provide services, priority should be placed on at-home services (including local-based

services). It is necessary to improving daily living conditions for elderly citizens and providing better

housing for them (barrier-free is absolutely necessary both for rental house and their own house), while

facility-based services should play complementary services for elderly citizens that suffer difficulties of

spending their life at home.

In the 21st century trend of decentralization reform, policymakers should put more emphasis on roles

of local governments, mainly municipalities that are closer to local residents. They should also make

clear elderly health welfare and care service program plans that incorporate appropriate framework for

comprehensive life supports and various services from the medium- and long-term perspectives, with

focus on care services, preventive and medical services.

Specifically, in light of problem-solving-type life zones (such as school districts for elementary or junior

high schools) that addresses ageing population with lower birthrate, it is necessary to establish 24-hours

7-day-a-week service system, or in other words, carefully setting up appropriate menu for comprehensive

life support services. As suggested in the attached newspaper article, elderly citizens wishing to move

in a special elderly nursing home but still are on the waiting list are also suffering serious problems. In

this context, it is urgently necessary to provide appropriate facilities or elderly housings with alternative

functions.

22

4-4. Desirable services: Elements of local comprehensive careAs for desirable services in the local comprehensive care system, because of an increase in physically

weak late-stage elderly citizens and home-care dementia patients as well as increased patients with cancer

or other “terminal” conditions, it is important to collaborate between care service and medical sectors (in

particular, fundamentally setting up a team care program consisting of at-home care services including

local home-visit care, and home-visit nursing-care), and collaborate between the care/welfare side and

attending doctors/medical institutions.

Specifically speaking, it is necessary to work on the tasks inside/outside the long-term care program and

expand various care services as shown below.

(1) Tasks for drastically expanding at-home services

i) Establishing care management approaches to support local comprehensive care (such as setting up

comprehensive and coherent assessment planning approaches) [Note 2]

ii) Enhancing 24-hour short-time routine-run services (mainly, at-home care and home visit nursing-

care)

iii) Pushing ahead with home visit nursing-care and rehabilitation services

iv) Pushing ahead with at-home medical services (Japanese-type GP = Outlook for comprehensive

clinician system, creation of at-home terminal care teams, etc.)

v) Expanding local support projects (providing comprehensive life supports, such as expansion of

catering and other meal services)

vi) Reexamining care prevention projects (developing/diffusing multilayered preventive programs

that incorporate health promotion and lifestyle-related diseases prevention as the primary service,

coupled with disease prevention, secondary and tertiary prevention services)

(2) Putting more emphasis on elderly housings (adding public housings, UR housings, and elderly-

exclusive-use rental housings, as well as smoother moving-in)

(3) Improving/reorganizing long-term care insurance facility categories (improving special elderly

nursing homes, reorganizing care/medical treatment-type medical facilities, etc.)

(4) Systematically pushing ahead with dementia care (including establishment of local stand-watching

network)

(5) Drastically enhancing capabilities/framework of local comprehensive support centers

(6) Making clear importance and services of family member supports (respite support, counseling

service, etc.)

In relation with care human resources, the following tasks and countermeasures are necessary.

(7) Fostering/securing care workers, mainly certified careworkers

(8) Improving employment management and organization management practices by the employer

(9) Providing better working conditions for care workers (health management and welfare programs

for care workers)

(10) Launching more effective evaluation on service quality

23

4-5. Agenda for the futureUnder the recent “gap society” phenomenon and “deflation and economic crises,” it is important to

expand policy actions in line with elderly people’s lifestyles.

(1) It is absolutely necessary to take policy actions with due considerations to low-income people

(overcoming difficulties of joining unit care facilities, group homes, etc.)

In addition, in terms of isolated death of elderly persons in local community as well as missing

elderly citizens older than 100 years old, the following efforts should be made.

(2) It is necessary to solve specific problems in daily life by better addressing basic matters of elderly

people-related policy actions. As specified in “Act on Social Welfare Service for Elderly,” it is

needed to grasp the overall picture of elderly local residents and provide substantive counseling/

support services, mainly by municipalities.

The author attaches importance to daily life of citizens in Japan, including elderly people, and puts

emphasis on the following actions in order to set up sustainable care program for elderly people.

(3) Policymakers should start to reexamine possible financial resources and financial resource

breakdown (Because insurance premium from the fifth period after 2012 will rise to \5,000 on

national average, it might be important to “mitigate” insurance premium hike by increasing the

public expenditures).

(4) Reexamination of insurance premium and user charges is necessary. (It might be an idea to shift

to the ability-to-pay principle by introducing cost burden categories in line with income levels, for

example)

(5) Examining appropriate cost-sharing between the central and local governments (providing

adjustment subsidies in an appropriate manner, trend and result of “lump-sum subsidies”

accompanied with the decentralization reform)

Conclusion

Policymakers are expected to seek for new approaches, including possible approaches stated above. At

the same time, analysts pay increased attentions to what policymakers would do when preparing FY2011

budget, amending Long-term Care Insurance Act and the Fifth-period plan from FY2012 onward. To

conclude this paper, the author would like to add some comments on urgent matters.

(1) As a possible policy approach in line with the characteristics of ageing society with lower birthrate

in Japan, policy actions on next-generation fosterage supports to mitigate lower birthrate will

ultimately pose direct positive impacts on elderly support policy programs (because it will secure

future generations that will support pension and other programs). To put it briefly, policymakers

should prepare FY2011 budget to keep the “Child Allowance” program and increase the amount of

Child Allowance.

(2) As a characteristic of ageing population in the immediate future, urban areas such as Tokyo

metropolitan area will see rapidly ageing population. In particular, it is urgently necessary to launch

24

the local comprehensive care system, and secure special elderly nursing homes and other long-term

care insurance-related facilities as well as elderly housings with alternative capabilities in Tokyo,

Kanagawa, Chiba, and Saitama Prefectures. [Note 3]

(3) As care services and life support services are characterized by “services by person, for person,”

mobilizing the human resources available as much as possible is absolutely necessary. By

continuing policy actions that will overcome low-wage for care workers and radically improve

their working conditions, policymakers should push ahead with necessary and sufficient conditions

to attract younger workers to the care service sector and thereby keep the care service sector more

sustainable.

Lawmakers passed “Care Work Force Securing Act” unanimously, including ruling and opposing

parties, in the Diet in May 2008, but Japanese citizens earnestly desire solving problems for

improving citizen’s life through political leadership, rather than chaotic “distorted” Diet as

envisioned by mass media.

Breaking News and ThanksWe Have had the Great earthquake in Eastern Japan on March 11, 2011 ! We must support Victims,

especially the Elderly Children and Disable persons. In near future Japan administration & the Diet shall

enact the new legislation on the relief programs for victims by the earthquake.

We are thankful to the Volunteers devoted and to the each country with the international Solidarity.

[Note 1] Local Comprehensive Care Study Group, “Report of Local Comprehensive Care Study Group,” March 2010 (The

secretariat: Mitsubishi UFJ Research & Consulting)

Hirokazu Murakawa “Local Comprehensive Care” in ‘Elderly Health Welfare Handbook,’ Dai-ichi Hoki, October

2010

Hirokazu Murakawa, et. al. (ed), “Study on Long-term Care Insurance,” Dai-ichi Hoki, 2009

[Note 2] “Developing Japanese-style CPAT (tentative title),” Kosei Kagaku Kenkyuusha, 2010 (to be published shortly)

CPAT: Care Planning Assessment Tool

This is the outcome of Japan-Australia joint research project and is developed as a compact, visual common tool

intended for professional care workers, medical staff, health workers, and welfare staff.

[Note 3] “Plan to Secure Housings for Elderly People in Tokyo,” October 2010

25

Reforms of Elderly Long-Term Care Insurance System in Germany and Japan - Focused on the Development of Community Services for the Elderly with Consulting and Support Functions -

Hirokazu MURAKAWA Kaori YASUMURA

Introduction

Japan entered the 21st century with the prominent social trends of low birth rate and ageing population.

The challenge regarding long-term care arose with the increasing number of the elderly who needs

medical and social cares, attracted much attention and it became one of the biggest issues to consider in

the latter half of the life for every older person in the country. This phenomenon is happening not just in

Japan but also globally, especially in most of the developed countries. The governments are trying various

ways to deal with this; Germany introduced long-term care insurance in 1995 that focuses on a social

insurance model. The United Kingdom and the Northern European countries, including Sweden, employ

tax-funded public service as its main provider with NPOs playing a certain roles, while the United States

relies heavily on the market mechanism. The techniques and methods for assessment of needs and the care

management that meet the needs of the elderly have also been developed against these backgrounds.

The present paper aims to explain and comment on the Japanese long-term care insurance system, its

social background, the structure and the features of the services, drawing comparison with the recent

trends in Germany. It also attempts to provide the mid-term vision for the Japanese system, based on the

sustainability and on-site practical knowledge.

Among others, the revision of long-term care insurance law in 2005 in Japan, as well as the German

long-term care reform of 2008 highlighted the need of the systems to function in a sustainable and

balanced manner, the need for popularization of comprehensive community services, including dementia

care, and collaboration with preventive system. The increase of the elderly population living alone and/or

with dementia, along with the rapidly ageing population of large cities are imperative challenges.

In the era of rapid social and economic changes domestically and internationally, including the

polarization of society with higher numbers of jobless, these reforms and supports clearly identify the

roles of long-term care, medical care, pension, and employment systems in social policies and measures,

which will contribute to creating more cohesive social policies.

26

1�.�German�long-term�care�insurance�reform�in�2008����(Pflegereform�2008)

1-1� Preceding Japan, the long-term care insurance law was enacted in 1994 in Germany with the gradual

implementation from 1995. The law went through several revisions and in 2008, a major reform

(Pflegereform 2008), including a gradual increase of benefit payments and provision for more thorough

care for dementia, was introduced. As in Japan, Germany faces challenges such as tight budgets for

long-term care, increase in the numbers of elderly with dementia, and lack of care services and human

resources. Though there are considerable differences, including the collection of contributions, the

provision of cash benefit as well as the scope of the benefit recipients, the trends in the German reform

provide a valuable suggestion for Japan to investigate its future long-term care insurance system.

As for the running of the long-term care insurance system, the care management function has been

playing a significant role in Japan. On the other hand, in the original German system, the function

equivalent to the Japanese care management was not clearly defined. Therefore, when applying for the

benefits and services including long-term care, the elderly and their families were using the information

providing service offered by the local authorities as well as consulting supports offered by care service

providers. Several issues were pointed out regarding this situation, and the 2008 reform, which was

implemented gradually from July 2008, created a consulting support and service coordinating function

within the long-term care insurance system.

In this paper, an overall picture of the German long-term care reform of 2008 is firstly outlined and its

issues are discussed. The focus is especially placed upon the newly created consulting support and service

coordinating function, the care support centers (Pflegestützpunkt). After discussing its notable points and

issues, we would like to move on to the investigation that seeks a favorable future of consulting support

and service coordinating function in Japan.

1-2��The�long-term�care�insurance�reform�in�2008�(Pflegereform�2008)To cater for the ageing population and accompanying increase of the elderly in need of care, a major

reform of the long-term care insurance system was introduced in Germany in 2008. The reform is focused

mainly on the following areas; (1) benefit payment increase with focus on home care, (2) enhancement of

information provision for the elderly in need of care and their families, (3) enhancement of comprehensive

support for individuals with dementia, and (4) enhancement of the information provision regarding the

quality of care-homes. To achieve these, the contribution rates were raised from 1 July 2008, to 1.95% of

income (2.2% for those without a child). Especially notable points of the reform are explained further as

follows:

(1) Increase of benefit payments

Monthly payments for care recipients will increase gradually till 2012. Table1 show the amounts given

for individuals in need of care but who prefer to stay at home. Increase is most apparent in the benefits

in-kind for at-home-care, compared to institutional care, with support enhancement of a shift from

27

institutional care, such as medical facilities, to homecare as well as an acceleration of benefit eligibility

evaluation procedures.

Table 1 Benefit levels for benefits in-kind

Care level（Monthly：€） Pre2008 2008 ＊ 2010 2012

Ⅰ 384 420 440 450

Ⅱ 921 980 1,040 1,100

Ⅲ ** 1,432 1,470 1,510 1,550

*Amount payable from 1 July 2008** Payment for most severe cases remains the same at 1,980EUR per month （Bundesministerium für Gesundheit: Gut zu wissen-das Wichtigste zur Pflegereform 2008, Juni 2008)

(2) Measures for dementia patients

Homecare benefits were raised for those with severe incapacity for everyday life, such as severe

dementia patients and mentally disabled individuals. It was 460 EUR per year before 2008 but was raised

to 100 EUR (basic benefit) or 200 EUR (severe cases) per month, resulting in 1,200 - 2,400 EUR annually.

This applies to those dementia patients in institutional care as well, enabling the institutions to provide

additional cares and activities with extra staff for the patients.

(3) Establishment of the care support centers (Pflegestützpunkt) as the comprehensive consultation

provider

This will be discussed in detail in the later sections.

(4) Enhancement of nursing leave

Those who work at a company with more than 15 employees are entitled to nursing leave for up to 6

months. Though the salary will not be paid during this period, the social benefit entitlement will continue.

(5) Improvement of care quality

A federal level of quality improvement measure (Expertenstandards) was introduced and care quality

assessment was enhanced.

Every institution is obliged to accept a yearly inspection without notice. The resulting quality

assessment report is published on the Internet, at the institution and Pflegestützpunkt.

The reform also includes guaranteeing of care workers’ wages, support enhancement of self-help groups

and volunteer activities as well as enhancing prevention and rehabilitation.

1-3��Notable�points�and�issues�of�the�reform1�The most notable and welcome point of the 2008 reform is the strong preference for homecare over

1The notable points and issues regarding the German long-term care reform of 2008 sums up the response of a questionnaire, sent to academics and care work practitioners in Germany by the author.

28

institutional care. Most of the frail elderly, in Germany or in Japan, want to continue living at their own

home as long as possible. Promoting home care is also financially favorable compared to institutional care.

However, it is not clear at this point whether the care quality and quantity required can be achieved, and

further improvement may be necessary.

There is also a positive advancement regarding the benefit amounts for individuals with dementia.

However the care service provision in terms of quality and quantity is not sufficient and it is imperative

that measures are put in place to train qualified caregivers.

The biggest challenge is the finance. Demographic changes and the increasing number of individuals

needing care will certainly reduce the contribution income and push up the cost. The long-term care

insurance system in Germany was conceived originally as a partial insurance, rather than intending to

cover all the living costs of the recipients. It is not clear at this point to what extent the long-term care

benefit can cover the cost in future, and personal provision will become more important.

The possibility of a support system other than the social insurance provision, such as community-led

services and volunteering, needs to be investigated as well. The ultimate goal is to make sure the frail

elderly stay and receive care at home till the last possible stage, without becoming dependant on the public

assistance. This in turn enables a comparative reduction of the cost over institutional care with increased

quality of life for the elderly.

1-4��Long-term�care�insurance�in�JapanThough there are considerable differences between the German and Japanese long-term care insurance

systems, the German reform in 2008 provides several insights for Japan.

The first point is the issue regarding homecare services. The increase of the benefit amounts

demonstrated the preference of homecare over institutional care in Germany, but this should not be taken

just as a cost cutting measure to control expensive institutional care. The challenge is to make it a really

supportive measure for the elderly to continue to live at home and be cared for as they wish. In order to

achieve that, it is necessary to secure the quantity and quality of homecare services as well as to provide

various out-of-the system services in order to meet the variety of needs of the elderly. So, establishing a

function that collects and provides the information regarding long-term care, that also organizes the actual

care effectively and efficiently, combining the services within and outside the official system, will become

more important. The comprehensive community support center, which will be discussed in detail later,

will be expected to play an important role here.

The second point is regarding the measures to cope with the increasing number of elderly with

dementia. The benefits for those who have severe incapacity for everyday life including the elderly with

dementia were significantly raised in the German reform. It is a welcome move; however, securing sufficient

number of qualified staff is necessary. The issue of the elderly with dementia is becoming widely reported

in Japan, but there are still many cases where the burden of caring for such individuals falls solely on the

families. It is imperative to improve the dementia care system so that it offers easy-to-use services.

Financing these cares is the biggest challenge for both countries. Increasing numbers of the elderly

and the individuals in need of care will put larger pressure on care budgets that both countries need to

29

address urgently. A reform that takes the cost effectiveness of the services into account is inevitable but

the situation where necessary care is no longer provided for the individual in need of such care must be

avoided. In the German reform in 2008, both the contributions and the benefit provision were raised at

the same time. Its financial outcome as well as the long-term trends such as improvement of the life of the

elderly in need to be monitored and analyzed carefully in future.

2�.�The�consulting�support�and�service�coordinating�function�for�the�elderly�in�Germany

Under the reform in 2008, Pflegestützpunkt (care support center) were newly created as the

comprehensive service provider for the elderly in need. Here, the background of establishing such a

service and its overall function are summarized and its notable points and issues will be discussed. From

there we will further provide some opinions regarding how consulting support organizations such as

comprehensive community support centers in Japan should be run.

2-1��Establishment�of�the�Pflegestützpunkt�(care�support�center)Traditionally in Germany, consultation and organizing the services for the elderly in need and their

families were offered by municipal information service and care service providers. However, this was

deemed to be unsatisfactory. The collaborative link between the municipal information service and the

care service providers was weak and there was qualitative variability among the municipalities. The care

service providers tend to work for their business interests. And the consultation for support had a too

narrow scope. To counter these problems, Pflegestützpunkt, a ‘one-stop-shop’ for information, consultation,

and service coordination was established. Following is a summary of Pflegestützpunkt. However, being a

federal republic with a large part of the power lying at the state level, it is the states which decide matters

concerning Pflegestützpunkt, including their establishment, thus there are wide regional differences.

(1) Function

Pflegestützpunkt offers comprehensive consultation to the elderly in need of care and their families. It

also coordinates, organizes, and arranges long-term care, medical care, and official aid and other support

services.

(2) Consulting support service

From January 2009, all individuals in need of care became legally entitled to access the care

consultation (Pflegeberatung). All the municipalities are now obliged to offer those individuals

comprehensive care support service; however, it is up to the individual whether to use this service or

not. The care consultation includes provision of information regarding local care services inside and

outside the long-term care insurance system as well as organizing and coordinating a comprehensive

service package. Consultation is given by a care advisor (Pflegeberater) stationed at Pflegestützpunkt. The

qualifications of a care advisor are not clearly defined, but social workers, geriatric caregivers and nurses

are considered appropriate candidates and a senior level case management course is being set up. Related

30

organizations such as social workers institutes produced a shared guideline that requires the care advisor to

have advanced expertise on case management, with on-site experience of at least one year after obtaining

a qualification from a specialized higher education course.

(3) Configuration

Pflegestützpunkt makes it a principle to be neutral and independent, but it is allowed to be set up as a

part of the existing consultation support organizations and care service providers.

2-2��Notable�points�and�issues�regarding�PflegestützpunktNotable and welcome points for setting Pflegestützpunkt are as follows: (1) Individuals in need of care

and their family can solve problems regarding the provisions of health, long-term care insurance, and other

related services at a one-stop organization. (2) The same dedicated care advisor continuously looks after

a care recipient enabling comprehensive planning, coordination, and follow-up of the services, which in

turn mitigates the burden of the care recipients and their family. (3) Comprehensive planning for each care

recipient is expected to have a positive effect toward rationalizing limited budgets. (4) Care advisers at

Pflegestützpunkt, in principle, do not belong to any care service providers, enabling avoidance of influence

peddling.

With the establishment of care support centers, the support for service activities run by volunteers was

enhanced. As a worsening of the insurance finance is expected in the future ageing society, enhancement

of variety of services that do not depend on the social insurance is necessary. It is expected that

Pflegestützpunkt will collect information about and coordinate various services including self-help groups

and volunteer services outside the official benefits as well as playing a role in promoting and creating new

services.

Meanwhile, problems are apparent too. First, it is up to the users whether they use their care consultation

entitlement or not, thus it is unknown at this point how many people would take up the service and how

effective it is. Since it is expected that the set-ups and management format of the centers would be varied,

it is also difficult to verify the effectiveness of the operation in terms of promoting homecare and lessening

the family burden. Though it is expected that enhancing at-home long-term care would reduce cost, setting

up the new support centers, as well as increasing provision of the benefits owing to the increasing number

of elderly clients would push up the cost considerably, thus financial outlook in future is still severe. And

if the take-up of the care consultation entitlement is low, the expected effects, such as the mitigation of

care recipients and families’ burden and efficient use of services, would be generally low. The challenge is

the actual functionality of Pflegestützpunkt and promotion of its existence to the would-be users.

2-3�� �The�consulting�support�and�service�coordinating�function�for� the�elderly� in�Japan

In Japan, care management/care managers play a core function in consulting support and service

coordinating. The German initiatives such as independent consultation, unified provision of information

and service coordination, and introduction of a higher qualification path for care advisors with courses that

31

place importance on interpersonal support techniques as well as basic qualifications, should be watched

carefully, since there are considerable benefits that Japan might be able to adopt in realistic ways.

In addition, the German initiative of Pflegestützpunkt may also give us some ideas regarding

the comprehensive community centers of Japan that is currently functioning as the comprehensive

consultation service for the elderly in need. In order to run care services within and outside of the long-

term care insurance system efficiently, effectively, and responsively to the needs of the users, it is firstly

necessary to form a close collaboration between consultation services, care planning entities, and care

service providers. As the independent comprehensive consultation organization, the comprehensive

community support centers can play an important role. Since there is a limit as to the extent of services the

long-term care insurance system can offer, and since further budget tightening is expected in the long-term

care area, it is clear that new services that do not rely on the system, such as volunteering and community

specified services, will become more important. Development and coordination of such new services is

one of the priorities that the comprehensive community support centers should address.

3�.� �Main� points� of� the�Japanese� reform�of� the� long-term�care�insurance�system�and�its�development

3-1��Strategic�viewpoints�of�the�reformThe basic standpoint of the revision of the long-term care insurance (June 2005, in force from April

2006) is long-term sustainability; to create a system that functions continuously in a stable manner, taking

the 2015 problem into consideration8) when the whole baby-boomer generation reaches retiring age.

One of the biggest challenges is to change the system toward a more prevention-oriented one, and it is

imperative to create a system in which the elderly lead healthy and active lives for as long as they can. At

the same time the system needs to be able to cope with new challenges such as the increasing number of

the elderly living alone or with dementia and the rapid population ageing of large cities8).

3-2��Shift�to�a�prevention-oriented�systemThe linchpin of the reform is the ‘shift to a prevention-oriented system’. Looking through the 5 years

trend since long-term care insurance was introduced in 2000, prominent increase of the elderly in need of

care, who were registered as having relatively mild impairment, is observed 9).

With rapid ageing of the society as the background, the class 1 insured, who are over 65 years old,

increased from 21.65 million, when the insurance started, to 25.16 million (as of April 2005). The number

of the elderly registered as in need of care or support also increased by about 2 million, from 2.18 million

(April 2000) to 4.11 million (April 2005) among which the biggest increase was of those with relatively

mild impairment with ‘need of support’ and ‘need of care level 1’ categories. The total number of elderly

who use the service doubled from the original 1.49 million to 3.23 million, showing that the system, which

started in April 2000, is now well established in the society after 6 years.

With the increase in the use of the service, the cost of long-term care insurance almost doubled from

3.6 trillion yen in 2000 to 6.8 trillion yen in 2005 showing more than a 10% increase every year. The

amount of the contributions is revised every 3 years and as the result of the increase in the service users,

32

the amount of class 1 contribution (contribution collected from those over 65 years old) jumped 13% from

the first phase (2000-2002) to the second phase (2003-2005) with the national average of 2,950 yen per

month, which further increased in the third phase (2006-2008) to 4,090 yen per month. It was calculated

as approximately 4,270 yen per month for the fourth phase but settled to 4,080 yen per month (national

average) by digging into the fund.

The definition, service contents and management of the so-called preventive measures benefit, which

was provided as a part of long-term care insurance system for those registered as in need of support, was

revised. New classification of support level was introduced and those registered as in need of support level

1 and 2 are now eligible to use the preventive measures care services.

3-3��Establishment�of�comprehensive�community�support�centers�and�its�issuesThe elderly who live in a community have a variety of needs and problems. An increasing number

of them living alone and/or with dementia (including early onset Alzheimer’s and mild cognitive

impairment), and new problems such as abuse of the elderly are emerging. The comprehensive community

support centers are positioned to combat needs of these varied and complex elderly in order to function as

the integrated consultation and support service provider 10) 11).

The main challenges that the comprehensive community support centers face are how to provide the

service to those who may need preventive measures; identifying the individuals who may be classified as

newly introduced and unique-to-Japan support level 1 and 2, and helping them to maintain and improve

their everyday life capabilities. The contents of the support care services are defined from the viewpoint

of maintaining and improving everyday life, new programs were introduced and the existing program

reviewed. In addition to the existing services such as day center, programs such as motor function

exercises, improvement of nutrition, and oral care were included. The widening of the scope of the service

recipient is being requested to include not just those registered as in need of support, but also those who

are officially ‘independent’ but may be frail and in need of certain support and care coordination.

Since the enactment of the Elderly Health Law of 1982, the importance of prevention has been pointed

out along with treatment and rehabilitation, and it covers a wider spectrum nowadays, such as health

promotion and prevention, illness prevention and treatment, and care preventive measures. However, there

are large differences between the municipalities in terms of community-based prevention and life support

programs, and those municipalities who have traditionally run the care services focused and limited on

the elderly in need of real care are now urged to change. Either way, in order that the elderly including

those living alone and/or with dementia can continue to live in the familiar environment with individual

needs met, the most important is to overhaul and promote the service management system so that it is

comprehensive and integrated in the community.

The comprehensive community centers firstly are to establish a prevention management system that is

consistent and continual, that provides service to the elderly before they become registered as in need of

support or care, and staffed by social workers, public health nurses, and chief care managers. In order to

secure independence and fairness for service recipients as well as for the provider, the center management

committees will run the service, of which the members are to be the municipality, community service

33

providers, and the representatives of the insured.

The comprehensive community centers are also to provide comprehensive consultation, work as the

advocacy of the rights and entitlement, and create local networks as an independent organization 10)11),

and, as with any new organization, such developments need to be monitored.

3-4���New�type�of�approach�–� introduction�and�popularization�of�community-based�services

In order for the elderly to continue their life in a community with which they are familiar, it is

important that various services be offered at the village/town/city level12). For this reason, community-

based services including such initiatives as small-scale multi-functional care, nighttime home-visit care

service, group homes that are able to care for dementia patients and specially designated small-scale

nursing homes were introduced. In principle, these services are available for the resident of any village/

town/city as a rule and price are set at the village/town/city level. Approval procedures of the care care

service providers have also been left to the village/town/city since April 2006.

With the introduction of the definition of ‘everyday life area’ set out in the third phase of the long-term

care plan, village/town/city authorities need to enhance concrete measures taking new viewpoints and

local needs into consideration.

The focus of the fourth phase plan, that covers the timescale of April 2009 onward, is the

popularization of the community-based service, with a part of management criteria regarding small-scale

multi-functional care and night-time home-visit care service amended in view of a 24x7 care approach.

3-5��Practical�issues�and�quality�improvement�of�group-home�careSince the introduction of the long-term care insurance, group homes for the elderly with dementia have

been rapidly established with 9,800 facilities as of December 2008. They are playing a very effective

role as social resources supporting the elderly with dementia and their families, and have been highly

praised from several fronts, including overseas specialists, at the 20th Alzheimer’s Disease International

Conference held October 2004 in Kyoto. However, problems regarding the running of these group homes

have become apparent recently, such as misconduct of staff and fire involving loss of lives (Nagasaki

prefecture and Sapporo city).

Except for certain areas, the quantity of group homes is being fulfilled, so the improvement in quality,

as well as the diversification of management configuration, is the challenge now. One of the examples of

quality improvement initiatives is the support for the residents at terminal care stages. From April 2006,

payment for such care was increased as well as the pay for the night-shift staff.

3-6��Residential�care:�promotion�of�unit�care�and�reorganization�of�institutions As a part of the long-term care insurance system reform, a new type of specially designated elderly

care homes were introduced from 2003, and the unit care initiative (small scale residential care) is well

underway. There are three types of residential care facilities for the elderly within the system and each of

them has its own management challenges.

34

(1) Specially designated long-term care facility: the immediate challenge is to enhance the capability

of providing sufficient terminal care, as well as to introduce and implement unit care approach.

(2) Long-term care and health facility: focus should be placed upon enhancement of rehabilitation

provision. The challenge for the service providers and related organizations is to establish the

preventive measures and short-term intensive rehabilitation services.

(3) Long-term care and medical facility: As the medical care structural reform is underway, the

Ministry of Health, Labour and Welfare is proposing to create convalescent wards in general

hospitals (December 2005), with a view achieving that by 2012. The basic purpose is to mitigate

so-called ‘social hospitalization’ (hospitalization of the elderly for non-medical reasons), with

the introduction of clear classification of medical treatment and long-term care.

As for the fourth phase (2009-2011), one that is drawing attention is the attempt to turn geriatric wards

in hospitals into long-term care and health facilities. The challenge is to establish a care infrastructure and

to set its direction in the community, including the development of aforementioned small-scale specially

designated long-term care facilities as well as housing policies for the elderly.

3-7���Revision�on�residential�care�benefit:�defrayment�of�accommodation�and�food�costs�by�users�and�supplementary�benefit

Up to now, the proportion of residential care users in the long-term care insurance system was

approximately 25%, but the cost of financing such care exceeded 50%. In order to balance the burden of

the users for homecare and residential care, as well as to adjust the long-term care benefits and pension

provision, the costs for accommodation and food (cost of meals including the cost of preparation, and

not just the cost of materials) at the long-term care facilities was placed outside the benefit and now users

have to pay them. As for the accommodation cost, the revision aimed to redress the difference of the

accommodation types (private room or dormitory) and as for the food, the cost of cooking food was added

to the cost of materials. These extra costs of accommodation and food are settled between the user and the

service providing facility.

As for the elderly who cannot afford to pay this extra cost, detailed measures are provided as a

supplementary benefit. For example, those care users (applicants) in the insurance contribution class 1 to

3, the difference between the officially set ceiling, and the actual average accommodation and food cost

(standard cost) of the facility is paid from the system as a supplementary benefit (specified long-term care

resident service cost). The user cost mitigation schemes by social welfare corporations need to be utilized

and popularized.

3-8��New�aspects�regarding�the�regulation�of�the�agency�service�providersAs more and more varied entities come into the care providers’ market, problems such as fraudulent

claims are also increasing. With this in mind, the revised law includes clauses regarding information

disclosure and reviewing of the regulations for the agency service providers, in order for the users to make

appropriate choices and high quality service to be provided.

The agency service providers are now legally obliged to publish information regarding the service

35

contents as well as administrative performance so that the users can choose the appropriate care for

themselves. The items to be disclosed include the features of the services, the costs, the physical features

of the facility, and staff ratios. The one-way provision of the information can invite the manipulation of

information, so the shift to a two-way interaction scheme is desirable where the requests and responses

from the users are received and acted upon.

The regulation of agency service providers was tightened as part of the revision. When applying to

be an authorized service provider, the application is now not accepted if the applicant or a board member

has had his/her authorization withdrawn within the past 5 years. In the past, once the authorization was

granted, authorized service providers could continue providing the services without renewal, but now,

reapplication must be made every 6 years to eliminate sub-standard agency service providers.

4.��Challenge�for�the�future:�service�quality�improvement�and�system�stability

Several points regarding the future challenge of the long-term care insurance system are described

below.

4-1��Service�quality�improvement�and�cultivation�of�human�resourcesFirstly, the issues regarding the cultivation of human resources, and staff education in order to improve

the quality of long-term care services, must be addressed. Especially as for the care management, the pillar

of the long-term care insurance system, the newly established 5 yearly renewal rule for the care managers

and introduction of the chief care manager position is expected to improve the present situation.

Secondly, the issues regarding the home visit care, the central service in the non-residential care, must

be addressed as follows in order to improve the quality; (1) identification of clear roles and responsibilities

of service providers etc, (2) improvement in the quality of care workers (cultivation of human resources

and staff training, positioning qualified care workers as its core), (3) identification of responsibilities and

qualifications of managers in agency services providers.

Thirdly, the issues regarding the education and creation of the career path of the on-site care workers,

who will play an important role in the promotion of the unit care approach in the facilities. Requirements

on education and training to improve care quality have been often talked about in the past but they lacked

clear consideration on the conditions of the work. It is essential, therefore, that the whole employment

environment improve, including the worker’s standard wage, as well as welfare and social security.

4.2��Restructuring�of�system�of�the�long-term�care�insurance�facilitiesThere are three types of residential care facilities for the elderly within the system; (1) Social and

Nursing care Homes, (2) Nursing-care and health facility, and (3) Long-term care and medical facility.

As for (3), with the medical care structural reform underway, the Ministry of Health, Labour and Welfare

is proposing to create convalescent wards in general hospitals (21 December 2005), with the aim of

achieving that by 2012. The basic purpose is to mitigate so-called ‘social hospitalization’ with the

introduction of a clear classification of medical treatment and long-term care.

36

As for the fourth phase (2009-2011), one that is drawing attention is the attempt to turn geriatric wards

in hospitals into long-term care and health facilities. The challenge is to establish a care infrastructure

and to set its direction in the community, including the development of small-scale specially designated

long-term care facilities that form a part of the aforementioned community-based care services and other

residential facilities (private care homes, care houses, and dedicated rental accommodation for the elderly).

4-3��Sharing�the�burden�in�the�mid�to�long-term�futureThe revision of 2005 also addressed the introduction of new contribution levels, taking into account the

payment capability of the contributors, the enhancement of the power of municipalities (insurers), and the

establishment of fairer assessments of individuals’ care levels.

With the widening range of incomes in the 2nd tier of the contribution levels, it was divided in two

to create the new 2nd tier and 3rd tier. It is important to note that the ‘pay-as-you-can’ approach became

clear, with emphasis on the paying capability of the insured.

Also in the revision of 2005, the contribution collection system was improved, with the convenience of

the users in mind.

Amalgamation of villages, towns, and cities continued during 2000 to 2010, and that must have

enhanced the care infrastructure of the insurers (municipalities). Strengthening of the functionalities of the

insurers, the managing entities of the long-term care system, on such issues as designation, guidance and

monitoring of aforementioned community-based care services, as well as the stability of the infrastructure,

all are of the utmost importance.

The trust in the nation’s social security system, which has traditionally leant heavily on the social

insurance method for its pension and medical insurance, has been shaken lately and new approach to

funding is urgently sought.

Conclusion:�From�the�structural�viewpoint�of�long-term�care�for�the�elderlyFrom the background of the introduction of the long-term care insurance and the recent revision, it is

important to raise issues from the structural viewpoint13) that can be summarized as follows.

Since around the time of the introduction of long-term care insurance in 2000, the tendency is emerging

to cram all kinds of problems that affect the elderly into the terminology ‘care need’, especially among the

government administrations and care experts. That in turn has created the mindset of creating more and

more services for the elderly ‘in need of care’, that again, in turn, rationalizes the agency care providers’

sub-standard behaviors including fee-for-service system and maximization of profit. In order truly to

support the elderly socially and generally, with elimination and correction of the sub-standard service

providers, as revealed in the ‘Comson scandal’ in 2007, the following points need to be addressed.

(1) Health promotion as a national value (Healthy Japan 21)

(2) Promotion of preventive healthcare with primary care as its core and streamlining of medical

costs (reducing of long hospital stays)

(3) Unification of homecare and community-based care (catering for the everyday life needs of the

elderly = introducing the viewpoint of stay-at-home care)

37

(4) Promotion of concrete preventive measures (development and popularization of health

promoting, illness prevention, care-dependence prevention programs)

(5) Limiting and restructuring of residential care facilities (clear classification of care, medical, and

residential facilities)

(6) Enhancement of accommodations for the elderly (specialized accommodation units for the

elderly and group homes)

(7) Consolidation and localization of related policies based on improving QOL (improvement of

residential environment, including the town planning level)

(8) Securing the human resources with care workers as its core and creating a career path for them

(9) Supporting the low income bracket elderly and reducing their charges & premium.

(10) Supporting Victims by Big earthquake of Eastern Japan in March 2011. especially Elderly,

Children and Disable persons.

Though the vision for 2015, when the baby boomers enter the age of retirement, is getting somewhat

clearer with the securing of the mid-term stability of the long-term care system, we cannot be optimistic

for the long-term future. We need to look carefully, along with the reforms of medical insurance and

pension systems, into the strengthening of the social security structural reform as well as mid to long-

term financing, including the possibility of raising consumption tax rates and restructuring of ring-fenced

welfare tax etc. A reform agenda with the keyword, ‘constructing comprehensive community care system’

will be tabled in 2011, which is expected to be introduced in the fifth phase starting April 2012, following

the amendment of the law.

Quotes�and�references 1 Tokyo Metropolitan Foundation for Social Welfare and Public Health (2005): Turning point in long-term care- The

mechanism of the new system and current situation in Germany

2 Matsumoto K. (2007) : German Social Security III - The long-term care insurance. Sinzansha

3 Bundesministerium für Gesundheit: Gut zu wissen-das Wichtigste zur Pflegereform 2008, Juni 2008

4 Richter E. (2008):Gerangel um Pflegestützpunkte. Forum Sozialstation 150/ Feb. 2008, 8-10

5 Richter E. (2008): Pflegestützpunkte: Länder entscheiden, Kassen zahlen. Forum Sozialstation 151/ Apr. 2008, 12-14

6 Wißmann P. (2003): Case Management. In: Zippel C, Kraus S (Hg.): Soziale Arbeit mit alten Menschen. Berlin:

Weißensee Verlag,121-137

7 Wißmann P. (2003): Informations-, Beratungs- und Vermittlungsstellen für ältere Menschen. In: Zippel C., Kraus S.

(Hrsg.): Soziale Arbeit mit alten Menschen. Weißensee Verlag, Berlin

8 The Ministry of Health, Labour and Welfare (2004): Care for the elderly in 2015

9 Health and Welfare Statistics Association (2005): Annual shift of long-term care insurance related statistics – The major

statistic data for 5 years since the establishment of the insurance system

10 The Ministry of Health, Labour and Welfare (2005): Comprehensive community support center guide

11 Preparing to establish comprehensive community support centers. (2006): Support Vol.14, Daiichi-hoki

12 Miyajima W. (2006): Small-scale multi-functional care. Community health and welfare policies study group.

Community health and welfare case study. Daiichi-hoki March addition

13 Murakawa H. (2004): The principles of the care of the elderly. The Elderly care practice case study. Daiichi-hoki

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39

Multiple Regression Analysis of Compassion Fatigue/ Satisfaction Questionnaires, and Correlation between these Questionnaires and Care Providers’ Behavior (FR behavior) in Japanese Child Welfare Facilities

Takashi Fujioka

【Abstract】

The purpose of this study was to examine multiple regression analysis of Compassion Fatigue/ Satisfaction Questionnaires and Correlation between these questionnaires and care providers’ behavior in Japanese child welfare facilities.

Through the hierarchical OLS regression analysis , experience as a care provider is very important for examining Compassion Satisfaction. It was predicted that Compassion Fatigue and Satisfaction will impact the burn out separately. The author constructed the linear multiple regression equation on Burnout risk, Compassion Fatigue and Compassion Satisfaction. The second purpose of this study is to ascertain the relationship of Compassion Fatigue /Satisfaction with FR(Frightened/ Frightening) behavior.

The hierarchical regression analysis was conducted to assess the relationship between Compassion Fatigue, Compassion Satisfaction, and FR behavior. As a result, only one factor , PTSD significantly effects Total FR behavior. From the results of Correlation between four factors of Compassion Fatigue and the three factors of FR behavior among care givers in child welfare facility, Frightened behavior in FR behavior have the significant correlation with Dissociation behavior, Secondary Traumatic Stress, PTSD, Denial tendency, and Trauma experience. Frightening behavior in FR behavior has a significant correlation with PTSD only in Compassion Fatigue. Depersonalized behavior in FR behavior check lists have a significant correlation with Dissociation behavior, and PTSD. Dissociation behavior has a significant correlation with all four factors in Compassion Fatigue.

Through the results, we discussed that "Trauma- dominance Compassion Fatigue" would be easy to cause a stronger dissociation tendency, and the degree of the burnout tendency would be different by the state of children with some problems and disorders, how to live in family and community, especially in the childhood. In other words, the care providers would be exposed to compassion fatigue, particularly secondary wound-related stress, in addition to own trauma experience. That is, the care providers must be exposed to trauma experiences of children double more while they are exposed to their own trauma experience.

40

【Keywords】

Compassion Fatigue , Compassion Satisfaction, Dissociation, FR behavior, Burnout risk, Secondary Traumatic Stress(STS), Third Traumatic Stress (TTS)

Recently there are some researchers who think that burnout seems to be connected with the concept of

Secondary Traumatic Stress or Compassion fatigue, especially among workers who contact with injured,

disordered or traumatized persons. A caregiver or a supporter who listens to the story by injured people

is hurt by the story at the same time. A clinical social worker or a therapist who works as a helper, a

caregiver, and a supporter with injured, disordered or traumatized persons experiences the drawing out

of earlier memories in which he or she has been hurt. In Japan there are many researches on Secondary

Traumatic Stress and Compassion Fatigue/Satisfaction, but it is necessary to investigate these concepts

from the standpoints of Japanese situation and culture in Japanese clinical field and facility(FujiokaT,,

2004,2005,2006,2007,2008,2010; Fukushima,M.2009; Kon,Y.&Kikuchi,A. 2007; Shinozaki,T.2007;Nishi

,M.&Nojima,K.2002).

When burnout risk/ compassion fatigue were prevented for care workers or care providers , for

example through consultation of support measures, training, and collaboration, maltreated children

would be supported from the viewpoint of attachment to developmental disability, and a state of the staff

as "a container of attachment" would be kept in good condition. I have challenged that many care givers

would be good container through the clinical attachment approach, for example the use of ‘Life Script of

Attachment’, and self-monitoring by Compassion Fatigue Self Check Test. The purpose of this study is

to examine the effect of self-monitoring by Compassion Fatigue/Satisfaction Self Check Test to Burn out

risk, and to investigate the relationship of these questionnaires with inadequate approach, FR behavior by

care providers to children in Japanese Child Welfare Facility.

Meaning of Compassion Fatigue

A Care giver has “Compassion Fatigue" by being an care giver, and by balance with “Compassion

satisfaction " which is joy of being a care giver , which is assumed to protect from risk of burnout

(Figley,1995). Originally, in the English word of “Compassion”, there are meanings such as "intense

feelings, eagerness, passions such as anger, intense love" in Passion. We use the word of Compassion, it

means that Com – means “with”. So when we say “Compassion with” , we always feel “passion with

together”. In addition to this meaning, I find that Passion means martyrdom. I think that “ Compassion”

means “become a martyr with hurt persons/especially maltreated abused children” in the clinical child

welfare field. It means profoundly to be with abused children and neglected children.

Dissociation and Compassion fatigue

Social workers, care workers and case managers working in welfare facilities and agents have a wide

range of stresses in performing their duty. Specifically, when they are concern with and support the clients

who had severe traumatic experiences, there is a possibility that care workers and case managers and

41

social workers themselves have to confront their own trauma. Moreover, the specialty of the helpers,

the building of sympathy and relationship with clients, increasingly means placing them in the process

of extending to the situation of burnout. In this case, the dissociation which is a peculiar reaction to the

trauma, happens to the side of the helper. The helper sometimes cuts off his/her character, personality

and feelings in the process to the burnout. Fujioka(2005) pointed out the importance of the process

of burnout and reexamined the process in through the concept of dissociation. As a result, the author

suggested the possibility that the helper confronts the situation of the similar phenomenon-dissociation-

as clients. To prevent such a high risk situation, the necessity of the self check list about the burnout and

compassion fatigue was suggested. Dissociation is the key concept of Pierre Janet, especially this concept

connects trauma and the attitude of protecting hurt mind.

Secondary Traumatic Stress or Compassion fatigue and the idea of Pierre Janet

Fujioka (2006) discussed secondary traumatic stress or compassion fatigue though some concepts of

Pierre Janet. He pointed out that treatment for Trauma follows two ways, to be confronted or to confront

with traumatic experiences. One is to confront trauma directly, and the other is to confront trauma

indirectly. The relationship between fatigue and traumatic memory was indicated in P. Janet’s idea.

When human being continues to confront trauma for long time, he/she avoids feeling pain, bitterness,

tightness and suffering and creates a condition of dissociation. In case of Compassion Fatigue, the same

situation or dissociation will be created in the mind for long time. But as Janet pointed out, keeping

trauma means continuing to feel serious fatigue. I think that compassion fatigue has two meanings, one is

fatigue by traumatized children and the other is fatigue by care givers’ own trauma. Perhaps the treatment

to traumatized children means severe situation for care givers with severe trauma through the relationship

with children who have some problems, some disorders or severe trauma.

I think that discussion about Treatment for traumatized children means the profound examination on

preventing Compassion Fatigue.

I discussed that it is necessary to investigate the relationship of compassion fatigue and personal

dissociation tendency. Perhaps many Japanese people have high dissociation tendency, so there will

be strong connection between compassion fatigue and personal dissociation tendency. If the expert in

child welfare facility has some traumatic experiences in his or her life, the relationship with traumatized

children would draw out pain or specific memories in the past time. He or she may be always exposed

to the traumatic memory or the traumatic emotion. If the supportive atmosphere would be prepared for

him or her, he or she might not be exposed to a risk of dissociation, and not feel Compassion Fatigue so

severely.

Compassion Fatigue in two facilities in Japan

Fujioka(2008) discussed secondary traumatic stress or compassion fatigue in relation to the concepts

of the helper’s own trauma and stress. He distributed questionnaires to facility A (16 people; 2 male 14

female), facility B (22 people; 12 male, 10 female). The results showed that the degree of compassion

satisfaction was low in both facilities in Japan. Even a certain level (level 2) poses a comparatively high

42

(40%) risk of burnout, while for 60%, there was low risk of burnout (together, 0;A,B provides equipment

for level 3,4 of a high domain). However, 36% occupied the classified level 4,5 and nearly 40% was in

a state of high compassion fatigue. The possibility is suggested that compassion fatigue becomes high

before actual burnout. A social worker may sense the degree of this compassion fatigue early, and it is

an important precaution to plan some countermeasures before it becomes severe burnout, and forces the

social worker to take leave of absence from duty or to resign.

The discussion in Fujioka(2008) is conducted from 4 standpoints. 1.Third Traumatic Stress ; Traumatic

stress in a family who has a caregiver, care worker, and/or social worker. 2. Defense against "Family

Burnout" of a helper. 3. The construction of relations between place of work and everyday life. 4.The

treatment for dissociation and the construction of integration of daily life as a worker in the people-

supporting field and as a member of family and community. It was necessary to investigate Compassion

Fatigue about other people in Japanese Child Welfare facility through the standard of Compassion

Fatigue/Satisfaction in Japanese.

Factor Analysis on Compassion Fatigue and Satisfaction in 110 persons in Japanese child welfare facilities.

Based on investigation by Japanese edition of questionnaires developed by Figley,C. et al.,

Fujioka(2007) studied the basics toward standardization of these questionnaires to relate to compassion

satisfaction and compassion fatigue. Furthermore, he suggested coping methods for burnout and

compassion fatigue based on them.

As a result of data analysis, four factors of "satisfaction in relations with fellow workers", "satisfaction

in relations with users", "satisfaction as nature of care workers or social workers " and "feeling of

satisfaction in life" were extracted on compassion satisfaction.

On compassion fatigue, four factors of "compassion fatigue accumulated as substitution-related

trauma", "denial feelings", "PTSD-like compassion fatigue" and "a trauma experience of care worker or

social worker oneself" were extracted.

From these results, it was suggested that there were 2 types of compassion fatigue; one is "Trauma-

dominance Compassion Fatigue" that has a certain trauma recurred, and another is "Stress-dominance

Compassion Fatigue" that has the possibility to become a new trauma.

About burnout standards by Figley,C. et al., correlation with the burnout standards that Maslach,C. et al

made was high and the result was provided that factor structures were approximately similar.

It was suggested that the general scores of compassion satisfaction, compassion fatigue and burnout

affects burnout prevention, coping with compassion fatigue and awareness of compassion satisfaction.

Especially "considerably high danger " group occupies 35%, and "high danger " group occupies 17%,

while " high- risk compassion fatigue" groups occupy 52% together. This suggests the necessity of support

for care workers or social workers in all child care or child welfare facilities.

Correlation of measures on compassion satisfaction, compassion fatigue and burnout with coping

methods with burnout, burnout in family and disagreement of policies of nursing and treatment were

examined in Fujioka(2007). 1, When a care worker or a social worker who feels bitterness and tightness is

supported by peers, friends, and families, compassion satisfaction becomes high. 2, Feelings that bitterness

43

and tightness are supported by peers, friends, and families may prevent from high depersonalization

tendency. 3, A person who feels enough compassion satisfaction does not give Third Traumatic

Stress(TTS) (for example, negative behavior and negative verbal expression to family. 4, A feeling of

emotional exhaustion is related to third traumatic stress. 5, Disagreement of a nurturing policy between

an administrator and a care worker or social worker lead the whole risk of burnout to a higher degree. 15

items were suggested as anti-burnout coping skills for compassion fatigue such as "inflection of a self-

check list".

Factor Analysis on Compassion Fatigue and Satisfaction in 212 persons in Japanese child welfare

facilities.

From the standpoint of many research on Compassion Fatigue/Satisfaction, Fujioka(2010) examined

some support programs in relation with burnout measures and compassion fatigue and satisfaction.

As a result of data analysis of 212 persons, he was able to get a result similar to Fujioka (2007). About

Compassion Satisfaction, four factors were extracted. Four factors were named as follows; "satisfaction

in relations with fellow workers", " satisfaction in relations with a child or children", " satisfaction in the

nature of care workers or social workers", and "feeling of satisfaction in life"

About compassion fatigue, four factors of "compassion fatigue accumulated as a substitution-related

trauma", "denial feelings", "PTSD-like compassion fatigue" and "a trauma experience of care worker or

social worker oneself" were extracted.

Correlation of these factors with Burnout Standard made by Maslach, C. and Jackson proved to be

statistically significance. On this basis, the following points were suggested. 1 Compassion satisfaction

showed significant negative correlation with "the emotional consumption feeling" that was a lower

factor and "de-personification" of standardized burnout measures, and equilateral correlation with

"sense of accomplishment of each individual" was suggested. 2 With a feeling of consumption and de-

personification, equilateral correlation with Compassion Fatigue was suggested. But Compassion Fatigue

was not related with personal sense of accomplishment. 3 A meaningful difference is seen in the number

of years in Compassion Satisfaction. It was suggested that for ten years, it was necessary to regard care

givers to be a professional care provider. 4 Compassion Fatigue accumulated as a substitution-related

trauma (Secondary Traumatic Stress) was related to Third Traumatic Stress by care givers’ families.

5 There was an association between Compassion Fatigue or Satisfaction and Burn out. Third Traumatic

Stress(TTS) is key concept for supporting a care giver’s family.

Third Traumatic Stress of Care givers’ and Social Workers’ Families

The family of a care giver has the possibility to be exposed to Third Traumatic Stress. I suggest that

members in care worker’s family have further stress if care workers receive Secondary Traumatic Stress

from children with some troubles and clients and he/she can not deal with as Secondary Traumatic Stress

or Compassion Fatigue. Fujioka (2007, 2008) called this " Third Traumatic Stress (TTS)". It is very

important for a care worker to receive enough support from families , fellow workers, and social system as

good environment.

44

Compassion Fatigue and the methods/attitudes of Child Care Support

The author thinks that Child Care Support is support for Parents and Care- Workers. It is important for

child care workers to investigate the relation of the main point of attachment parenting with Compassion

fatigue or Satisfaction. For child care, it is necessary to construct pro-support, pro- help to Parents and

Care givers. "The problem" that children have, "a problem" and "a feeling of maladjustment" are "the

points of contact of a relation with care givers and children". Problems in attachment become the point of

contact with children. A look at such " problems“ is very important. The author thinks that Compassion

Fatigue /Satisfaction affects occupational commitment just like FR(Frightened/ Frightening) behavior.

But nobody has investigated this standpoint on Compassion fatigue/Satisfaction and Burnout. Especially,

FR action (including an expression / a gesture etc.) “Frightened or Frightening” (FR) is very important in

the area of Child welfare facility. An inappropriate action for parenting is a point to "let a child feel fear"

with an abused child. A care giver who has various "unsolved models" was hurt (a trauma), and cannot

arrange experiences.

When burnout risk/ compassion fatigue were prevented for care workers, for example; consultation of

measures supports, the training, collaboration, maltreated children would be supported from a viewpoint

of attachment to developmental disability, and a state of the staff as "a container of attachment" would

be kept in good conditions. The author have challenged that many care givers would be good container

through clinical interview and insight to own self by ‘Life Script of Attachment’, and self-monitoring and

self-awareness by Compassion Fatigue Self Check Test.

When relations with the staff and children become complicated, feelings of satisfaction with children

are reduced, and that compassion fatigue increase mainly on substitute trauma. In this way it is thought

that further examination of compassion fatigue and compassion satisfaction as support programs to abused

children effectively.

Purpose of the study.

The purpose of this study is to conduct a multiple regression analysis of Compassion Fatigue/

Satisfaction Questionnaires and examine the correlation between those Questionnaires and Care Providers’

Behavior in Japanese Child Welfare Facilities.

To that purpose, we had three primary research questions: (1) Is there an association between Burn out

and Compassion Fatigue/Satisfaction ?; (2)Is there an association between three control variables and

Compassion Fatigue/Satisfaction ? : and (3) Does Compassion Fatigue /Satisfaction effect care provider’s

professional commitment as FR(Frightened/ Frightening) behavior on the standpoint of clinical attachment

approach ?

Methods

Sample and Procedures

For purpose (1)(2) data was obtained from some child welfare facilities in Japan. The author

distributed a questionnaire to each facility. Explanation of the research was conducted at a workshop. The

45

purpose of the questionnaire, the observance of obligation of keeping secrecy, management of personal

information, a way of entry were explained to all care providers in each facility. I had each staff fill out

the questionnaire and collected them later. These were unsigned. Study questionnaires were coded in

a manner that prevented duplicate responses while maintaining anonymity of respondents. Completed

questionnaires were received from 212 respondents.

For purpose (3) data was obtained from some child welfare facilities in Japan. The same procedure

was used as purpose (1)(2). Study questionnaires were coded in a manner that prevented duplicate

responses while maintaining anonymity of respondents. Completed questionnaires were received from 61

respondents.

Measures

Compassion Fatigue/Satisfaction Scale -Original Version- (66 items)

We used Care giver Compassion Fatigue/Satisfaction was measured with the Compassion Fatigue/

Satisfaction Scale (Original version, Figley and Stamm,2002; Japanese Translated version , Fujioka 2007).

The Compassion Fatigue/Satisfaction Short Version is a 66-item self- report instrument that instructs

respondents to indicate how frequently they experienced each of 66 symptoms during the previous week

using a 6-choice, Likert-type response format ranging from never (0) to very often (5). The 66 items of the

Compassion Fatigue/Satisfaction and burn out are designed to be congruent with the 26 symptom criteria

of Compassion Satisfaction, the 23 symptom criteria of Compassion Fatigue and the 17 symptom criteria

of Burn out (Figley and Stamm, 2002).

FR behaviors.

The author constructed new check lists about FR behavior with reference to Main, M., & E. Hesse (1996)

and Abrams,K.Y., Rifkin,A.& Hesse,F. (2006) .

For example, parts of FR behavior Check lists are as follows; I change how to put out and intonation of

a voice suddenly . I change an expression suddenly. I suddenly access a child. I take no notice of crying.

I leave a crying child and go to other places. I stare with a look letting a child be afraid. I will not dare

to look at a child. I contact in a voice letting a child be afraid. I scowl at a child. I contact a child with no

expression. I take an incomprehensible action for even myself . I contact a child stickily. I contact not

to harm a mood of a child. I contact a child with a frightening face. I hurl negative words at a child. I am

irritated and put up a hand to a child. I catch a child and strongly shake it.

FR behavior Check lists is a 25-item self- report instrument that instructs respondents to indicate how

frequently they experienced each of 25 symptoms during the previous week using a 5-choice, Likert-

type response format ranging from never (1) to very often (5). These FR behavior Check lists have three

factors, Frightened behavior, Frightening behavior and De-personalized behavior by Factor Analysis.

Dissociation behaviors.

The author picked up the five items from the daily dissociation check lists of Masuda (2006) . The

check lists is a 5-item self- report instrument that instructs respondents to indicate how frequently they

46

experienced each of 5 symptoms during the previous week using a 5-choice, Likert-type response format

ranging from never (1) to very often (5).

Compassion Fatigue/Satisfaction Scale -Short Version -(34 items)

Care giver Compassion Fatigue/Satisfaction was measured with the Compassion Fatigue/Satisfaction

Scale (based on Figley and Stamm,2002; Fujioka 2007,2010). The Compassion Fatigue/Satisfaction

Short Version is a 34-item self report instrument that instructs respondents to indicate how frequently

they experienced each of 34 symptoms during the previous week using a 5-choice, Likert-type response

format ranging from never (1) to very often (5). The 34 items of the Compassion Fatigue/Satisfaction

are designed to be congruent with the 17 symptom criteria of Compassion Satisfaction and 17 symptom

criteria of Compassion Fatigue by factor analysis of 66 original items of Compassion Fatigue/

Satisfaction self check lists (Figley and Stamm,2002). These Compassion Fatigue/Satisfaction Scale

-Short Version - have 8 factors; 4 factors on Compassion Fatigue,(1,Secondary Traumatic Stress or

compassion fatigue accumulated as a substitution-related trauma, 2,PTSD-like compassion fatigue,

3,Denial Feelings , 4,Trauma Experience of care worker or social worker oneself ) and 4 factors on

Compassion Satisfaction (1,satisfaction in relations with fellow workers, 2 satisfaction in relations

with a child or children, 3, satisfaction as nature of care workers or social workers, and 4,feeling of

satisfaction in life) by Factor Analysis(based on Figley and Stamm,2002; Fujioka 2007, 2010).

Control variables.

Based upon previous research linking them to independent and dependent variables, the following three

control variables were included in the study questionnaire: care giver age, gender, experience. Experience

was operationalized as the number of years working in a child welfare facility.

Data analysis

Data were analyzed with the Statistical Package named SPSS. First, a hierarchical ordinary least

squares regression analysis was conducted to assess the relationship between Compassion Fatigue and

Compassion Satisfaction and the relationship between these questionnaires with FR behavior . Next

multiple regression analysis was conducted to assess the relationship between Compassion Fatigue,

Compassion Satisfaction and Burn out. In addition to these analyses the correlation between four factors

of Compassion Fatigue/Satisfaction and the three factors of FR behavior among care givers in child

welfare facility were determined.

Results

Sample Characteristics

For investigating purposes (1) and (2), Table 1 presents the descriptive statistics for demographic and

other key variables. 212 study participants had five age groups; 20's(50%), 30's(30.2%), 40's(8.5%),

50's(9.9%), 60's(1.4%). Gender ; male(45.3), female(54.7). The sample had an average of 8.14 years (SD

47

= 8.30) of experience. Scores on the Compassion Satisfaction Scale ranged from 29-119 with a mean of

72.887 (SD =14.980). Scores on the Compassion Fatigue Scale ranged from 8-77 with a mean of 34.821

(SD =13.433 ). Scores on the Burn out Scale (Figley and Stamm, 2002) ranged from 9-61 with a mean of

35.283 (SD =10.084).

Table 1. Descriptive statistics for key variables (n = 212).Number (%) Mean (SD) Range

Gender

Male 96 (45.3)

Female 116 (54.7)

Age

20's 106 (50 )

30's 64 (30.2)

40's 18 ( 8.5)

50's 21 ( 9.9)

60's 3( 1.4)

Experiences (Years) 8.140 ( 8.300)

Compassion Satisfaction 72.887 (14.980) 29-119

Compassion Fatigue 34.821 (13.433) 8-77

Burn out (Figley and Stamm 2002) 35.283 (10.084) 9-61

For investigating purposes (3) new study participants attended this study. 61 study participants had five

ranges of age; 20's(67.2%), 30's(27.9%), 40's(0%), 50's(3.3%), 60's(1.6%). Gender ; male(24;39.34%),fem

ale(37;60.66%). The sample had an average of 5.32 years (SD = 5.82) of experience.

Multiple regression analysis

Table 2 displays the results of the hierarchical OLS regression analysis for predicting Compassion

Satisfaction among care givers in a child welfare facility. Of the three control variables entered in Step 1

only experience significantly predicted Compassion Satisfaction. When Compassion Fatigue was added

in Step 2, only experience was significant. Compassion Fatigue did not predict Compassion Satisfaction.

48

Table 2. Hierarchical regression analysis predicting Compassion Satisfaction among care givers in child welfare facility.

Step 1

B(se) β p R2

Age -1.845 (2.063) -0.038 0.111

Gender -1.150 (2.063) -0.038 0.578

Experience 0.315 (0.145) 0.174 0.031*

0.026

Step2

B(se) β p R2

Age -1.751 (1.153) -0.122 0.130

Gender -1.300 (2.061) -0.043 0.529

Experience 0.307 (0.145) 0.170 0.035*

Compassion Fatigue -0.109 (0.076) -0.098 0.155

0.035

* p<.05

Table 3 displays the results of the Multiple regression analysis for predicting Burnout among care

givers in child welfare facility. In MRA Compassion Fatigue and Compassion Satisfaction significantly

predicted Burn out.

Linear multiple regression equation ;

Burnout risk = 0.490×Compassion Fatigue + (-0.163×Compassion Satisfaction) + 30.123

……………………. (a)

Table 3. Multiple regression analysis predicting Burnout among care givers in child welfare facility.

B(se) β p R2

Compassion Fatigue 0.490(0.036) 0.652 .0001**

Compassion Satisfaction -0.163(0.033) -0.242 .0001**

Constant Term 30.123(2.841)

0.516

Table 4 displays the results of the hierarchical OLS regression analysis for predicting FR behavior. The

hierarchical regression analysis was conducted to assess the relationship between Compassion Fatigue,

Compassion Satisfaction, and FR behavior. Step 1 FR behavior regressed on the three control variables.

Step 2 added the Compassion Fatigue variable in addition to the three control variables to determine if

Compassion Fatigue predicts FR behavior. Step 3 added Compassion Satisfaction as a predictor variable

in addition to the control variables and Compassion Fatigue.

49

Table 4. Hierarchical regression analysis predicting FR Behavior among care givers in child welfare facility.

Step 1

B(se) β p R2

Age 1.058 (2.808) 0.093 0.708

Gender -4.135 (2.537) -0.215 0.109

Experience 0.035 (0.401) 0.021 0.931

0.054

Step2

B(se) β p R2

Age 1.239 (2.109) 0.109 0.591

Gender -2.059 (2.109) -0.107 0.333

Experience -0.135 (0.329) -0.083 0.684

Compassion Fatigue 0.553 (0.104) 0.587 0.0001**

0.380

Step3

B(se) β p R2

Age 1.203 (2.316) 0.106 0.606

Gende -2.198 (2.173) -0.114 0.316

Experience -0.128 (0.332) -0.079 0.703

Compassion Fatigue 0.538 (0.116) 0.570 .0.0001**

Compassion Satisfaction -0.033 (0.107) -0.0376 0.756

0.381

Table 5 displays the results of the Multiple regression analysis for predicting FR behavior. The Multiple

regression analysis was conducted to assess the relationship between Compassion Fatigue, Compassion

Satisfaction, and FR behavior.

Linear multiple regression equation ;

FR behavior = 0.550×Compassion Fatigue + (-0.007×Compassion Satisfaction) +32.8756

……………………. (b)

Table 5. Multiple regression analysis predicting FR behavior among care givers in child welfare facility.

B(se) β p R2

Compassion Fatigue 0.550 (0.106) 0.594 .0001 **

Compassion Satisfaction -0.007 (0.099) -0.008 0.945

Constant Term 32.876(6.995)

0.357

Table 6 displays the results of the h Multiple regression analysis for predicting FR behavior. The

hierarchical regression analysis was conducted to assess the relationship between four factors of

Compassion Fatigue and FR behavior.

50

Linear multiple regression equation ;

FR behavior = 0.381 × Secondary Traumatic Stress + 1.167 × PTSD + (-0.039×Denial Feeling)

+ 0.157×Trauma Experience + 31.356 ……………………. (c)

Table 6. Multiple regression analysis predicting FR behavior among care givers in child welfare facility.

B(se) β p R2

Secondary Traumatic Stress 0.381 (0.324) 0.151 0.244

PTSD 1.167 (0.211) 0.5916 .0001 **

Denial Feeling -0.039 (0.457) -0.0096 0.932

Trauma Experience 0.157 (0.387) 0.0488 0.687

Constant Term 31.356 2.286

0.466

Table 7 displays the results of Correlation between four factors of Compassion Fatigue and the three

factors of FR behavior among care givers in child welfare facility.

4 factors of Compassion Fatigue contained Secondary Traumatic Stress, PTSD, denial tendency, trauma

experience . 3 factors of FR behavior contained Frightened behavior, Frightening behavior, Depersonalized

behavior.

Frightened behavior in FR behavior have the significant correlation with Secondary Traumatic

Stress, PTSD, denial feeling, trauma experience in Compassion Fatigue and Total FR Behavior ,

Dissociation behavior . Frightening behavior in FR behavior has significant correlation only with

PTSD in Compassion Fatigue. Total FR Behavior have the significant correlation with Dissociation

Behavior. Depersonalized behavior in FR behavior check lists has significant correlation with

Dissociation behavior, PTSD in Compassion fatigue. Dissociation behavior has significant correlation

with all four factors in Compassion Fatigue (Secondary Traumatic Stress, PTSD, Denial feeling, Trauma

experience).

Table 7. Correlation between four factors of Compassion Fatigue and the three factors of FR behavior among care givers in child welfare facility.

BehaviorFrightened

Behavior

Frightening

Behavior

Depersonalized

Behavior

Total FR

Behavior

Dissociation

BehaviorFrightened Behavior 1.0000

Frightening Behavior -0.0007 1.0000

Depersonalized Behavior 0.1967 0.521** 1.0000

Total FR Behavior 0.608** 0.692** 0.804** 1.0000

Dissociation Behavior 0.643** 0.123 0.329** 0.541** 1.0000

Secondary Traumatic Stress 0.590** 0.075 0.119 0.394** 0.439**

PTSD 0.359** 0.488** 0.552** 0.662** 0.500**

Denial Feeling 0.457** -0.058 0.021 0.219 0.440**

Trauma Experience 0.338** 0.124 0.221 0.333** 0.325*

Total Compassion Fatigue 0.588** 0.274* 0.366** 0.597** 0.594**

* p<.05 **p<.01

51

4 factors of Compassion Fatigue (Secondary Traumatic Stress, PTSD, Denial Feeling, Trauma Experience )

3 factors of FR behavior (Frightened Behavior, Frightening Behavior, Depersonalized Behavior)

Table 8 displays the results of Correlation between four factors of Compassion Satisfaction and the

three factors of FR behavior among care givers in child

welfare facility. Frightened behavior in FR behavior has significant negative(-) correlation with

satisfaction as nature of care workers . Frightening behavior and Depersonalized behavior in FR behavior

have no significant correlation with four factors in Compassion Satisfaction. Total FR Behavior has

significant negative(-) correlation with satisfaction in relations with a child or children. Dissociation

Behavior has significant correlation with Total Compassion Satisfaction, especially satisfaction in

relations with a child or children and satisfaction as nature of care workers.

Table 8. Correlation between four factors of Compassion Satisfaction and the three factors of FR behavior among care givers in child welfare facility.

BehaviorFrightened

Behavior

Frightening

Behavior

Depersonalized

Behavior

Total FR

Behavior

Dissociation

BehaviorFrightened Behavior 1.000

Frightening Behavior -0.001 1.000

Depersonalized Behavior 0.197 0.521** 1.000

Total FR Behavior 0.608** 0.692** 0.804** 1.000

Dissociation Behavior 0.643** 0.123 0.329** 0.541** 1.000

Satisfaction in relations　with fellow workers

-0.104 -0.054 -0.211 -0.176 -0.207

Satisfaction in relations　with a child or children

-0.202 -0.144 -0.206 -0.265* -0.265*

Satisfaction as nature　of care workers

-0.351** 0.086 -0.207 -0.240 -0.468**

Feeling of satisfaction in life 0.006 0.071 -0.119 -0.021 -0.115

Total Compassion Satisfaction -0.222 -0.031 -0.250 -0.246 -0.351**

* p<.05 **p<.01

4 factors of Compassion Satisfaction (Satisfaction in relations with fellow workers, Satisfaction in relations with a child

or children, Satisfaction as nature of care workers, Feeling of satisfaction in life)

Table 9 displays the results of Multiple regression analysis predicting Three factors of FR behavior

among care givers in child welfare facility. We investigated each Criterion Variable. As a result, Frightened

behavior in FR behavior has significant correlation with Secondary Traumatic Stress or compassion

fatigue accumulated as a substitution-related trauma. And Frightened behavior has significant –tendency

correlation with Denial Feeling(p=0.068 † < .10 ). Both Criterion Variable, Frightening Behavior and

Depersonalized Behavior have significant correlation with PTSD-like Compassion Fatigue.

52

Table 9. Multiple regression analysis predicting Three factors of FR behavior among care givers in child welfare facility.

Criterion Variable; Frightened Behavior

B(se) β p R2

Secondary Traumatic Stress 0.590 ( 0.176) 0.453 0.001**

PTSD 0.159 (0.115) 0.156 0.172

Denial Feeling 0.461 (0.248) 0.221 0.068

Trauma Experience -0.082 (0.210) -0.049 0.698

Constant Term 10.841 (1.241)

0.408

Criterion Variable; Frightening Behavior

B(se) β p R2

Secondary Traumatic Stress -0.075 (0.169) -0.066 0.660

PTSD 0.476 (0.111) 0.538 0.0001 **

Denial Feeling -0.300 (0.239) -0.165 0.214

Trauma Experience 0.052 (0.202) 0.036 0.798

Constant Term 11.137 (1.195)

0.272

Criterion Variable; Depersonalized Behavior

B(se) β p R2

Secondary Traumatic Stress -0.133 (0.1700) -0.113 0.435

PTSD 0.533 (0.111) 0.576 0.0001 **

Denial Feeling -0.200 (0.240) -0.105 0.408

Trauma Experience 0.187 (0.203) .124 0.362

Constant Term 9.378 (1.201)

0.330

†p<.10 * p<.05 **p<.01

Discussion

The purpose of this study was to examine multiple regression analysis of Compassion Fatigue/

Satisfaction Questionnaires and determine the correlation between those Questionnaires and Care

Providers’ Behavior in Japanese Child Welfare Facilities.

An association between Burn out and Compassion Fatigue / Satisfaction

Through the hierarchical OLS regression analysis , when Compassion Fatigue was added in Step 2, only

experience was significant. Experience is very important in thinking about Compassion Satisfaction.

The author described the relationship between experience and Compassion Satisfaction in Fujioka(2007) .

Fujioka(2007) indicated that Compassion satisfaction changes up and down every year after beginning to

work, and numerical value of Compassion satisfaction is stabilized from 7 years to 10 years.

In this study, Compassion Fatigue did not predict Compassion Satisfaction. It was predicted that

Compassion Fatigue and Satisfaction will impact burn out separately. So the author constructed the linear

53

multiple regression equation (a) as follows;

Burnout risk = 0.490 × Compassion Fatigue + (-0.163 × Compassion Satisfaction) + 30.123

We have to investigate the reason of the influence to Burn out. This was first challenge to construct the

numerical formula, Burnout risk and Compassion Fatigue / Satisfaction.

The relationship of Compassion Fatigue /Satisfaction with the interaction between care providers and

children, just like FR(Frightened/ Frightening) behavior

The hierarchical regression analysis was conducted to assess the relationship between Compassion

Fatigue, Compassion Satisfaction, and FR behavior. Step 1 FR behavior regressed on the three control

variables. But we had no significant effect of three variables to FR behavior. Next it was indicated

that the Compassion Fatigue predicts the FR behavior significantly. Step 3, we added the third factor,

Compassion Satisfaction. We did not find significant effect in this research. So the author constructed the

linear multiple regression equation (b) as follows;

FR behavior = 0.550 × Compassion Fatigue + (-0.007 × Compassion Satisfaction) + 32.8756

……………………. (b)

The hierarchical regression analysis was conducted to assess the relationship between four factors of

Compassion Fatigue and FR behavior as follows;

FR behavior =0.381 × Secondary Traumatic Stress + 1.167×PTSD

+ (-0.039×Denial Feeling) + 0.157 × Trauma Experience + 31.356

……………………. (c)

These were first challenge to construct the numerical formula, FR behavior and Compassion Fatigue /

Satisfaction.

A hierarchical regression analysis was conducted to assess the relationship between four factors of

Compassion Fatigue and FR behavior. PTSD significantly affected FR behavior. PTSD is an important

factor in four factors of Compassion Fatigue.

Fujioka(2005) described that compassion fatigue has two kinds, one is stress-based compassion fatigue

and the other is trauma-based compassion fatigue. It is thought that FR behavior is connected with stress-

based compassion fatigue.

Table 7 displays the results of Correlation between four factors of Compassion Fatigue and the

three factors of FR behavior among care givers in child welfare facility. Frightened behavior in FR

behavior has significant correlation with Secondary Traumatic Stress, PTSD, denial feeling, trauma

experience. Frightened behavior in FR behavior seems to be connected to a care provider’s trauma or

scar in childhood. It is necessary for a care provider to confront his or her own trauma experience with a

supervisor .

Frightening behavior in FR behavior has significant correlation with only PTSD in Compassion

Fatigue. Frightening behaviors are inadequate for care providers, but it is possible to deal with PTSD

54

before it leads to severe FR behavior, if care givers can notice beforehand. Depersonalized behavior in

FR behavior check lists have significant correlation with Dissociation behavior, PTSD. Depersonalized

behavior in FR behavior

Depersonalized behavior can be dealt with before it leads to severe FR behavior. Dissociation behavior

has significant correlation with all four factors in Compassion Fatigue (Secondary Traumatic Stress,

PTSD, Denial feeling, Trauma experience). In this study we confirmed the relation between Dissociation

and Compassion Fatigue. It could be determined that Fatigue and Dissociation were related closely, just as

Pierre Janet already described in 19 century.

In addition, we found that three parts of concepts of FR behavior connect with each part of Compassion

Fatigue. Especially Frightened behavior in FR behavior connect with all aspects of Compassion Fatigue.

And Frightening Behavior has significant correlation only with PTSD in Compassion Fatigue. It could be

ascertained that FR behavior and Compassion Fatigue are closely related.

Table 8 displays the results of Correlation between four factors of Compassion Satisfaction and the

three factors of FR behavior among care givers in child

welfare facility. Frightened behavior in FR behavior has significant negative(-) correlation with

satisfaction as nature of care workers . Satisfaction as nature of care workers will be developed by training,

workshop and supervision. For Protecting FR behavior by care workers we have to construct career

development system in Child welfare facility. Monitoring the nature of care workers is very important for

support to care workers.

Frightening behavior and Depersonalized behavior in FR behavior have no significant correlation with

four factors in Compassion Satisfaction. Total FR Behavior have the significant negative(-) correlation

with satisfaction in relations with a child or children. Satisfaction in relations with a child or children

is main part of compassion Satisfaction with children. Dissociation Behavior has significant negative(-)

correlation with Total Compassion Satisfaction, especially satisfaction in relations with a child or children

and satisfaction as nature of care workers. Awareness and talking about satisfaction in relations with a

child or children and satisfaction as nature of care workers have the role of protection from consequences

of dissociation in the field of facility.

Table 9 displays the results of Multiple regression analysis prediction. Frightened behavior in

FR behavior has significant correlation with Secondary Traumatic Stress or compassion fatigue

accumulated as a substitution-related trauma. And Frightened behavior has low correlation with Denial

Feeling(significantly tendency; p=0.068). Frightened behavior will be connected to a care giver’s own

trauma, so Secondary Traumatic Stress and denial feeling will be activated in a care giver when contacting

with abused children. Both Criterion Variable, Frightening Behavior and Depersonalized Behavior have

the significant correlation with PTSD-like Compassion Fatigue. For protection of burnout and inadequate

behavior to children, it will be very important to be aware of and to treat PTSD-like symptoms among

care givers and supervisors.

55

Compassion Fatigue of Trauma Dominance and Compassion Fatigue of Stress Dominance

Fujioka(2005) described that compassion fatigue has two types of, Trauma-dominance Compassion

Fatigue(TDCF) and Stress- dominance Compassion Fatigue(SDCF). In Stress- dominant Compassion

Fatigue, the trauma may be deeply and profoundly hidden in the mind, and stress would be felt in a

situation of work. I think Trauma-dominance Compassion Fatigue would be easy to cause a stronger

dissociation tendency, and the degree of the burnout tendency would differ by the state of a child, how to

live in family and community and how to live in the past, especially in childhood. Deep sadness (grief,

sorrow, lament) and profound trauma will draw out compassion fatigue for a care giver or a care provider

who continues to be exposed to Trauma-dominance Compassion Fatigue and experiences dissociation

unconsciously under those situations. Children who had a severe trauma will draw compassion fatigue

of trauma dominance of a care provider easily. I think that under these helping situations with abused

or traumatized or neglected clients(children or elderly people or handicapped people), compassion

fatigue would be easy to connect to severe burnout situation. In this study we found dissociation

tendency is connected with all four factors in Compassion Fatigue (Secondary Traumatic Stress, PTSD,

Denial tendency, Trauma experience). I have to emphasize that dissociation tendency is a key concept

of Compassion Fatigue. P. Janet already pointed out the relationship between traumatic memory and

psychological fatigue in the latter part of 19 century or early 20 century. The author discussed this

point through compassion fatigue and dissociation in child welfare facilities. In other words, when care

providers are exposed to compassion fatigue, particularly secondary wound-related stress, their own

trauma experience may be drawn out. And care providers must be exposed to trauma experiences of

children doubly more while they are exposed to their own trauma experience. This is Trauma- dominance

Compassion Fatigue.

Further tasks in these area

Fujioka(2010) described four tasks of support programs as follows. 1, Necessity of enhancing

investigations in other child welfare facilities. 2, Continuity of investigations. 3, Necessity of construction

of individually-related examination about Compassion fatigue/Satisfaction and FR behavior or Clinical

Attachment Approach. 4, Necessity of construction of the Academic Domain on Support for Care

Giver or other professionals for users and clients.

The author emphasized in this study that it is necessary to investigate the relationship of professional

approach to clients with Compassion Fatigue and satisfaction. Perhaps it is very important for the

protection of burnout or inadequate behavior in care providers and social workers to examine these

subjects on Compassion fatigue/Satisfaction.

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A Study of Methods of Model Formulation and Assessment to Construct Models of Effective Program Implementation Based on a Nationwide Survey of Support Providers Based on Implementation of Critical Ingredients of an Employment Transition Support Program for Persons with Disabilities and Analysis of Factors Governing that Implementation

NORIYASU KOSAZA IWAO OSHIMA

HISAO SATO

【Abstract】

The purpose of this study is to examine model formulation and assessment approaches in order to construct an effective model of program implementation using results of a nationwide survey of support providers. This study examined the development of methods of formulating and assessing effective models of program implementation based on the example of the employment transition support program for persons with disabilities pursuant to the Services and Support for Persons with Disabilities Act.

Measurement of its performance primarily via the employment transition rate also demonstrated the effectiveness of program implementation in accordance with this model. And results indicated that the Nationwide Survey of Support Providers is an effective approach to construction of an effective model of program implementation. Though there are some points that should be examined, this approach using results of a nationwide survey of support providers is proven to be effective.

I. Introduction

Overall, Japanese programs to provide social welfare services tend to involve support systems

independently established by individual support providers. Thus, forms and methods of support that

are considered effective are common among many of the parties concerned, and establishment of

methodologies to formulate more effective program models is delayed. In such circumstances, avenues

to formulate better methods of providing support based on findings from sites of program implementation

are blocked, and providers are not required to ensure the quality of services. Often, the forms of support

60

provided by a provider cannot be adequately ascertained from outside the provider. Moreover, program

users have difficulty selecting critical services.

Varied entities operate in the field of social welfare, making construction of an effective model of

program implementation difficult. An effective model of program implementation must be formulated in

accordance with varying levels of implementation. However, many ingredients are known to be common

to critical forms of support and the way they are organized, i.e. the heart of a program1). Use of findings

from sites of program implementation and collaboration between program implementers and researchers

are essential to the construction of an effective model of program implementation2).

Exchange of information by program implementers and researchers is needed to develop a more

effective model of program implementation. An effective model of program implementation created in

collaboration with program implementers should be adjusted and revised in accordance with conditions at

various sites of program implementation.

This study sought to examine model formulation and assessment approaches in order to construct an

effective model of program implementation using results of a nationwide survey of support providers.

Specifically, this study examines the example of the employment transition support program for persons

with disabilities introduced pursuant to the Services and Support for Persons with Disabilities Act. This

study seeks to clarify the implementation of critical program ingredients based on results of a survey of

support providers nationwide, it seeks to analyze factors governing the implementation of those program

ingredients, and it seeks to examine methods of formulating and assessing effective program models as

would be feasible in light of the provision of welfare services in Japan.

II. Methods

1. Selection of survey participantsThis study examines the development of methods of formulating and assessing effective models

of program implementation based on the example of the employment transition support program for

persons with disabilities pursuant to the Services and Support for Persons with Disabilities Act. A

self-administered nationwide survey (denoted here as the Nationwide Survey of Support Providers)

of providers of employment transition support (denoted here as Support Providers) for persons with

disabilities was conducted by mail. This employment transition support program was selected for several

reasons, including the substantial need for the program on the part of program users, the fact that the

program is relatively new since it was created under the Services and Support for Persons with Disabilities

Act, the fact that the program has a usage deadline, and the fact that measurements of its performance

have not been made adequately available.

2. Survey content and structure of the survey formThis study consisted of 2 surveys. The first was a basic survey that primarily sought to determine basic

information about Support Providers. The second was a survey on implementation of critical program

ingredients (denoted here as the Survey on Implementation of Critical Ingredients or Implementation

61

Survey) that consisted of indices to measure critical program ingredients in an effective model of program

implementation constructed on the basis of theories of program assessment and studies to qualitatively

assess programs.

The basic survey sought to ascertain the basic status of the support provider, e.g. year the program

started, user capacity, the number of persons with disabilities who were entering the workforce, the

number of employees, and the provider’s orientation, indices related to program effectiveness, and the

provider’s efforts at implementing the program.

The Survey on Implementation of Critical Ingredients sought to ascertain the implementation of

Critical Program Ingredients that comprised an effective model of program implementation3). An

effective model of this program will be constructed through adjustments to the program’s structure based

on theories of program assessment, observing sites of program implementation and conducting studies,

like those involving interviews, to qualitatively assess the program, and exchanges of opinions among

program implementers and researchers; thus, a model will be formulated with the consensus of program

implementers and researchers4). There are 169 critical ingredients that fall under 23 items. This study

measured the adherence of a model created by our research group by determining the implementation of

ingredients falling under each item. These items were classified into 5 domains depending on their content

(Table 1). The Implementation Survey rated each item on a 4-point scale. Ingredients that represented

specific methods of support were checked off if applicable. Based on survey results, scale scores were

from 4 points, indicating extensive implementation, to 1 point, indicating minimal implementation. This

Likert scale provided a fidelity scale to measure model adherence. When the scale score for a domain is

indicated, this indicates the sum of the scale scores for each item divided by the number of items. Thus,

all of the scale scores for each domain and each item range from 1 to 4 points.

Characteristics of each domain were as follows. Domain A indicated The Organization Providing

Services and consisted primarily of aspects like the form of organization implementing the program,

its system of contacts, and fostering of staff members. Domain B indicated the Provision of Services

to Program Participants and consisted of acceptance criteria and publicity efforts. Domain C indicated

Support Processes from the Start of Program Use to the Formulation of an Employment Transition

Support Plan and consisted of activities ranging from forming relationships at the start of program use to

drafting of a support plan. Domain D indicated Support Processes Facilitating Employment Transition

and consisted primarily of a wide range of support efforts like acquiring the skills to find employment,

assessment of the individual’s current status, and job placement. Domain E indicated Processes Required

in Support of Continuous Employment and consisted of construction of support systems and required

actions with a focus on conditions after entry into the workforce. Rather than merely indicating support

based on actual laws and ordinances, these domains encompassed a broader range of support services and

how long they were provided. This was done in order to formulate a model of a program that would help

users to enjoy a stable career and ultimately enjoy a better quality of life. In addition, the model was the

result of collaboration between program implementers and researchers and items included were deemed

valid.

62

Table 1 Critical Ingredients of the employment transition support program

Domain name・Item name No. ingredientsA The Organization Providing Services

A1 Support provided by employment support staff

A2 Roles and responsibilities of employment support staff

A3 Team approach to employment support

A4 Coordination with living support services and healthcare facilities

A5 Function of coordinators (service administrators/managers)

A6 Fostering and supervising staff members

9

6

5

6

16

7B Provision of Services to Program Participants

B1 Acceptance of individuals who wish to receive employment transition support with no

exclusion criteria

B2 Active publicity efforts to identify and retain users

7

10

C Support Processes from the Start of Program Use to the Formulation of an Employment Transition

Support Plan

C1 Sharing of employment goals, motivation, and partnering

C2 Providing assessment predicated on the users’ wishes in a realistic employment environment

C3 Drafting an employment transition support plan in order to promptly satisfy the desire to

work

5

6

4

D Support Processes Facilitating Employment Transition

D1 Acquiring the skills needed to find employment

D2 Assessment in environments similar to actual workplaces

D2-1 Assessment when the individual primarily wishes to work within the facility

D2-2 Assessment when the individual primarily wishes to work outside the facility

D3 Maintaining and improving the individual’s motivation to enter the workforce

D4 Use of apprenticeships and trial employment at potential employers

D5 Actively and routinely cultivating cooperative support providers in accordance with

individual needs

D6 Active job placement with the goal of open employment

D7 Hunting for a variety of jobs in accordance with the individual’s inclinations

D8 Efforts to promptly facilitate entry into the workplace in accordance with the individual’s

wishes

9

-

6

7

8

7

7

7

7

6

E Processes Required in Support of Continuous Employment

E1 Providing assistance with settling in and continued support after entry into the workforce

E2 Support for individuals who wish to leave or transfer jobs

E3 Continued support for businesses

E4 Team approach to provide comprehensive employment and living support

5

6

4

9

Source: Koukanoagaru-Syurouikoushien-Program-no-Arikata-kenkyukai (2009)

3. Conduct of a Nationwide Survey of Support Providers (1) Survey period

This survey was conducted from March-July 2009.

63

(2) Survey participants

Potential survey participants were all Support Providers nationwide. Prefectural and city governments

were asked about the actual number of those providers in December 2008. In accordance with their

responses, survey forms were mailed to 1,213 Support Providers.

(3) Number of responses and response rate

Responses were received from 738 Support Providers, indicating a response rate of 60.8%. Of the

responses, valid responses were received from 727 Support Providers, indicating a response rate of 59.9%.

4. Ethical considerationsA written description clearly explaining the purposes of this research, a summary of the study, and how

responses would be handled was enclosed with the survey form. In addition, participants were allowed

to respond anonymously to the survey form, and survey forms were coded to protect anonymity. Both

survey forms were combined when collected and then coded and analyzed. With regard to comments,

slight changes were made to proper names and the like so that the names of Support Providers could not

be identified, but considerations were made to leave passages intact.

III. Survey results

1. Basic surveyThe primary results from the survey forms were previously published by Kosaza, Oshima, Kouda et al.

(2010). The following describes only significant survey results.

The most prevalent major disability of users was a mental disability; such users were accepted by

81.8% of all Support Providers. In addition, 44.8% of Support Providers accepted users with a mental

illness and 31.5% of Support Providers accepted users with a physical disability.

The most prevalent user capacity was fewer than 6 users, according to responses from 181 Support

Providers. Forty-seven point eight percent of Support Providers had a user capacity of 10 or fewer users,

revealing that most Support Providers were relatively small-scale. That said, other programs were often

offered by the same entity, and only 15 Support Providers responded that they offered no programs besides

this program. Over half of the other programs offered by the same entity were a Type B (non-contracted

work) continuous employment support program (70.3%) or a group home/total care facility (54.1%).

Programs that the Study Group considered critical were an employment and living support center program

for persons with disabilities, offered by 13.3% of providers, and a job coaching program, offered by 19.1%

of providers.

In addition, Support Providers most often (65.2%) had users using the program for a duration of longer

than a year and a half. This is close to the cap on the length of time programs can be used and indicates

that this method of support must be reconsidered.

From April to December 2008, 1,391 persons with disabilities entered the workforce. The employment

transition rate during this period was 12.1%; calculated annually, this rate would be 16.1%. This result is

64

higher than the 14.7% in the latest study published by the Ministry of Health, Labor, and Welfare.

Table 2 Number of Support Providers by user capacity

User capacity No. of Support Providers (%)Fewer than 6 users

7-10

11-15

16-20

21-25

26-30

31 or more users

181(26.0)

152(21.8)

118(16.9)

103(14.8)

36(5.2)

42(6.0)

65(9.3)

Source: Kosaza, Oshima, Kouda et al. (2010)

Table 3 Average duration of program usage by users

Average duration of usage No. of Support Provider (%)Under 1 month

Up to 3 months

Up to half a year

Up to a year

Up to a year and a half

Longer than a year and a half

6(0.9)

8(1.3)

16(2.5)

89(14.0)

102(16.1)

414(65.2)

Source: Kosaza, Oshima, Kouda et al. (2010)

Table 4 Breakdown of major disabilities of program users

Type of disability No. of Support Providers (%)Physical disability

Mental disability

Mental illness

Developmental disability

Refractory illness

No specific disability

229 (31.5)

595 (81.8)

326 (44.8)

113 (15.5)

18 (2.5)

9 (1.2)

Note) Multiple responses were allowed, so the number of support providers responding exceeds the total number of 727

Support Providers

Source: Kosaza, Oshima, Kouda et al. (2010)

65

Table 5 Programs offered by the same entity

Program name No. of Support ProvidersEmployment and living support center for persons with disabilities

Job coaching

Businesses that encourage the hiring of persons with severe disabilities

Job acclimatization training system

Contracted [vocational] training program

Counseling and support program*

Type A (contracted work) continuous employment support program*

Type B (non-contracted work) continuous employment support program*

Independence training program*

Group home/Total care facility*

Regional activities support program*

In-home care*

Psychiatric hospitals and clinics

Other

97

139

9

14

47

243

82

511

207

393

166

148

16

171

Note) An asterisk (*) indicates services pursuant to the Services and Support for Persons with Disabilities Act. Multiple

responses were allowed.

Source: Kosaza, Oshima, Kouda et al. (2010)

2. Survey on Implementation of Critical Program IngredientsThe level of implementation of Critical Program Ingredients falling under 23 items from A1 to E4 was

ascertained. That said, D2 featured a question with responses regarding assessment within the facility and

assessment outside the facility, so results were tallied for 24 items.

By domain, the average scale scores on the fidelity scale are as shown in Table 6. Roughly half of the

scores for Domains A to C adhered to the model while those for Domains D and E tended to be somewhat

lower.

Table 6 Average scale scores on the fidelity scale by domain

Freq. Scale avg. (Item avg.) SDDomain A

Domain B

Domain C

Domain D

Domain E

All

671

684

681

602

666

569

2.45

2.57

2.58

2.14

2.18

2.33

.652

.726

.729

.646

.825

.589

The average scale scores on the fidelity scale were then determined by item. Specific figures are as

shown in Table 7; variations in average scale scores were noted even in the same domain. Below, scale

scores for the top items and bottom items in each domain were compared.

Domain A included items among the top 5 items and the bottom 5 items, with a difference between the

two of 0.81 points. In Domain B, both items had relatively high scores with a difference of 0.32 points.

66

Items in Domain C also had relatively high scores with a difference of 0.39 points. In Domain D, items

D21 and D7 had relatively high scores but overall most items had low scores with a difference of 0.56

points. Items in Domain E had relatively low scores overall with a difference of 0.49 points.

In addition, about 40% of Support Providers had no persons with disabilities who were entering the

workforce during the survey period, so scores for some items in Domain D, which included employment

transition performance, and scores for items in Domain E, which primarily involved support after entry

into the workforce, were low overall. However, systems for support after entry into the workforce should

be provided once users have registered to receive support, so efforts by Support Providers with no persons

with disabilities who were entering the workforce at the time of the study were also assessed.

Table 7 Average scale scores on the fidelity scale by item

Item Freq. Avg. SD Item Freq. Avg. SD

A1

A2

A3

A4

A5

A6

697

692

693

694

683

684

2.89

2.68

2.29

2.08

2.76

2.29

.825

.867

.970

.893

.845

.903

D21

D22

D3

D4

D5

D6

D7

D8

629

632

637

636

635

637

636

637

2.46

2.13

2.14

1.92

2.15

2.04

2.48

1.80

.926

.950

.842

.889

.864

.849

.974

.797

B1

B2

686

685

2.73

2.41

.897

.868

C1

C2

C3

686

686

682

2.76

2.60

2.37

.809

.838

.919

E1

E2

E3

E4

682

674

678

681

2.28

2.29

2.23

1.96

1.086

1.064

.996

.851D1 686 2.20 .892

3. Fidelity scale scores by domain in terms of Support Providers’ basic attributesIndicators of the scale of the Support Provider, the effects of user capacity, the effects of the average

duration of program usage, and the effects of parallel programs were determined. That said, the effects of

different disabilities have been omitted here since many of the Support Providers accepted persons with

multiple disabilities. In addition, there were no differences in the fidelity scale scores by domain for the

number of persons with disabilities who were entering the workforce and the employment transition rate.

The number of persons with disabilities who were entering the workforce and the employment transition

rate served as indices of performance and are indicated in the Discussion.

(1) The effects of user capacity

Assignment of personnel to the program is dictated by laws and ordinances, so user capacity can also

affect the number of staff members assigned. The number of users per staff member may be the same,

but Support Providers with a small user capacity are likely to have a small number of total staff members.

A reduction in the total number of staff members carries the drawback of precluding specialization in

various support efforts and publicity efforts. In actuality, many Support Providers do not provide adequate

services under current criteria for staff assignment.

67

Fig. 1 Average scale scores on the fidelity scale by user capacity

2.42 

2.30 

2.23 

2.67 

2.64 

2.55 

2.23 

2.06 

2.06 

2.49 

2.50 

2.44 

1.0  1.5  2.0  2.5  3.0 

All

Domain E

Domain D

Domain C

Domain B

Domain A

10 individuals or fewer

11 individuals or more

As confirmed by actual data, average scale scores for Support Providers with a user capacity of 10

individuals or fewer were lower than those of Support Providers with a user capacity of 11 individuals

or more in all domains (Fig. 1). The difference in Domain E, which involves services after entry into the

workforce, in particular was marked.

(2) The effects of the average duration of program usage

A short duration of program usage indicates that users have soon developed the desire to work.

Thus, Support Providers with a short duration of program usage would be more effective at program

implementation.

Comparing actual scale scores indicated that Support Providers with a short average duration of

program usage had high scale scores in all domains (Fig. 2).

Fig. 2 Average scale scores on the fidelity scale by duration of usage

2.26 

2.09 

2.05 

2.53 

2.55 

2.45 

2.53 

2.47 

2.41 

2.73 

2.66 

2.64 

1.0  1.5  2.0  2.5  3.0 

All

Domain E

Domain D

Domain C

Domain B

Domain A

Shorter than 1.5 yrs

Longer than 1.5 yrs

68

(3) The effects of parallel programs

Most of the Support Providers studied offered some form of parallel program. The 4 most prevalent

of these programs were: a Type B (non-contracted work) continuous employment support program, a

counseling and support program that can serve as a point of contact for users, an employment and living

support center for persons with disabilities that can serve as a local base for services, and a job coaching

program, which is considered to be a critical form of support after entry into the workforce. The scale

scores in individual domains were compared for these 4 programs.

When a Type B (non-contracted work) continuous employment support program is offered as a parallel

program, the scale score was lower than when it was not offered in parallel. In regard to the other 3

programs, Support Providers with parallel programs had higher scale scores.

The average scale scores were compared for Support Providers with parallel programs. A Type B (non-

contracted work) continuous employment support program resulted in the lowest scale scores in all of the

domains. A counseling and support program resulted in a relatively high scale score in Domain B, which

includes publicity efforts and tended to result in somewhat higher scores in other domains as well. In

addition, an employment and living support center program for persons with disabilities resulted in the

highest score in Domain A, which indicates The Organization Providing Services, and resulted in rather

high scale scores in other domains as well. A job coaching program resulted in high scale scores overall.

It resulted in higher scale scores in Domains C, D, and E, which are directly affected by support, than did

other parallel programs (Fig. 3).

These results indicate that programs offered in parallel by the same entity also affect the employment

transition support program for persons with disabilities.

Fig. 3 Average scale scores on the fidelity scale in terms of parallel programs

2.31

2.16

2.13

2.55

2.54

2.48

2.39

2.30

2.22

2.63

2.64

2.57

2.46

2.35

2.32

2.73

2.65

2.69

2.52

2.48

2.36

2.75

2.61

2.66

1.0 1.5 2.0 2.5 3.0

All

Domain E

Domain D

Domain C

Domain B

Domain A

Job coaching program

Employment and living support center program for persons with disabilities

Counseling and support program

Type B continuous employment support program for persons with disabilities

69

IV. Discussion

1. Validity of an effective model of program implementationAn effective model of program implementation constructed through collaboration between program

implementers and researchers has a certain degree of validity because of the way in which it was

established. In addition, measurement of its performance primarily via the employment transition rate

also demonstrated the effectiveness of program implementation in accordance with this model.

Specifically, Support Providers with an annually calculated employment transition rate during the

survey period of over 20% had average scale scores substantially exceeded those of Support Providers

with no persons with disabilities who were entering the workforce from April-December 2008. This was

true in Domain E, which primarily involved support after entry into the workforce, and similar trends were

noted in all of the domains, assuring the validity of this effective model of program implementation (Fig. 4).

In addition, Support Providers with a relatively short duration of program usage had high average scale

scores for all items, so this effective model of program implementation can be deemed to be consistent

with the original goals of the program in the sense of achieving entry into the workforce, which is what

users want (Fig. 2).

Thus, the validity of this effective model of program implementation and its critical ingredients is

assured.

Fig. 4 Average scale scores on the fidelity scale by the employment transition rate

2.08 

1.73 

1.87 

2.40 

2.47 

2.34 

2.56 

2.61 

2.42 

2.78 

2.65 

2.68 

1.0  1.5  2.0  2.5  3.0 

All

Domain E

Domain D

Domain C

Domain B

Domain A

20% or higher 

none

2. Improvement in average scores on the fidelity scaleResults of this study have indicated the validity of this effective model of program implementation with

regard to the employment transition support program for persons with disabilities. Thus, improvements

70

in average scores on the fidelity scale must be examined based on results of other studies. Having

specifically examined the bottom 5 items in terms of average scale scores, the current work will examine

improvements in the average scale scores for each domain.

Items with low average scale scores were items D8, D4, E4, D6, and A4. Items D8 and D4 can be

classified as items directly related to support with an eye towards entry into the workforce while items

E4, D6, and A4 can be classified as items required for liaison with other organizations, like obtaining

workplace information.

Item D8 asked about the results of employment transition support, and this item is likely to be

improved as a result of a review of support systems overall. Item D4 involved apprenticeships and trial

employment, so this item will be readily affected by changes in the employment transition rate. Thus,

program orientation must be reviewed from a long-term perspective. Actual survey results also indicated

that about 40% of Support Providers had no persons with disabilities who were entering the workforce,

and items D8 and D4 corroborate this finding.

Items E4, D6, and A4 will now be examined. Item E4 involved network-building to maintain quality

of life after one’s entry into the workforce and is an essential ingredient to a stable career. Responses

from Support Providers with no persons with disabilities who were entering the workforce from April-

December 2008 may have affected this item, but a network must be constructed prior to employment

transition. Item D6 indicated the difficulty of job placement. This item was affected by both the lack of

adequate network-building primarily in the form of Hello Work (public employment offices) and external

factors such as a lack of privately owned support providers to cultivate depending on the region. Item

A4 indicated that liaison with networks to sustain quality of life was lacking when programs had to

specialize in employment transition. Issues common to these 3 items were the lack of adequate sharing of

information and network-building in regions. As an example, information on job placement is often not

shared with other support providers offering the same program. In addition, small-scale support providers

lack the sheer number of staff members and are unable to allocate time to network-building. As a result,

information is likely to be concentrated in large-scale support providers and support providers offering

other programs in parallel. Personnel assignment criteria are based on laws and ordinances, and Support

Providers often are unable to make improvements themselves. These points were noted in the comments

and indicate the limitations of a model based on laws and ordinances.

An orientation towards improving average scale scores on the fidelity scale indicated the effectiveness

of parallel programs offered by the same entity. As an example, Support Providers that used a job

coaching program had average scale scores in Domains C to E that substantially exceeded the average. In

addition, a counseling and support program resulted in higher average scale scores for Domain B, which

involved publicity efforts and acceptance. Offering an employment and living support center program for

persons with disabilities (such centers are considered to have a wealth of information) in parallel led to

high scale scores for each item. Conversely, average scale scores tended to decrease when a Type B (non-

contracted work) continuous employment support program, which is not predicated on an employment

contract, was offered in parallel. The extent of a user’s disability and factors such as regional differences

must be taken into account, but a Type B (non-contracted work) continuous employment support program

71

cannot readily coexist with a program that has an employment transition to open employment as its goal.

Given these facts, construction of regional networks and sharing of information will lead to

improvements in average scale scores on the fidelity scale. In addition, parallel programs differ in

effectiveness depending on their nature but can be considered effective when predicated on employment

transition. Whether or not personnel assignment criteria as stipulated by laws and ordinances are

appropriate must also be reexamined.

3. Formulation and assessment approaches using the Nationwide Survey of Support Providers

This study used the Nationwide Survey of Support Providers to examine examples of model

formulation and assessment approaches based on the example of the employment transition support

program for persons with disabilities. This survey allowed the validity of an effective model of program

implementation to be ascertained and it allowed the current status of the aforementioned program to be

ascertained. In particular, this survey indicated that an effective model of program implementation will

help to improve the employment transition rate, which is a major issue with the program, and this survey

allowed the closer examination of program orientation with an eye towards specific improvements. As a

result of analyzing changes in average scores on the fidelity scale by individual efforts, the effects of those

efforts on program implementation can be measured. Thus, measuring a program’s effects using a fidelity

scale can also be used to verify models of effective implementation of other programs.

There were other anticipated benefits of conducting the Nationwide Survey of Support Providers.

These were that the Nationwide Survey of Support Providers allowed many program implementers to

determine an effective model of program implementation and that the survey provided an opportunity

for program implementers to reaffirm their own practices, e.g. pros and cons of the models of effective

implementation. Survey responses took some time but represented less of a burden to sites of program

implementation in comparison to observation of other sites of program implementation or participation

in training workshops. Thus, the survey was particularly effective for Support Providers with substantial

time constraints. Another major benefit was the ability to provide research results to Support Providers

throughout the country as a result of their completion of the survey form. The survey form featured a

number of research results, allowing the systematic provision of information. A benefit for researchers

was the fact that responses from numerous program implementers facilitated the obtaining of information

needed to restructure this effective model of program implementation. Program assessment requires

collaboration with program implementers, so increasing the exchange of information between program

implementers and researchers is crucial.

4. Topics for the futureAs indicated, methods of model formulation and assessment using the Nationwide Survey of Support

Providers are effective, but several issues remain at this point. First is the process by which an effective

model of program implementation is constructed. The effective model of program implementation

used in this study was originally devised based on theories of program assessment and has been revised

72

in conjunction with program implementers. This study began by using an effective model of program

implementation that had already been constructed, but cooperation by numerous program implementers

and researchers was needed to construct this model. The model had to be constructed using appropriate

techniques and studied repeatedly in order for the Nationwide Survey of Support Providers to be effective.

The current model represents the fruits of about 2 years of research and it proved effective. Second is

the difficulty of applying the model to programs that do not have a consistent format. As an example,

support systems and intended users may change when systems are run by prefectural and city governments

and municipalities even if programs are pursuant to the same laws and ordinances. This issue can be

overcome by adequately determining the evaluability of a program beforehand. Third is the difficulty of

applying the current technique to programs that are highly unique and rooted in the community. In such

instances, efforts in the community must be assessed by assembling case studies. Fourth, there was no

weighting by item or ingredient in the Implementation Survey conducted in this study; the inability to

emphasize particularly important forms of support is an issue worthy of note. However, the current survey

content has been improved through the development of a fidelity scale with weighting4). Fifth and last are

the budgetary constraints on all research. In some instances a survey of all support providers nationwide

would be difficult. Carefully scrutinizing prerequisites in terms of the region, program scale, and the like

will allow effective model formulation and assessment even on a small scale, and the same technique can

be used to resolve Issues 2 and 3.

V. Conclusion

Results of the Nationwide Survey of Support Providers conducted in this study were closely

examined, and methods of improving those results were studied. Results indicated that the Nationwide

Survey of Support Providers is an effective approach to construction of an effective model of program

implementation. In addition, the Nationwide Survey of Support Providers was also effective as a means

of promulgating or sharing research results. Some issues remain at this point, but all of these issues can

be remedied. Several have already been remedied and revised to take advantage of the lessons learned.

Collaboration with a greater number of program implementers is required to improve the accuracy of

this research. When there are various constraints, however, opportunities must be provided for program

implementers and researchers to disseminate information. The Nationwide Survey of Support Providers

was effective a means of accurately ascertaining current conditions at a range of sites of program

implementation and the survey will allow the construction of better program models.

This study was conducted with a 2008 research grant for joint research at the Japan College of Social

Work. In addition, an effective program model of the employment transition support program for persons

with disabilities was constructed by our research group on the basis of a Ministry of Education, Culture,

Sports, Science, and Technology Research Grant for Basic Research (A) (Topic No. 19203029) (Principal

Investigator: Iwao Oshima) and served as the basis for the Survey on Implementation of Critical Program

73

Ingredients in this study. The authors wish to express their thanks to all of the Support Providers who

responded to the surveys for their numerous notes and encouragement.

Note

1) Koukanoagaru-Syurouikoushien-Program-no-Arikata-kenkyukai(2009)

2) Oshima, I., et al. (2010). kosaza, N., Oshima, I., Domyo, A., et al. (2010)

3) Koukanoagaru-Syurouikoushien-Program-no-Arikata-kenkyukai(2009)

4) Koukanoagaru-Seishinsyogaisyataiinsokushienjigyo-Syurouikoushienjigyo-Monitoring-System-no-

kaihatsukenkyukai(2010)

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Weiss, C. H., (1997). Evaluation -2nd ed. Prentice Hall.

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75

Contributors

Hirokazu MurakawaProfessor Japan College of Social Work

Takashi FujiokaProfessorJapan College of Social Work

Miyuki MurataLecturerKyoei University

Noriyasu Kosazaproject ResearcherJapan College of Social Work

Kaori YasumuraCoordinatorWork Support Center Shinjuku

Iwao OshimaProfessorJapan College of Social Work

Hisao SatoProfessorJapan College of Social Work

“Journal of Social Policy and Social Work”Edition Guidance

1. The document discussed in this guidance is named "Journal of Social Policy and Social Work", an English journal published by the Japan College of Social Work. It shall be published annually on or around March 1st.

2. Contributors to the "Journal of Social Policy and Social Work" shall be basically researchers and educators of the Japan College of Social Work and guest professors of the Social Work Research Institute. When co-authoring a paper, a researcher or education member shall be the primary author. Contribution of an overseas researcher may be requested if the administration committee admits the need.

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