Japanese Long-term Care Insurance Research Articles

The development of a scale for social participation among community-dwelling frail older adults: a preliminary survey.

The aim of our study was to draft a scale measuring the social participation of community-dwelling frail older adults. A questionnaire consisting of 37 items was prepared based on the findings of previous studies. We recruited community-dwelling older adults ≥65 years of age living in Mitaka City, Tokyo. The inclusion criteria were as follows: native speakers of Japanese; not being covered as support and care level; support level 1; support level 2; care level 1; and care level 2. In total, 328 individuals were investigated. The selected individuals were categorized into the following six groups, according to a Japanese frailty scale and the Japanese Long-term Care Insurance System: non-frail, frail and at high-risk of requiring long-term care, support level 1, support level 2, care level 1, and care level 2. We then randomly selected individuals adjusted for age and gender in each group. The Rasch model was used to select items and to examine the validity. Cronbach's α was calculated to examine reliability. We analyzed 170 subjects. Of the 37 items, 22 were considered based on the Rasch model for inclusion in a draft scale of social participation. The Cronbach's α for these items ranged from 0.86-0.87. We conducted a preliminary survey to develop a scale describing social participation among community-dwelling frail older adults. The construct validity and reliability were adequate for this scale. Based on the findings of this preliminary survey, we will investigate a larger sample size to enhance the scale.

Effects of an Updated Preventive Home Visit Program Based on a Systematic Structured Assessment of Care Needs for Ambulatory Frail Older Adults in Japan: A Randomized Controlled Trial.

The aim of this randomized controlled trial was to determine the effects on functional parameters of an updated preventive home visit program for frail older adults in the Japanese Long-term Care Insurance (LTCI) system. The program included home visits by nurses or care managers every 3 months for 24 months, with a systematic assessment of care needs to prevent functional decline. Eligible participants (N = 360) were randomly assigned to the visit (VG: n = 179) or control group (CG: n = 181). Functional parameters were gathered via mail questionnaires at baseline and at 12- and 24-month follow-ups. Care-need levels in the LTCI were obtained at 12-, 24-, and 36-month follow-ups and the utilization of the LTCI service through 36 months. Participants in VG were significantly more likely to maintain their activities of daily living (ADL) functioning (p = .0113) and less likely to increase care-needs level, compared with CG participants, over 24 months. A generalized linear model showed that the estimate of the effect on increase in care-needs level (ie, functional decline) was -0.53 (p = .042) over 36 months. These results suggest that the updated preventive home visit program could be effective for the prevention of ADL and care-needs deterioration, and these effects could continue up to 1 year after program completion.

Gatekeeper incentives and demand inducement: An empirical analysis of care managers in the Japanese long-term care insurance program

This study analyzes the incentives and supplier-induced demand of care managers, who are intermediaries between consumers and service providers in the Japanese social insurance program for long-term care. Care managers can be considered as pure gatekeepers, in that their function is limited to referral people to specialists and they themselves do not provide care. Care managers are rewarded by capitation, which is considered as a cost-effective payment mechanism for insurers. However, many care managers actually work for firms that also operate as service providers. Service providers are rewarded by a fee-for-service payment and can have a motivation to induce excess consumer demand. The violation of the neutrality of care managers might result in a financial burden on social insurance. In this study, we empirically test whether there is a positive correlation between care manager density and care costs, which might imply the existence of supplier-induced demand. Our results show a positive correlation, particularly in the case of care managers who work for firms that jointly operate in service provision sectors. Based on these results, we conduct a quantitative analysis, and show that the demand induced by care managers might produce a considerable financial burden on social insurance.

Long-Term Care Policy: Singapore’s Experience

ABSTRACTSingapore, like many developed countries, is facing the challenge of a rapidly aging population and the increasing need to provide long-term care (LTC) services for elderly in the community. The Singapore government’s philosophy on care for the elderly is that the family should be the first line of support, and it has relied on voluntary welfare organizations (VWOs) or charities for the bulk of LTC service provision. For LTC financing, it has emphasized the principles of co-payment and targeting of state support to the low-income population through means-tested government subsidies. It has also instituted ElderShield, a national severe disability insurance scheme. This paper discusses some of the challenges facing LTC policy in Singapore, particularly the presence of perverse financial incentives for hospitalization, the pitfalls of over-reliance on VWOs, and the challenges facing informal family caregivers. It discusses the role of private LTC insurance in LTC financing, bearing in mind demand- and supply-side failures that have plagued the private LTC insurance market. It suggests the need for more standardized needs assessment and portable LTC benefits, with reference to the Japanese Long-Term Care Insurance program, and also discusses the need to provide more support to informal family caregivers.

The Reform of the Japanese Long-term Care Insurance System and Resulting Changes in the Context of Daily Living Support for Older People --from its 2000 intoroduction to 2014 reform--

The Reform of the Japanese Long-term Care Insurance System and Resulting Changes in the Context of Daily Living Support for Older People --from its 2000 intoroduction to 2014 reform--

Combined Effect of Slow Gait Speed and Depressive Symptoms on Incident Disability in Older Adults

ObjectivesTo elucidate whether a combination of slow gait speed and depressive symptoms result in higher risk of incident disability in older adults than either symptom individually. DesignProspective cohort study. SettingObu City, Aichi Prefecture, Japan. ParticipantsParticipants were 4038 older adults (48.7% male, mean age = 71 years) who met the study inclusion criteria. MeasurementsLongitudinal data on incident disability were collected up to 33 months [median 31 months (interquartile range 29–32 months)] after baseline. We monitored monthly incident disability, defined as Japanese long-term care insurance certification for personal support or care. Baseline measurements included covariates for incident disability, gait speed, and the Geriatric Depression Scale for assessing depressive symptoms. The associations between slow gait, depressive symptoms, or their co-occurrence, and incident disability were examined. ResultsControl participants were the reference in an adjusted Cox proportional hazard regression model. Participants with co-occurring slow gait and depressive symptoms showed a greater risk of incident disability [hazard ratio (HR) 3.08, confidence interval (CI) 95% 2.00–4.75]. Greater risk was also found for participants with slow gait speed alone (HR 2.44, CI 95% 1.71–3.47) and depressive symptoms alone (HR 1.60, CI 95% 1.01–2.53). ConclusionsOlder adults with both risk factors may require early detection and physical and psychological intervention.

Gatekeeper Incentives and Demand Inducement: An Empirical Analysis of Care Managers in the Japanese Long-Term Care Insurance Program

This study analyzes the incentives and supplier-induced demand of care managers, who are intermediaries between consumers and service providers in the Japanese social insurance program for long-term care. Care managers can be considered as pure gatekeepers in that their function is limited to referral people to specialists and they themselves do not provide care. Care managers are rewarded by capitation, which is considered as a cost-effective payment mechanism for insurers. However, many care managers actually work for firms that also operate as service providers. Service providers are rewarded by a fee-for-service payment and can have a motivation to induce excess consumer demand. The violation of the neutrality of care managers might result in a financial burden on social insurance. In this study, we empirically test whether there is a positive correlation between care manager density and care costs, which might imply the existence of supplier-induced demand. Our results show a positive correlation, particularly in the case of care managers who work for firms that jointly operate in service provision sectors. Based on these results, we conduct a quantitative analysis, and show that the demand induced by care managers might produce a considerable financial burden on social insurance.

グループホームの建物特性が骨折に及ぼす影響<br>その１ 転倒・転落骨折数の分析を通して

Data about the incidence of fractures in group homes for the elderly with dementia at 937 facilities was analysed on following aspects. 1) Per 100 residents per year, 60.0 residents had experienced a high fall, 9.7 had experienced a low-height fall, 4.3 had broken a bone during a high fall, and 0.3 had broken a bone during a low-height fall. 2) A meaningful decrease in fractures was found where average of residents' care level was ranked “over 3” in Japanese Long-term Care Insurance than ranked “over2 and under3”. 3) Comparing the rate of fracture, reinforced concrete structures with hard finished floor have a meaningfully greater rate of fall-related fractures than steel structures and reinforced concrete with shock absorbing materials under floor, and that steel reinforced concrete structures have a greater rate of fractures than do steel structures.

在宅要介護高齢者における2.4 m歩行時間と運動機能とFunctional Independence Measureの関係

在宅要介護高齢者における2.4 m歩行時間と運動機能とFunctional Independence Measureの関係

Can formal elderly care stimulate female labor supply? The Japanese experience

This study analyzes the impacts of the Japanese Long-Term Care Insurance (LTCI), a decade after its launch, with respect to the female labor supply in Japan. The radical program has caused the emergence of markets for various care services apart from permanent institutional care, which is only a major formal care sector in many developed countries. The availability of various formal care services can stimulate female labor supply through a reduction of the burden of informal caregiving. To investigate the impacts of the LTCI, we compare the labor market behavior of females who face requirements for elderly care in their household for three periods—before the launch of the LTCI, four years after the launch, and ten years after the launch. Our empirical analysis indicates positive effects of the launch and diffusion of the LTCI on female labor supply. As a result of the LTCI, care for male elders is no longer an obstacle for female labor supply, but care for female elders is still burdensome. We also find that the care requirement reduces the probability of being a regular worker; however, regular workers are more likely to utilize formal care, whereas many nonregular workers provide informal care by themselves.

Assessing the quality and effectiveness of an updated preventive home visit programme for ambulatory frail older Japanese people: research protocol for a randomized controlled trial

To describe the programme and research protocol of our updated preventive home visit programme for ambulatory frail older adults in the Japanese Long-Term Care Insurance system. Our previous trials have shown that the nature of recommendations during preventive home visits is a key issue. The present programme has updated our previous one by including a unique structured assessment with treatment recommendations tied to an ongoing programme for quality assurance. A randomized, controlled trial. Eligible participants (n=360) will be randomly assigned to home visit (n=179) and control (n=181) groups in three suburban municipalities. Nurses provide recommendations based on structured assessments to participants in visit group every 3months from September 2011-October 2013. The primary outcomes are parameters related to quality of life, including activities of daily living, instrumental activities of daily living, depression, cognitive capacity, daily-life satisfaction and self-efficacy for health promotion; these are collected by mail at baseline, 12 and 24months. The secondary outcome is long-term care use over the study period. To evaluate the visit process, we are qualitatively analysing documentation data from the assessment sheet and chart. This study is collecting and analysing evidence regarding the process and outcomes of preventive home visits based on structured care-need assessments. The study protocol was registered for the UMIN clinical registry approved by ICMJE (No. UMIN000006463, October 04, 2011).

Factors associated with the level of disability in elderly adults based on the Japanese long-term care insurance system.

The aim of this study was to identify factors associated with the level of disability in elderly adults based on the Japanese long-term care insurance system. The participants included 3,198 frail elderly subjects (mean age: 82.0±6.45). The slightly disabled group, with a support level in the long-term care insurance system, comprised 1,129 elderly adults, and the moderately disabled group, with a care level of 1 or 2 in the long-term care insurance system, comprised 2,208 elderly adults who received day-care services. The following parameters were evaluated: grip strength, chair stand test 5-times (CST), one-leg standing with eyes open (OLS), timed "up & go" (TUG), walking speed, the mental status questionnaire (MSQ) score and functional independence measures (FIM). The participants were categorized into two groups based on the 13 motor subscales of the FIM (FIM-M): the activity of daily living (ADL) independent group, who scored 6 points or higher on all ADL measurements, and the ADL care need group, who scored 5 points or under on at least one item in all ADL measurements. A multiple logistic regression analysis was used to examine the relationships between the long-term care insurance level and the potential correlates. The multiple logistic regression model indicated that gender, grip strength and the MSQ and FIM-M scores were significantly associated with the long-term care insurance level (p<0.05). The FIM-M score exhibited a particularly strong correlation with the type of long-term care required (odds ratio: 2.47, 95% confidence interval: 1.89-3.24). The Japanese long-term care insurance level is associated with physical performance, the cognitive function and the ability to perform ADL's. These results suggest that comprehensive assessments are useful for understanding the impact of the long-term care insurance level in elderly adults.

The Role of Public Health Nurses in Japanese Long-term Care Prevention Projects in the Community

As the frontrunner of ageing countries, we would like to introduce the role of public health nurses in Japanese long-term care prevention projects in the community and our research on healthy longevity in this review article. Previous studies in Japan reported that lack of participation in social activities was significantly related to an increased risk to suffer from disability and subsequently requiring the application of Japanese long-term care insurance. As for primary/secondary prevention for old populations, public health nurses are expected to develop and utilize the social capital in health promotion interventions at individual and community levels in Japan. Since 2006, long-term care insurance was revised focusing on preventive care by detecting people aged 65 years and older who are at high risk of needing future care or support. There will be increasing demand for health care professionals to promote a community's overall health status in cost-effective ways, and public health nurses should play an important role to make it.

Impact of Initial Conservative Treatment Interventions on the Outcomes of Patients With Osteoporotic Vertebral Fractures

Prospective multicenter study. To examine whether initial conservative treatment interventions for osteoporotic vertebral fractures (OVF) influence patient outcomes. OVFs have been described as stable spinal injuries and, in most cases, are managed well with conservative treatment. However, systematic treatments for OVF have not been clearly established. A total of 362 patients with OVF (59 males and 303 females; mean age, 76.3 yr) from 25 institutes were enrolled in this clinical study. All the patients were treated conservatively without any surgical interventions. The patient outcomes were evaluated 6 months after the fractures on the basis of Short Form-36 (SF-36) physical component summary (PCS) and mental component summary (MCS), activities of daily living (the Japanese long-term care insurance system), back pain (visual analogue scale), cognitive status (mini-mental state examination), and vertebral collapse, which were used as response variables. Furthermore, brace type, hospitalization, bisphosphonates after injury, and painkillers after injury were explanatory variables for the treatment interventions. To evaluate the independent effects of treatment interventions on patient outcomes, we performed multivariate logistic regression analyses and obtained odds ratios that were adjusted for the potential confounding effects of age, sex, level of fracture, presence of middle-column injury, pain visual analogue scale at enrollment, mini-mental state examination score at enrollment, and previous use of steroids. There was no significant difference for treatment intervention factors including brace type, hospitalization, bisphosphonates after injury, and painkillers after injury. For adjusting factors, the presence of middle-column injury was significantly associated with SF-36 PCS ≤ 40, reduced activities of daily living, prolonged back pain, and vertebral collapse. Female sex and advanced age were associated with SF-36 PCS ≤ 40. Low mini-mental state examination scores at enrollment were associated with SF-36 PCS ≤ 40 and reduced activities of daily living. The previous use of steroids was associated with SF-36 MCS ≤ 40, prolonged back pain, and vertebral collapse. No other examined variables were significant risk factors for patient outcomes. These results showed that treatment intervention factors did not affect patient outcomes 6 months after OVF. Middle-column injury was a significant risk factor for both clinical and radiological outcomes. In the future, establishing systematic treatments for cases with middle-column injuries is needed. 2.

Care for Alzheimer's Disease

Cognitive impairment due to dementia deprives those afflicted with the disease of their autonomy and ability to take care of themselves, making them dependent on care provided by formal and informal resources. Moreover, as the disease progresses, behavioral and psychological symptoms of dementia (BPSD) may occur. BPSD are often troublesome to both caregivers and the patients themselves. The care burden is often heavy and disrupts the lives of family members surrounding the patient. Early screening and identification of cognitive decline will help those with the disease and family members prepare for better care and may reduce the patients' BPSD. Effective screening for dementia, which can be administered at ambulatory care facilities, is warranted. Vascular risk factors, especially type 2 diabetes mellitus, have been found to increase the risk of developing Alzheimer's disease (AD). The prevalence of type 2 diabetes mellitus is increasing in Japan. In this special issue, T. Matsuzawa et al. describe an index for screening for mild or moderate AD cases among the elderly with type 2 diabetes mellitus. The index includes self-reported answers to a questionnaire regarding subjective memory complaints and daily functioning and information on vascular risk factors obtained from clinical charts. The index had satisfactory discriminatory ability to identify those with AD among patients with diabetes. This may contribute to an effective screening for AD among those with diabetes, that is, known high-risk populations. Current treatments for AD are limited to alleviating symptoms, but not reversing the pathological progress. Pharmacological treatments for BPSD, which are critical for the well-being of both patients and caregivers, are also limited in their effectiveness. The study by H. Fukui et al. examines changes in sex hormones associated with the pathogenesis of AD before and after music therapy among patients with AD. They show that music therapy modified the secretion of sex hormones, and the results also suggest that problematic behavior may be reduced this way. The therapy has the potential to become a safe alternative treatment that is as effective as hormone replacement, but with fewer side effects. The underlying biological mechanism of effects shown in this study is convincing and a welcome addition to the field. The number of those suffering from dementia is increasing worldwide. Effective caregiving strategies and targeted care management programs are urgently needed to enhance the well-being of those with AD and their caregivers. T. Passos et al. examined the met and unmet needs of the elderly with mental health problems and their care in Portugal. The main unmet needs identified were daytime activities, social benefits, company, psychological distress, and incontinence. Some of these unmet needs may be universal across countries worldwide, but others may differ depending on specific health care systems and cultures. A comparison with similar surveys in other countries may help identify common unmet needs for patients and caregivers. M. M. Poysti et al. compare the characteristics and burdens of male and female spousal caregivers of patients with dementia in Finland. This is an important issue because the proportion of male caregivers is rapidly increasing in many countries. In the study, male caregivers experienced a lower burden than female caregivers even though female caregivers were responsible for more severe cases. The finding should be confirmed, and the reasons behind it should be explored further, so that factors that may reduce high caregiver burden can be identified. Finally, the economic and social costs for caring of the demented are of significant importance as the at-risk population grows rapidly around the globe. Japan has one of the fastest growing elderly populations, and in 2000 it launched a new public long-term care insurance system [1]. S. Shinagawa et al. report that the requisite costs in the Japanese long-term care insurance are different between AD and vascular dementia (VD). In this special issue, we highlight several important themes in the care for dementia. We hope that the results presented contribute to developing and providing better care of the demented and increase awareness of the importance of international studies of dementia caregiver issues. Hiroyuki Umegaki Hajime Takechi Hiroko H. Dodge

Predictors for Increasing Eligibility Level among Home Help Service Users in the Japanese Long-Term Care Insurance System

Objectives. This cross-sectional study described the prevalence of possible risk factors for increasing eligibility level of long-term care insurance in home help service users who were certified as support level 1-2 or care level 1-2 in Japan. Methods. Data were collected from October 2011 to November 2011. Variables included eligibility level, grip strength, calf circumference (CC), functional limitations, body mass index, memory impairment, depression, social support, and nutrition status. Results. A total of 417 subjects (109 males and 308 females, mean age 83 years) were examined. There were 109 subjects with memory impairment. When divided by cut-off values, care level 2 was found to have higher prevalence of low grip strength, low CC, and depression. Conclusions. Some potentially modifiable factors such as muscle strength could be the risk factors for increasing eligibility level.

Models for Designing Long-Term Care Service Plans and Care Programs for Older People

The establishment of a system for providing appropriate long-term care services for older people is a national issue in Japan, and it will likely become a worldwide issue in the years to come. Under Japanese Long-term Care Insurance System, long-term care is provided based on long-term care programs, which were designed by care providers on the basis of long-term care service plans, which were designed by care managers. However, defined methodology for designing long-term care service plans and care programs has not been established yet. In this paper, we propose models for designing long-term care service plans and care programs for older people, both by incorporating the technical issues from previous studies and by redesigning the total methodology according to these studies. Our implementation model consists of “Function,” “Knowledge Structure,” and “Action Flow.” In addition, we developed the concrete knowledgebases based on the Knowledge Structure by visualizing, summarizing, and structuring the inherent knowledge of healthcare/welfare professionals. As the results of the workshop and retrospective verification, the adequacy of the models was suggested, while some further issues were pointed. Our models, knowledgebases, and application make it possible to ensure the quality of long-term care for older people.

Prognostic Factors for Reduction of Activities of Daily Living Following Osteoporotic Vertebral Fractures

Prospective cohort study. To elucidate the prognostic factors indicating reduced activities of daily living (ADL) at the time of the 6-month follow-up after osteoporotic vertebral fracture (OVF). OVF has severe effects on ADL and quality of life (QOL) in elderly patients and leads to long-term deteriorations in physical condition. Many patients recover ADL with acceleration of bony union and spinal stability, but some experience impaired ADL even months after fracture. Identifying factors predicting reduced ADL after OVF may prove valuable. Subjects in this prospective study comprised 310 OVF patients from 25 institutes. All patients were treated conservatively without surgery. Pain, ADL, QOL, and other factors were evaluated on enrollment and at 6 months. ADL were evaluated using the criteria of the Japanese long-term care insurance system to evaluate the degree of independence. We defined reduced ADL as a reduction of at least single grade at 6 months after fracture and investigated factors predicting reduced ADL after OVF, using uni- and multivariate regression analysis. ADL were reduced at 6 months after OVF in 66 of 310 patients (21.3%). In univariate analysis, age more than 75 years (P = 0.044), female sex (P = 0.041), 2 or more previous spine fractures (P = 0.009), presence of middle column injury (P = 0.021), and lack of regular exercise before fracture (P = 0.001) were significantly associated with reduced ADL. In multivariate analysis, presence of middle column injury (odds ratio [OR], 2.26; P = 0.022) and lack of regular exercise before fracture (OR, 2.49; P = 0.030) were significantly associated with reduced ADL. These results identified presence of middle column injury of the vertebral body and lack of regular exercise before fracture as prognostic factors for reduced ADL. With clarification and validation, these risk factors may provide crucial tools for determining subsequent OVF treatments. Patients showing these prognostic factors should be observed carefully and treated with more intensive treatment options.

Predictors of eligibility for long‐term care funding for older people in Japan

To determine the predictors of Japanese long-term care insurance system (LTCI) certification. Care needs of 784 persons aged 65-84 were followed through LTCI over 5 years. Each participant's score was divided into quartiles according to handgrip strength and one-leg standing time with eyes open. Cox proportional hazard models were conducted for the onset of certification of LTCI. Over the 5-year period 64 women (14%) and 30 men (9%) were certified. Adjusted hazard ratios for certification were significantly higher for those of the lowest groups of one-leg standing time with eyes open at baseline than those in the highest groups, but no significance was found for handgrip strength. Other predictors were age and low social activity for women; and living alone and diabetes for men. One-leg standing time with eyes open predicts the onset of care-need certification in older people.

Both conventional indices of cognitive function and frailty predict levels of care required in a long‐term care insurance program for memory clinic patients in Japan

To delineate relationships among cognitive function, frailty and level of care required in the Japanese long-term care insurance program (LTCIP) in outpatient memory clinic patients. This was a cross-sectional study carried out at an outpatient memory clinic. Participants were 201 cognitively impaired patients. Cognitive function was measured by the Mini-Mental State Examination (MMSE). Frailty was measured by Timed Up & Go (TUG) and grip strength. Waist circumference, body mass index, living arrangement and level of care required in the LTCIP (rank 1 minor disability to rank 7 severe disability) were also assessed. Mean age, MMSE score, TUG score and grip strength were 78.8 ± 6.9 years, 19.6 ± 6.1, 14.6 ± 6.7 s and 16.9 ± 7.5 kg, respectively. A total of 70 patients (34.8%) had not applied for the certification, at least in part because of their younger age and existence of family caregivers. LTCIP rank was correlated both with MMSE score (β: -0.49, P = 0.001), grip strength (β: -0.27, P = 0.005) and living alone (β: -0.18, P = 0.03), but not with TUG score (β: 0.14, P = 0.105). In outpatients of a memory clinic, care ranks, which define the upper limit of monthly benefit in the Japanese LTCIP, were influenced by age, cognitive function, frailty and living arrangements. Understanding the relationship among these parameters would be useful in predicting the needs of cognitively impaired patients and important when comparing the possible services provided by long-term care systems for them worldwide.