Slides focused on the essence of Japanese health care system for the elderly.and how to teach it. Community-based integrated care system is the core content.

1. Interprofessional Care
for Elderly in Japan
Hirotaka Onishi MD, MHPE, PhD
Department of International Cooperation for Medical Education
International Research Center for Medical Education
Graduate School of Medicine,
The University of Tokyo

2. Trend and Estimate of
Life Expectancy in Japan
55
60
65
70
75
80
85
90
95
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
0yo M
0yo F
Year
Age

3. Changes in the % Population Over Age 65
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
2070
2075
2080
2085
2090
2095
2100
India China
Taiwan Japan
Korea Indonesia
Malaysia Sweden
UK France
Germany USA

4. Trend and Estimate of
Life Expectancy at 65yo
Year
Age
10
15
20
25
30
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
2065
65yo M
65yo F

5. Overview
1. Changes in health care in Japan
2. Community-based integrated care
system in Japan
3. Interprofessional work/education

6. 1. Changes in Health Care in
Japan

7. Various Changes in
Health Care in Japan
 Disease structure
 Health/long-term care insurance
 Change in family style and carers
 Conceptual change in end-of-life care
and deaths
 Patient autonomy

8. 0
50
100
150
200
250
300
1947
1949
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
Tuberculosis
Malignant neoplasm
Heart diseases
Cerebrovascular diseases
Pneumonia
Disease structure
Trends in death rates for leading causes of death

9. Development of welfare policies for the elderly
Aging Major policies
60s
5.7%
(1960)
Beginning of welfare policies for the elderly
1961 Universal health insurance has started
1963 Act on Social Welfare Services for the Elderly
 Intensive care homes for the elderly created
 Legislation on home helpers for the elderly
70s
7.1%
(1970)
Expansion of healthcare expenditures for the elderly
1973 Free healthcare for the elderly
80s
9.1%
(1980)
“Social hospitalization” and “bedridden elderly people” as social problems
1982 Health and Medical Services Act for the Aged
 Adoption of the payment of co-payments for elderly healthcare, etc.
1989 Gold Plan (10-year strategy for the promotion of health and welfare
for the elderly)
 Promotion of the urgent preparation of facilities and in-home welfare
services
90s
12.0%
(1990)
Promotion of the Gold Plan
1994 New Gold Plan (new 10-year strategy for the promotion of health
and welfare for the elderly)
 Improvement of in-home long-term care
14.5%
(1995)
Preparation for adoption of the Long-Term Care Insurance System
1997 Long-Term Care Insurance Act
00s
17.3%
(2000)
Introduction of the Long-Term Care Insurance System
2000 Long-Term Care Insurance System

10. Number of Senior People Certified
for Long-term Care Insurance
2000
3000
4000
5000
6000
7000
1000people
Year

11. How Should We Support
Senior People?
 Long-term care insurance is the key to provide
supportive care. 65yo< people (also 40yo< with
specific diseases) are eligible to apply for the
certificate of long-term care insurance.
 City/town/village office will decide the care need level
after the client applies. The higher care need level,
the more clients can use the care services but the
unit price of care will be more expensive.
 Clients must tell which service they like to use to a
care manager. He/she will contact service providers
to decide which service they use.

12. Previous Family Style
 3 generations
 Working man
and housewife
 Child-raising
and elderly
care is also
included in
housekeeping?

13. Current Family Style
 Nuclear family
 Double income
 Shared housework
 Small house
 Discord between mother-in-
law & daughter-in-law
 Separation of households
 Nostalgia won’t work…

14. Family with Senior Person
0%
10%
20%
30%
40%
50%
0
5
10
15
20
25
30
1980 1985 1990 1995 2000 2005 2010 2015
Others Three-generation
Parent with single child Only couple
Living alone % of family with senior member
millionpeople
Year

15. Change in Carers
 Some senior people
care their parent(s)
 8050 issue
 Socially withdrawn
50yo people are cared
by 80yo parents

16. How Do People Would Like
To Die?
 Parents do not want sons/daughters to
take care of them
 They have taken much time/effort/money to
raise them…
 However, they are scared of death…
 PPK: pin-pin-korori (healthy life and abrupt
death)
 Shukatsu (終活): preparation for death and
consider the meaning of the rest of the life

17. Lonely Death
 Living alone is carefree
and easy
 When a disease attack
happens, he/she can’t
call anyone  Lonely
death
 Most senior people say
they like to avoid this…
 Single person’s PPK…

18. % Change in Place for Deaths
in Japan
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
Home
Nursing home
Others
Health facilities

19. Trends of Numbers and
Sites of Deaths in Japan
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
900,000
1,000,000
1,100,000
1,200,000
1,300,000
1951
1953
1955
1957
1959
1961
1963
1965
1967
1969
1971
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
1995
1997
1999
2001
2003
2005
2007
2009
2011
2013
2015
2017
Medical facility
Others
Nursing care home
Home

20. Concerns for Death
 Where do they die?
 With whom do they live until death?
 Who should make decision for those?

21. Four Types of Illness Trajectory
(Lunney, Lynn, & Hogan, 2002)
Sudden death Malignancy
Organ
failure
Frail, dementia
Time course
BodyfunctionBodyfunction
BodyfunctionBodyfunction
Time course
Time course
Time course

22. Long-term Care Facilities
 Home
 Public
 Care house
 Private
 Elderly housing with
care services
 Pay nursing home
for healthy person
 Nursing care home
 Public
 Special nursing home
 Geriatric Health
Services facility
 Group home (mainly
for dementia persons)
 Private
 Pay nursing home

23. Difference in Facilities
 “Home” is for more independent users, and
“Nursing care ~” is for more dependent users
 Private ones are more expensive
 Pay nursing home costs JPY150,000<
 Public ones are competitive but inexpensive
 Some special nursing home has long list (e.g. 500)

24. Trend in Nutrition for Those
Who Cannot Intake Orally
Early
1990s:
IVH
Late 1990s:
Nasal
2000s:
Gastrostomy
2010s:
Oral
only?

25. Patient Autonomy
 Until early 1990s most physicians did not tell
the diagnosis if it was “cancer”
 Because patients cannot make palliative
decision with autonomy, situation has been
dramatically changed
Your disease is severe
gastric ulcer. All you have
to do is to take medication

26. Patients without Decision
Making Capacity
 Medical power of attorney will make
surrogate clinical decisions
 Some children are dependent on income
from the parent’s pension…
 Some senior people start to prepare by
documenting ending note – medical care
expectations especially resuscitation, where
they live/die, funeral, inheritance, whether to
contact with friends/relatives…
 Advance care planning is a boom in Japan.

27. 2. Community-based
Integrated Care System

28. Generational Population, % of Aged,
and (Working Age) / (Aged)
0
5
10
15
20
25
30
35
40
45
0
20
40
60
80
100
120
140
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
2045
2050
2055
2060
Year
0-14yo 15-64yo 65-74yo 75yo≦ % of Aged
PopulationforEachBandingofGeneration(mil)
SeniorPeople(65yoormore)/Population(%)

29. Need for a New Health System
for 2025 and 2040
 Mutual support in senior generation
 Development of a new community with
social capital
 Integration of health/medical care with
everyday life
 Community-based integrated care
system (CICS)

30. Health Care
in Super Ageing Society
Cure, Therapy,
Hospitalization
Aim
FacilityCare place
BiomedicalPerspective
IndividualFocus
Care, Maintenance of
Function, Daily life support
Home
More on psychosocial
Family, Community

31. Model for CICS
Flower by Five Rings (2008)
 For everyday
living area
equivalent to
junior high
school
 Professionals
can arrive
users at home
in 30 mins
Long-term
Care
Medical
Practice
PreventionHousing
Life
Support

32. Flower Pot
2012 version 2015 version
 Nursing care prevention became a key phrase
 Self-choice is more emphasized

33. 地域包括ケアシステム
Whole Picture of CICS Model
Ambulatory/
Residence
Inpatient
Outpatient/
Medical
care
Nursing
care
Housing
Life
support,
Keeping
active
Participating in
community/volunteer
Community
comprehensive
support center/
Care manager
Medical care/
service
provision
Provision of activity
settings
Provision of
nursing care/
service

34. Health Care: 2 Steps
Hospital
Specialty care
General care
Clinic
Health
professionals/
staff
Referral
Free access to either

35. Nursing Care: In-Home or
Facility/Residence Services
Facility care
Day service
Rehabilitation
Short stay
Long stay
Home care
Various life
support
Body care

36. Home & Community Activities
Exercise Hobby, socializing
Walking,
sunbathing

37. List of Health-related Professionals
and Year of Law Promulgation in Japan
 Medical doctor / Dentist / Nurse (incl. Public health nurse/
Midwife) / Dental hygienist (1948)
 Veterinarian (1949)
 Radiology technologist (1951)
 Dental technician (1955)
 Clinical laboratory technologist (1958)
 Pharmacist (1960)
 Physical therapist / Occupational therapist (1965)
 Orthoptist (1971)
 Prosthetist / Clinical engineering technologist / Certified social
worker / Certified care worker (1987)
 Emergency life-saving technician (1991)
 Speech therapist / Psychiatric social worker (1997)

38. Systemic – Specific
Practical – Administrative
Medical
doctor
Dentist
Nurse
Dental
hygienist
Radiol.
tech.
Dental
tech.
Clin. labo.
tech.
Pharm.
PT
OT
Orthoptist
Prosthetist
Clin. Engin.
Tech.
Cert. SW
Cert. CW
Emerg. LS
tech.
ST
PSW
Specific Systemic
Practical
Administrative

39. Key Professionals
 Home nurses
 Rehabilitation therapists: physical/
occupational/speech (PT, OT, ST)
 Care managers (CM)

40. Home Nursing
 Partly by health insurance,
mainly by long-term care insurance
 Observation of conditions, Patient guidance,
Rehabilitation, Sanitization, Monitoring for
drug therapy, Care for dementia/psychiatry
problems, Nutritional/dietary care, prevention/
care for decubitus ulcer, Enema/Stool
extraction, Airway aspiration, Management
for bladder catheter, Tubal feeding…
 Home nurses are rather independent.

41. Home Nursing Station
 Work along with a physician’s order
 Care managers also connect them.
 24hr care is expected by users but it is
hard for small station to apply for it
 46% is less than 5 members.
 Relatively healthy users tend to demand
services from rehabilitation therapists
 Some station has rehabilitation therapists
for at-home rehabilitation

42. PT, OT, ST
 Services by physical/occupational/speech
therapists are partly covered by health
insurance but mostly by long-term care one.
 Both assessment and therapy can be offered
through the observation of life at home.

43. Care Manager (CM)
 However, it was difficult for users to
select and order care services.
 Many helpers were upgraded to
care manager.
 Some health professionals took
certificate of CM but they do not
work as CM because of lower
income level.
 Before long-term care insurance is implemented,
users are freely able to select long-term care
services within the limit.

44. CM Relationship with Users
 Regular visit to the users is mandatory.
 Users/family members tend to have
closer relationship with CM than other
health professionals.
 Some CMs do not have ability to assess
best medical care for each user and
may become an order-taker.

45. Community Comprehensive
Support Center
 Members
 Community health nurse
 Chief care manager
 Social worker
 Functions
 Construction of community network
 Community care meeting: case/community study
 One-stop service counter

46.  Functions (cont’d)
 Advocacy for human
rights
 Elderly abuse
 Adult guardianship:
decision making by a
third party
 Support for care
manager

47. Information Sharing
 Paper-based medical chart
 Electronical medical chart
 Stand alone computer 
Computer server at the
center  Cloud service
 Only in the same health
facility  With other
facility/service

48. 3. Interprofessional Work/
Education (IPW/IPE)

49. Global Needs for IPE
 In the 20th century, various health
professionals were newly born to
complement the tasks of other health
professionals.
 Consequently, professional-specific
capacity increased, yet collaboration
among professionals became more
complicated and difficult.

50. Framework for Action on Interprofessional
Education & Collaborative Practice
WHO 2010
Local Health
Needs
Collaborative
Practice study
Health
workforce
Health and Education System
Local context
Present and
Future Health
workforce
Optimal
health
service
Source: WHO, 2010. Framework for Action on IPE and CP
Fragmented
health system
Interprofessional
Education
Collaborative
Practice
Strengthened
health system
Improved
Health
outcome

51. How To Develop IPE
Collaborative
Professionals
Present and
Future
Professionals
Interprofessional
Education
Staff
training
Institutional
support
Management
commitment
Learning
outcomes
Champions
Logistics &
scheduling
Program content
Compulsory
attendance
Shared
objectives
Adult learning
principles
Learning
methods
Contextual learning
Assessment
Educators
Mechanism
Curriculum
Mechanism

52. How To Organize IPW
Optimal
health
services
Collaborative
practice-ready
workforce
Collaborative Practice
Governance
models
Shared operating
resources
Personnel
policies Supportive
management
practices
Structured
protocols
Communication
strategies
Conflict resolution
policies Shared
decision
making
procedures
Built
environment
Space design
Institutional
Support
Mechanisms
Environmental
Mechanisms
Facilities
Working Culture
Mechanisms

53. Preconditions for IPE
 Most health professionals understand IPE is
important but do not act very much on
changing the current situations.
 Perception for each professional depends on
the culture.
 Lack of/skewed IPW works as a hidden
curriculum for IPE.
 Rectifying authority gradient (those with
power control the conflict, e.g. Dr-Nr, Male-
Female) is a key.

54. Competency-based Model
for IPE (Barr, 1998)
Common
Complementary Collaborative
 Anatomy & physiology
 Basis for scientific thinking
 Human life and society
 Common diseases and support for recovery
 License-specific competency
(e.g. care by nurses, Dx/
surgery by Dr)
 Competencies to improve
collaborative practice (IPW)
 Main content for IPE
Currently too
profession-
specific
Currently
too scarce

55. Comptencies Focused in
IPE
1. Teamwork
2. Roles and responsibilities
3. Communication
4. Learning and reflection
5. Patient-health professional relationship,
understanding of patients’ needs
6. Ethical practice
(WHO 2010)

56. Terminology
Difference
Care planCare decisionIndividual relationship
Parallel
Practice
Multidisciplinary
Practice
Interprofessional
Practice/Work
pt
pt
pt
Minimal communication
More communication among health professionals
Trustful relationship to make shared decision
Journal of Physical Therapy
Education 15 (2), 2001

57. Interprofessional Teams
in the Hospital
 Cancer therapy
 Nutritional support
 Decubitus ulcer
 Palliative care
 Infection control
 Ethics
 ……

58. Responsible Professionals
Meeting
 When some
members in the
home care team
feel they need
discussion, care
manager calls for
the meeting.
 If patients allow,
meetings are held
at home.
CM
Pt
Pt’s
wife
Dr
Ns
Home
helper

59. When We See Complicated
Cases…
 Normally conference/referral/consultation
may improve the condition.
 Sometimes we need support from the local
government
 Supervision from police, human rights protection…
 Monetary/legal/job placement support
 Mutual support from the community people
including volunteer
 Community comprehensive support center

60. Different Levels of IPE
 Students from different courses:
 Sit together in the classroom.
 Run small group discussion.
 Are involved in simulation-based learning.
 See patients together to discuss the case.
 Go to a community together to be involved
in meeting/activity/patient home visit…

61. New Era of IPE
Hospital Community
One
university Two or more schools
One shot Continuous, spiral
curricula

62. Emerging Issues
 Study level
 4th-yr Nursing with 3rd-yr Medicine
 Study area division
 Scheduling
 Day of the week, curricular conflict, time frame
(one school 50 mins but the other 90 mins)
 Credit
 Only some schools provide credits for IPE…

63. Summary
 In Japan we widen the care from hospital to
community and from physician only to
interprofessional.
 Changes in health care are starting points for
the systematic changes.
 Professional members, insurance system,
combination of home/facility/clinic/hospital
care, etc. are the components for CICS
 IPW/IPE is keys to develop future CICS