Long-term Care Insurance Services Research Articles

Individual and regional determinants of long-term care expenditure in Japan: evidence from national long-term care claims.

BackgroundJapan, with the oldest population in the world, faces a financial challenge caused by rising long-term care (LTC) expenditure. For policymakers to address this, it is important that we have a better understanding of how individual and regional characteristics affect LTC expenditure.MethodsWe linked national LTC insurance (LTCI) claim data, covering the entire population who used LTCI services in Japan, with municipality data on an individual level. Individuals 65 years and older (n=3 876 068) who had used LTCI benefits at least once in the fiscal year (FY) 2016 were included. We examined the associations of individual and municipality characteristics regarding supply and demand of healthcare with the LTC expenditures on facility care, home and community care, and total care (the sum of both types of care), after adjusting for regional differences in LTC extra charges.ResultsThe following variables were associated with higher total expenditure; at the individual level: female, a higher care-need level, a lower income (0% co-payments) or a facility service user; at the municipality level: municipalities locating in metropolitan areas, with a higher proportion of single elderly households, more doctors per 1000 citizens, more nursing homes per 100 000 LTC benefit users or more outpatient medical spending per citizen ≥75 years old.ConclusionsAs we are able to identify several individual and municipality characteristics associated with higher LTC expenditure in Japan, the study offers insights into dealing with the rapidly growing LTC expenditure.

Potentially Avoidable Hospitalization among Long-Term Care Insurance Beneficiaries with Dementia.

BackgroundThis study investigated the differences in the risk of potentially avoidable hospitalization (PAH) among eligible long-term care insurance (LTCI) beneficiaries with dementia for LTCI services in Korea. Nested case-control study was conducted using the National Health Insurance Service–Senior claim database.MethodsCases of individuals who had a PAH incident diagnosis and controls were selected by incidence density sampling and matched to cases based on age, sex, and difficulty of daily living among dementia patients. We conducted incidence density sampling three times by PAH type.ResultsOur main results were presented by conditional logistic regression analysis for the matched case–control studies. Out of the 7,352 eligible LTCI beneficiary patients, there were 1,231 cases (16.7%) in overall PAH, 132 cases (19.0%) in acute PAH and 1,114 cases (16.7%) in chronic PAH categories. In terms of individual risk of overall and chronic PAH, the odds ratios of those who did not receive any services were 1.336 time higher (95% confidence interval [CI], 1.159–1.540) and 1.280 time higher (95% CI, 1.103–1.485) compared to those who received home care, respectively. For risk of acute PAH, the odds ratios of those who did receive institutional care were 2.046 time higher (95% CI, 1.170–3.578) compared to those who received home care.ConclusionThis study identified the differences in risk of PAH incidents according to the type of LTCI service in the elderly population in Korea. Therefore, it will require substantial effort and strategy from health policy makers to improve care quality.

Clinical characteristics of participants enrolled in an early identification and healthcare management program for dementia based on cluster analysis and the effectiveness of associated support efforts.

Although early identification and management services for dementia have become more widespread, their efficacy and the clinical characteristics of service have yet to be fully evaluated. Therefore, the objective of this study is to clarify these issues. The subjects were 164 Japanese users of an early identification and management program for dementia, known as the Initial-phase Intensive Support Team (IPIST), between 2013 and 2015. Nonhierarchical cluster analysis was used to derive subgroups based on cognitive status and ability in activities of daily living (ADL) and behavioral and psychological symptoms of dementia (BPSD). One-way analysis of variance was performed to evaluate differences among the groups derived by the cluster analysis. A paired t test was used to assess how the clinical status of the groups changed between baseline and follow-up. Four groups were identified by cluster analysis, i.e. a mild group, a moderate group, a BPSD group with moderate cognitive impairment and severe BPSD, and a severe group with severe cognitive impairment and severe BPSD. Although there were no significant improvements in cognitive impairment or ADL in any group, significant improvements were found in BPSD in the BPSD and severe BPSD groups. Caregiver burden was significantly lessened in all groups. Clinical diagnosis and long-term care insurance service utilization rates were significantly improved overall. The users of IPIST were classified into four subgroups based on their clinical characteristics. The IPIST program could improve the quality of life of people with dementia and their caregivers.

Are Self-Reported Masticatory Ability and Regular Dental Care Related to Mortality?

The aim of the study was to examine whether a combination of self-reported masticatory ability and regular dental care is linked to mortality and issuance of new long-term care insurance (LTCI) service certifications. Older residents in institutions or in need of LTCI certification requirements were excluded, and self-administered questionnaires were sent to 5,400 older adults in 2013; these participants were followed for 5 years. The total response rate was 94.3%, and our final sample comprised 4,824 older adults (89.3%). We used 3 items to assess self-reported masticatory ability and regular dental care. These included (1) decline in chewing abilities of the posterior teeth on either side, (2) not brushing one's own teeth or dentures at least once a day, and (3) not visiting the dentist at least once a year. The mean age of the participants at baseline was 75.9 years, and 58.4% of them were women. Main outcomes included mortality (n = 562) or new LTCI certification requirements (n = 1187) during the 5-year period. Multivariate analyses revealed that a poor score on masticatory ability and on regular dental care produced significant adverse health outcomes leading to earlier negative outcomes. The score is considered poor as it increases relative to the 0-point reference. Regular dental care (both self-and professional care) and maintaining masticatory ability are both important. Hence, public activities focusing on preventive oral health from middle age onward is important.

Relationships between Functional Assessment for Control of Trunk (FACT) and Physical Functions in Community-dwelling Elderly Using the Long-term Care Insurance Service

Relationships between Functional Assessment for Control of Trunk (FACT) and Physical Functions in Community-dwelling Elderly Using the Long-term Care Insurance Service

Why Did the Policy to Convert Hospitals Into Facilities Not Work in Japan?

The government of Japan formulated measures to significantly reduce the number of hospital beds for long-term care in 2006. In particular, long-term care hospital beds covered by long-term care insurance (sanatorium medical facilities) were to be abolished in 2012, and existing sanatorium medical facilities were to be converted into long-term care insurance services such as geriatric health services facilities. However, the conversion did not progress in spite of various support measures, and the deadline for abolishment was extended. In order to clarify the reason for this, we selected 28 hospitals with 402 or more long-term care beds and 28 health services facilities with 158 or more beds and examined their management philosophies and analyzed the keywords included. The most popular keyword was “community” in both hospitals and facilities. Hospitals had a significantly higher rate of 60.7% (P< 0.05) of including “trust” or “feeling of relief” in their management philosophies. Facilities had higher rates of including any of the terms “return” or “independence” or “home” (32.1%, P= 0.051), and also of including either “service” or “care” (46.1%, P< 0.05). In conclusion, it is suggested that hospitals with long-term care beds differentiate themselves from neighboring facilities in that they are able to simply accept the situation and be responsible for terminal care whenever inpatients may have difficulty returning home. In addition, it seemed difficult for hospitals to convert into health service facilities, the aim of which is to enable residents to return home.

Self-Reported Cognitive Frailty Predicts Adverse Health Outcomes for Community-Dwelling Older Adults Based on an Analysis of Sex and Age.

The present study examined whether the combination of self-reported mobility decline (SR-MD) and cognitive decline (SR-CD) was associated with mortality and new long-term care insurance (LTCI) service certifications based on sex and age. A prospective cohort study. We analyzed cohort data from a sample of older adult residents in Kami Town, Japan. The response rate was 94.3%, and we followed 5,094 older adults for 3 years. Full analyses were conducted on 5,076 participants. A total of four groups were determined through self-reported responses on the Kihon Checklist for SR-MD (a score of 3 or more on 5 items) and SR-CD (a score of 1 or more on 3 items): non-SR-cognitive frailty, non-SR-MD and SR-CD, SR-MD and non-SR-CD, and SR-cognitive frailty. Main outcomes included mortality (n = 262) or new certifications for LTCI services (n = 708) during the 3-year period. Excluding overlapping, this included 845 older adults (16.6%). Among men, prevalence of non-SR-cognitive frailty, non-SR-MD and SR-CD, SR-MD and non-SR-CD, and SR-cognitive frailty (SR-MD and SR-CD) was 48.2%, 26.4%, 11.5%, and 13.8%, respectively. Respective rates for women were 45.7%, 15.5%, 23.1%, and 15.7%. Multivariate analyses revealed that for men, SR-MD and non-SR-CD significantly affected adverse health outcomes, leading to earlier negative outcomes relative to the non-SR-MD and SR-CD group. For women, non-SR-MD and SR-CD and SR-MD and non-SR-CD had similar slopes. The impact of SR-MD or SR-CD on adverse health outcomes differed as a function of age and sex. Thus, we need to consider preventive approaches according to these specific target group features.

Impact of increased long-term care insurance payments on employment and wages in formal long-term care

This paper examines the effect of raising Long-term care insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

Prevalence of cervical canal stenosis in farmers: Epidemiological study based on radiographic parameter of spinal cord injury patients

BackgroundFarming is one of the effective community activities for preventing the need for new long-term care insurance services. This study was conducted to compare spinal canal diameters between patients injured during orchard work (i.e., cultivating apples) and other situations that lead to cervical spinal cord injury without major fracture or dislocation and to investigate the frequency of cervical spinal canal stenosis among farmers in a Japanese community. MethodsSubjects were 23 patients with cervical spinal cord injury without major fracture and dislocation. Charts and radiographs of these patients were retrospectively reviewed to evaluate the characteristics of the spinal cord injury. The spinal canal diameter at the injury level in the mid-sagittal plane of magnetic resonance imaging (MRI) and mechanism of injury were compared between patients injured by orchard work and other situations. Moreover, 358 Japanese general residents were evaluated for the prevalence of cervical canal stenosis using MRI and comparisons were made between farmers group and non-farmers group. ResultsSpinal canal diameters at the injury level were 5.8 ± 1.4 mm in patients injured during orchard work and 5.6 ± 1.0 mm in those injured in other situations; there were no differences between the two groups. Head contusion as mechanism of injury was more frequent in the orchard work group than in other situations group. Among farmers, the rate of spinal canal stenosis increased with age, and it was 62.3% in men and 66.2% in women. ConclusionsThe frequency of cervical spinal canal stenosis was high with age regardless of farming work. In addition, head contusion might be a characteristic mechanism that causes spinal cord injury during orchard work. Therefore, screening of cervical degenerative conditions among farmers and education for prevention of cervical spinal cord injury during farming work are necessary.

Reduced long-term care cost by social participation among older Japanese adults: a prospective follow-up study in JAGES

ObjectivesReducing costs related to functional disabilities and long-term care (LTC) is necessary in ageing societies. We evaluated the differences in the cumulative cost of public LTC insurance (LTCI) services by...

Impact of Sedentary Time on Chronic Kidney Disease and Disability Incidence in Community-Dwelling Japanese Older Adults: A 4-Year Prospective Cohort Study.

This study examined the association between the estimated glomerular filtration rate (eGFR) and disability incidence according to sedentary time in community-dwelling Japanese older adults. This prospective cohort study sampled 5,104 community-dwelling older adults (≥65 years) enrolled in a health promotion study in a general population. The participants (n = 4,457; ≥65 years) were monitored for inclusion in the long-term care insurance system for 4 years. This study used blood samples to assess eGFR. Cox proportional regression analysis was used to determine predictors of disability. In total, 461 participants (10.3%) became newly certified as needing long-term care insurance services. Cox regression models were adjusted for multiple confounders: eGFR < 45ml/min/1.73m2 (hazard ratio = 1.741, 95% confidence interval [1.193-2.539]) and eGFR < 45ml/min/1.73m2 with high sedentary time (≥8hr) (hazard ratio = 4.367, 95% confidence interval [2.021-9.438]) remained significantly associated with disability incidence. Our findings suggest that in the case of chronic kidney disease, the disability incidence rate may be affected by sedentary time.

Estimation of duration of formal long-term care among frail elderly people in Japanese communities using national long-term care insurance claims records

Objective The aim of this nationwide study was to estimate the duration of formal long-term care, provided by Japanese long-term care insurance (LTCI) services, among frail Japanese elderly people living in the community.Methods The study subjects were 2,188,397 (men: 579,422, women: 1,124,022, age≥65 years) beneficiaries who used LTCI services for community living in June 2013. The duration of LTCI services for community living per diem per capita was estimated by converting the benefit amount to duration of care using the code for service in claims bills according to gender and care levels, which are a nationally certified classification of individual needs for long-term care (care level 1: lowest need, care level 5: highest need). Subsequently, LTCI services for community living were categorized into respite services and community services. Community services were further subcategorized into home visiting services and daycare services.Results The overall average duration of formal care per diem per capita for men and women were 97.4 and 112.7 minutes for care level 1, 118.3 and 149.1 for care level 2, 186.9 and 246.4 for care level 3, 215.2 and 273.2 for care level 4, and 213.1 and 261.4 for care level 5, respectively. Length of respite services increased gradually with care level, whereas duration of community services peaked at care level 3 and decreased at care levels 4 and 5. With regard to the community service subcategories, duration of home visiting services increased with care level, but duration of daycare services peaked at care level 3.Conclusion Although the care levels in the LCTI system are designed to assess the need for formal care in terms of duration of care, our results suggest that the use of formal LTCI services for community living is not vertically equitable. Services that efficiently increase duration of formal care for those with higher needs for care may improve the equity and sustainability of formal long-term care services for community living.

A Current Status of Care Plans for Independent Excretion in Japan’s Long-term Care Insurance Services

A Current Status of Care Plans for Independent Excretion in Japan’s Long-term Care Insurance Services

Impact of Increased Long-Term Care Insurance Payments on Employment and Wages in Formal Long-Term Care

This paper examines the effect of raising Long-term Care Insurance (LTCI) payments on employment and wages of workers in the long-term care (LTC) industry. Specifically, I use the change in the regional premium in 2012 as an exogenous shock to the insurance fee schedule: the change in the unit price of LTCI service ranges from a decrease of 2.8% to an increase of 4.2%. I find no increase in the number of employees in the establishments, registered under the LTCI scheme, in municipalities where the regional premium increased. The earnings and working hours of LTC workers did not increase, either.

Social Frailty Predicts Incident Disability and Mortality Among Community-Dwelling Japanese Older Adults

ObjectiveTo determine the prevalence of social frailty and its relation to incident disability and mortality in community-dwelling Japanese older adults. DesignProspective cohort study. Setting and Participants6603 community-dwelling adults aged 65 years and older who were living independently in a city in Shiga prefecture in 2011. OutcomesThe outcomes were incident disability and mortality. We defined incident disability using new long-term care insurance (LTCI) service requirement certifications, and the follow-up period was 6 years after the mailed survey. MeasurementsThe 4-item social frailty screening questionnaire was developed and included general resources, social resources, social behavior, and fulfillment of basic social needs. We categorized the respondents into 3 groups based on the level of social frailty. Additionally, we assessed physical/psychological frailty by the frailty screening index and other demographic variables. ResultsThe prevalences of social frailty, social prefrailty, and social robust were 18.0%, 32.1%, and 50.0%, respectively. During the 6-year follow-up period, 28.1% of those with social robust, 36.9% of those with social prefrailty, and 48.5% of those with social frailty died or experienced incident disability. Those with social prefrailty [adjusted hazard ratio (HR) 1.28, 95% confidence interval (CI) 1.16-1.41] and social frailty (adjusted HR 1.71, 95% CI 1.54-1.90) had significantly elevated risks for incident disability and mortality based on multivariate analyses that used social robust as the reference. Furthermore, the combination of social frailty and physical/psychological frailty is more likely to result in incident disability and mortality compared to social frailty or physical/psychological frailty alone. Conclusions/ImplicationsCommunity-dwelling older adults with both social frailty and physical/psychological frailty are at higher risk of death or disability over 6 years than are older adults with only one type of frailty or no frailty. Screening and preventive measures for social frailty are suggested for healthy aging.

SUPPORTING CARERS OF COMMUNITY-DWELLING FRAIL OLDER ADULTS: HIDDEN AGENDA IN LONG-TERM CARE SYSTEM IN JAPAN

The establishment of “the Community-based integrated care” is emphasized in the 2017 Long-Term Care Insurance (LTCI) Reform but the role of family carers in the system remains unclear. The purpose of this presentation is to explore how the issue of carers is treated in LTC policies in Japanese political, economic and cultural contexts from Carers’ perspectives. We found that the 2016 Child Care and Family Care Leave Act Reform, the policies to prevent giving up jobs due to caring roles, the 2015 National Dementia Strategy and the LTCI reform have not fully addressed the issue of family carers. The results of our survey on the Community-based integrated care support centers also indicated carers faced various difficulties despite the use of LTCI services. We will argue the societal risk in the increasing burden to carers for the frail older adults and the paradox of “socialization of care” in Japanese LTC model.

Does long-term care insurance reduce the burden of medical costs? A retrospective elderly cohort study.

To examine whether long-term care insurance (LTCI) reduces medical utilization and the burden of medical costs of beneficiaries. The elderly cohort database of the National Health Insurance Service during 2005-2013 was used. The participants were 3029 beneficiaries who received consecutive LTCI services. We carried out a 1:3 case-control match on the propensity score to select a comparison group, and the final participants were 12 116 people, including 9087 who formed the control group. The dependent variables were semi-annually measured medical utilizations (inpatient, outpatient and drug prescription) and the burden of medical costs at the individual level. This study applied the method of generalized estimating equations to the data. The present study showed that the number of hospitalizations of beneficiaries significantly decreased compared with non-beneficiaries (ratio 0.95, 95% CI 0.95-0.96). Similarly, the length of stay of beneficiaries also showed a significant reduction compared with non-beneficiaries (ratio 0.76, 95% CI 0.73-0.79). The number of outpatient visits and receipt of drug prescriptions of beneficiaries and non-beneficiaries increased marginally. The burden of medical costs of beneficiaries reduced considerably compared with non-beneficiaries (ratio 0.80, 95% CI 0.77-0.83). The study results show that the burden of medical costs for LTCI beneficiaries were significantly reduced compared with non-beneficiaries, despite the rise in medical costs among older adults. The positive effect of LTCI supports continuous implementation and expansion of the LTCI service for non-beneficiaries who require care assistance. Geriatr Gerontol Int 2018; 18: 1641-1646.

Day care vs home care: Effects on functional health outcomes among long-term care beneficiaries with dementia in Korea.

First, to compare changes in cognitive function, behavioral symptoms, and physical function for Korean Long-Term Care Insurance (LTCI) beneficiaries with dementia in day care (DC) and home care (HC) settings over 1year. Second, to examine the association between LTCI service type and the aforementioned health outcomes. A retrospective matched cohort study was conducted using the national data set of the National Health Insurance Service in Korea. We identified 7822 beneficiaries with dementia who received either DC or HC services consistently for 1year from 2008 to 2009. The propensity score matching method was used, yielding 416 participants in each group. Paired samples t-tests and logistic regression analyses were conducted. Baseline differences between the two groups are present. According to multiple regression models, DC, when compared with HC, was related to less deterioration in cognitive and physical function but was associated with less improved behavioral symptoms 1year after the LTCI enrollment. In the comparison between matched cohorts, DC, when compared with HC, was associated with less cognitive decline, less disability progression, and similar decrease in behavioral symptoms. Cognitive function and disability declined less in the DC group, compared with the HC group. Conversely, behavioral symptoms showed a similar decrease between the two groups after 1-year follow-up. Further research is necessary to examine key features of DC services that have helped delay functional deterioration and alleviate behavioral symptoms.

Community activities predict disability and mortality in community-dwelling older adults.

With aging, it is important to maintain older community dwellers' regular engagement with familiar community activities (CA) engaged in close to home to protect them from frailty. Thus, the present study aimed to examine whether CA items or CA score were associated with mortality or the need for care under the new long-term care insurance service requirements over 3 years among community-dwelling older Japanese adults. We analyzed cohort data for older adults from a prospective cohort study in Kami town, Japan. The response rate to the self-reported questionnaire was 94.3% (n = 5094), and we followed these participants for 3 years. Our final sample comprised 5076 older adults. Missing data were filled in using multiple imputation. We used seven items to assess CA: (i) volunteer activity; (ii) regional activity related to the neighborhood; (iii) visiting friends; (iv) hobbies or favorite lessons; (v) earning an income; (vi) farm work and growing vegetables; and (vii) shopping daily by oneself. The Kihon Checklist and new long-term care insurance service certifications were used as the frailty screening and disability indices, respectively. During the follow-up survey, 705 participants obtained new long-term care insurance service certifications and 262 died. Using the receiver operating characteristic curve, the desirable cut-off of the CA score to predict disability and mortality was at least two items for all elderly age groups in rural areas. CA items and CA score could predict disability and mortality in community-dwelling older adults in Japanese rural areas. Therefore, it is recommended that older adults from all age groups participate in CA. Geriatr Gerontol Int 2018; 18: 1114-1124.

Association Between the Functional Independence and Difficulty Scale and Physical Functions in Community-Dwelling Japanese Older Adults Using Long-term Care Services.

The Functional Independence and Difficulty Scale (FIDS), a newly developed basic activities of daily living (BADL) assessment tool, assesses both independence and subjective difficulty of BADL performance. This patient-reported outcome measure has been shown to have acceptable internal consistency, concurrent validity, and reliability. However, little is known about the relationship between FIDS and objective measures of physical function among older Japanese adults using long-term care insurance services. This study aimed to reveal the relationship between FIDS and physical functions and to examine the concurrent validity of FIDS against physical functions. Participants of this cross-sectional, correlational research study included community-dwelling Japanese adults aged 65 years or older and certified as long-term care insurance service users with musculoskeletal disease, internal disease, cerebrovascular diseases without observable motor paralysis, and others. Data on physical functions, including muscle strength (grip strength and isometric knee extension muscle strength [IKEMS]), flexibility (range of motion [ROM] of hip flexion and knee flexion), balance (Modified Functional Reach Test [M-FRT]) and gait performance (timed 2.4-m walk), and BADL performance assessed by FIDS, were obtained. Associations between FIDS scores and physical functions were determined by Spearman correlation coefficient and partial correlations after controlling for subject age and sex. Data were collected on 53 participants (mean age = 81.9 years; 62.3% women). Spearman partial correlation coefficients controlled for sex and age between FIDS score and grip strength, IKEMS, ROM of hip flexion, ROM of knee flexion, M-FRT, and timed 2.4-m walk were 0.47 (P = .001), 0.44 (P = .001), 0.29 (P = .04), -0.05 (P = .73), 0.51 (P < .001), and -0.64 (P < .001), respectively. The strength of association was moderate for the M-FRT and 2.4-m walk and was low for grip strength and IKEMS. However, ROM of the knee showed no significant association and hip flexion had negligible association with FIDS. The FIDS, a patient-reported BADL assessment tool, mainly reflected balance and gait performance and had concurrent validity as an objective measure of balance and gait performance.