Transcription
Nursing for the older peoplein Japan2. Nursing for the Older People:Current Situation and ChallengesJapanese Nursing Association
1. The Aging of the Japanese Population2. Nursing for the Older People: CurrentSituation and Challenges3. The Japanese Nursing Association inAction(to be issued soon)2Japanese Nursing Association
Glossary Welfare facility for the elderly requiring longterm care: Living facility for older people whorequire long-term care Healthcare facility for the elderly requiringlong-term care: Rehabilitation facility for theolder people requiring long-term care to goback to home/community Sanatorium-type medical care facility for theelderly requiring long-term care: Long-termmedical care facility for older people whorequire high-level medical care and/or longterm care Long-term care level: Classified to five levelsin accordance with the conditions of the user(e.g. intensity of care). Care level 5 signifiesthe highest level of requirement for longterm care, and care level 1 the lowest.3Japanese Nursing Association
Japanese government switching its focus in care forthe aged from facilities to local communitiesWhen get sickAfter discharged Community based comprehensive caresystem Acute care hospitaladvanced medicine includingemergency and surgeryEarly dischargeSub-acute / subacuterehabilitationhospitalFocused onrehabilitation early recoveryLocal partnerhospitalEverydayhealth carePrimary carephysicianHomeRequired staff at acute care settingswill be increase to 1.6-2 fold ofcurrent staff in FY2025Comprehensivemanagement- Hub for thecollaborationamong homebased medicine- Communitygeneral supportcenter- care managerHealthandmedicalcareLongtermcareVisit a Attend ahospitalcareHome visitfacility Home visitmedicine/long-termnursingcare/ nursingLiving placeHome/ Elderly housing with careFacilitating thesmooth transitionfrom medical tonursing careconsultation andcoordination ofservicesUsers of home based medicineand nursingFY2012 170,000 people/dayFY2025 290,000 people/daySenior citizen’s club/ long-term careprevention/ livelihood support etc.Livelihood support/Preventive long-term caresupportUsers of in-home /Home basedlong-term careFY2012 3,5million people/dayFY2025 5,2 million people/dayNote: It is assumed that the geological unit for community-based comprehensive care represents a “middle-school” area with a population of about10,000.Source: Public relations office, government of Japan; Comprehensive reform of social security and tax, accessed at mg/jujitsusaku 01 l.gif in September 18,2003.In the backdrop of aging society, increasing patients with chronic diseases, tighteninghealth economy, etc., the Japanese government has powerfully promoted homehealthcare. In December 1989, the Ten-Year Strategy for Promoting Health and Welfareof the Aged ("Gold Plan") was enacted, setting a flow for switching from care at facilitiesto care at home. In 1992, the Medical Care Act was revised to position homes as placesfor providing health care. In 2000, the long-term care insurance system was introduced,based on the Long-Term Care Insurance Act.As the aging of society proceeds, the government aims at establishing a communitybased comprehensive care system by around 2025, when the baby boom generationreaches the age of 75 or above, which could provide a package of housing, health care,long-term care, preventive care, and support for living, so that older people could4continue living in the places they are familiar with, as long as possible toward the end ofJapanese Nursing Associationtheir life.
Many older people hopeto live at homeOne’s own homeChild’s homeMaleRelative’s homeWelfare facility for the elderly requiringlong-term careHealth care facility for the elderlyrequiring long-term careMedical institutionFemalePaid nursing home for the elderlyOthers0%20%40%60%80%100%UnknownThe desired place to receive long-term careOne’s own homeChild’s homeMaleRelative’s homeResidence with care for the elderlySpecial nursing home for the elderly or otherwelfare facilityFemaleHospital or other medical facility0%20%40%60%80%The desired place to die100%OthersUnknownSource: Attitude Survey on Health of the Aged, 2012, Cabinet OfficeMany older people hope to live at home.5Japanese Nursing Association
More number of older people haveincreasingly high needs for health care Evolving health care technologies Reduced days of hospitalizationDue to evolving health care technologies and reduced days of hospitalization,the number of older people who requires medical procedures after dischargedfrom hospital are increasing.6Japanese Nursing Association
More number of patients with dementiaare linked to expanding population aged65 and over One out of approx. seven people aged65 and over suffer dementia. The prevalence rate of dementiaamong people aged 65 and over inJapan is estimated at 15%.Source: Comprehensive Research Project on Measures against Dementia, Health Labour SciencesResearch Grant"Incidence Rate of Dementia in the Urban Area, and Response to Living Functional Disability Caused byDementia", Comprehensive Research Report 2011 to 2012, Published by Takashi Asada, PrincipalInvestigator, March 2013The Ministry of Health, Labour and Welfare estimated the population of olderpeople with dementia who require any kind of support at 2,800,000, based on2012 data. This makes up 9.5% of the overall population aged 65 and over. Thispercentage is expected to further increase.The research on the prevalence rate of dementia uncovered that one out ofapprox. seven people aged 65 and over, which means approx. 4,390,000 peopleoverall, suffer dementia, with or without need for support, as of 2012.In order to support these people on a community basis, it is required that mostresidents properly understand and take appropriate actions to older people withdementia.7Japanese Nursing Association
Municipal governments are providingservice for prevention of dependence onlong-term care to support independentliving of older people in local communities Primary care preventionTarget: People aged 65 and overActivities: Dissemination of long-term care prevention,development of volunteers and other human resources,development of and support to local activity organizations,etc. Secondary care preventionTarget: Older people with lowered physical functionalitywho may use long-term care service in the near futureActivities: Identification of target older people, provision oflong-term care prevention program through daycare service,comprehensive clarification of issues through visits, andprovision of necessary consultation and guidance servicePrevention of dependence on long-term care is an initiative to prevent andrestore deterioration of mental and physical activities, so that older peoplecould continue independent living without necessity for care covered by thelong-term care insurance system. This initiative is undertaken by individualmunicipal governments. For older people with remarkable deterioration ofmental and physical activities, who may use long-term care service in the nearfuture, support toward independent life is provided by specialists, such as publichealth nurses, certified social workers, care managers, etc. The servicesprovided may include, in accordance with conditions of the older people,1) improvement of motor function, 2) improvement of oral function, and3) improvement of nutritional conditions.8Japanese Nursing Association
Long-term care services Facility Service Home-based ServiceHome visit nursing, home visit long-term care, home visitbathing, day care rehabilitation, day care service, shortterm stay, rental service/ purchase of equipment for longterm care, etc. Community-based ServicesCombined services, periodical round, multifunctional longterm care in a small group home, home-visit at night forlong-term care, etc.Services under the long-term care insurance system are largely divided into facilityservices, home-based services, and community-based services. Facility and homebased services are designated and supervised by the competent prefecturalgovernment, while community-based services are designated and supervised by thecompetent municipal government.Facility services are provided to those staying at nursing homes for the elderly andsimilar facilities. Home-based services provides the essential support to continue thelife at home. Typical home-based services include home visit nursing and day careservice. Community-based services are long-term care provided in the places that arefamiliar to older people, taking into account the expected further increase in olderpeople who suffer dementia and/or who live by themselves. Service types other thanthe above include group shared residence for older people with dementia, etc.9Japanese Nursing Association
Many Users of the Long-Term CareInsurance System Use Home-basedServices(1,000 people)3,0002,5002,0001,5001,0005000Home-based serviceCommunity-based servicesFacility servicesHome-based services f or prevention of dependence on long -term careCommunity-based prevention of dependence on long -term care services* The Long-Term Care Insurance Law was revised in 2005, introducing preventive services.Source: Based on Annual Data on May, "Survey of Long-term Care Benefit Expenditures",Monthly Reports, Ministry of Health, Labour and WelfareIncreased number of population are using the long-term care insurance system.Users are particularly on the rise of home based services, which are indispensableto continue living in the familiar community.More than half of people who require high-level care use facility services.10Japanese Nursing Association
The number of beds at long-term carefacilities for the elderly in Japan are lessthan its older peopleComparative Beds at Facilities for Care of the older people(per 1,000 people aged 65 and sSpain20Sweden10SwitzerlandUnited Kingdom02000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011United StatesSource: OECD Health Data, accessed on October 3, 2013The number of beds at facilities for care of the older people in Japan are far lessthan its population aged 65 and over.On the other hand, the government is proceeding toward establishing a regionalcomprehensive care system for providing a basis of community-based living to olderpeople who suffer dementia and/or who live by themselves, taking into account theexpected further increases in their population. Residence with services for the olderpeople is also put in place to support community-based living of older people wholive by themselves or of aged couples.11Japanese Nursing Association
Nursing human resources who work forcare of older peopleThe percentage of nurses who work for long-term care tothe population aged 65 and over (2009)(%)76543At f acilities2At home10* Estimates are used for Czech and the Netherlands. The figure for Japan is an adjusted value (break in series).Source: OECD Health Data, accessed on October 3, 2013The OECD data suggests that the number of nursing personnel who work for long-term care inJapan is small relative to the share of aged population.12Japanese Nursing Association
Nursing at Facilities13Japanese Nursing Association
Long-term care facilities:Types, human resource allocation criteriaand the number of facilities in JapanWelfarefacilities forthe elderlyrequiring longterm care(Specialnursing homefor the elderly)Healthcarefacility for theelderlyrequiring longterm careSanatoriumtype medicalcare facility forthe elderlyrequiring longterm careGroup sharedresidence forolder peoplewith dementiaLong-term carefor residents ofspecifiedinstitutions(e.g. paidnursing homefor the elderly,residence withservices for theelderly)Characteristicsof the facilityLiving facilityfor olderpeople whorequire longterm careRehabilitationfacility for theolder peoplewho requirelong-term careto go back tohome/communityLong-termmedical carefacility forolder peoplewho requirehigh-levelmedical careand/or longterm careGroup homesetting forolder peoplewith dementiaLiving facilityfor olderpeopleincluding thosewho requirelong-term careAllocation ofnursesUsers:Staff3:13:1(Nursing staffmake upapprox. 2/7 ofthe full timeequivalent(FTE)workforce.)At least 6:1Allocation oflong-term carestaffFacilitiesQuotaAt least 6:1At least 3:1At least 1 longterm care ornursing stafffor every threeolder peoplewho requirelong-term 41,941183,980Source for facilities and quota:"Survey of Institutions and Establishments for Long-term Care", 2011,Ministry of Health, Labour and WelfareThe number of nursing staff to be allocated varies by the characteristics of long-termcare facilities. The allocation criteria have been set by law.14Japanese Nursing Association
Many users of facilities require high-levelcareWelfare facility for the elderly requiringlong-term careHealthcare facility for the elderlyrequiring long-term careSanatorium-type medical care facilityfor the elderly requiring long-term care0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%Care level 1Care level 2Care level 3Care level 4Care level 5OthersSource: "Survey of Institutions and Establishments for Long-term Care", 2011,Ministry of Health, Labour and Welfare, as of September 30, 2011Many users of facilities require high-level care.15Japanese Nursing Association
Present status of Nurses at long-termcare facilitiesFTE staff per facilityWelfarefacilities forthe elderlyrequiringlong-term care(Specialnursing homefor theelderly)Healthcarefacility for theelderlyrequiringlong-term careSanatoriumtype medicalcare facilityfor the elderlyrequiringlong-term careGroup sharedresidence forolder peoplewith dementiaLong-termcare forresidents ofspecifiedinstitutions(e.g. paidnursing homefor the elderly,residence withservices forthe 66.50.2*1.1Long-termcare staff31.529.514.111.417.4* Included in long-term care staffSource: "Survey of Institutions and Establishments for Long-termCare", 2011, Ministry of Health, Labour and WelfareThe number of nurses who work at long-term care facilities is small. Each nursingstaff member take care of 17.7 residents at a welfare facilities for the elderlyrequiring long-term care, and 8.2 residents at a healthcare facility for the elderlyrequiring long-term care.16Japanese Nursing Association
Current situation of night shift at longterm care facilitiesWork shifts of nursesDay shift onlySpecial nursing home for the elderlyTwo shiftsHealthcare facility for the elderlyrequiring long-term careThree shiftsNight shift onlyGroup shared residenceOtherNo answer0%20%40%60%80%100%Allocated number of nursing staff5.00 am11.00 am9.00 AverageStandarddeviationSpecial nursinghome for theelderly0.10.64.12.00.10.5Healthcarefacility for theelderly requiringlong-term care1.20.65.62.51.20.9Group sharedresidence0.10.21.20.70.10.3Source: "Status Survey of Nursing Staff who Work at Facilities for Care ofthe Elderly", 2012, Japanese Nursing AssociationAccording to the survey conducted by Japanese Nursing Association, targeted atnursing staff who worked at facilities for care of the elderly registered as JNA'smembers as of 2012, 60.8% of all respondents worked at night shift. At two-shiftfacilities, respondents worked for 16.1 hours per night shift on the average.Among respondents, 38.7% said that they worked for facilities with anon-call system.17Japanese Nursing Association
Nurses at long-term care facilities play awide range of roles Supporting the living of residents in healthcare and nursing aspects Exercising nursing expertise as a member ofhealth care team Protecting health of the entire facility Taking into account the management of theentire facility while fulfilling one's own roles Identifying information on necessary socialresources in alignment with the localcommunityBecause long-term care facilities are places for living, nurses are required toprovide high-quality care in collaboration with long-term care staff and otherprofessionals, while trying to understand the life of each resident and respondingto their preference. For this purpose, nurses are required to have not onlynursing expertise and skills necessary for providing nursing care to residents, butalso management perspectives and competency, in order to guarantee safe andhealthy conditions of the entire facility, to prepare resources required forproviding necessary care, to establish an information sharing system, etc.18Japanese Nursing Association
Nurses at long-term care facilitiesprovide care for better everyday life Nursing care at the time of admission Basic care to establish the rhythm ofeveryday life Management of medications Emergency response, including accidents Support for end-of-life care Nursing care at the time of dischargeNurses who work at facilities for the elderly provide care for better everyday lifethrough health management of older people who require support in their life, incollaboration with long-term care staff and other professionals.Their main tasks include the assessment of body temperature, blood pressure, etc.,observing health conditions and maintaining physical cleanliness, nutritionmanagement, excretion management, prevention and treatment of bedsores,management of medications, respiratory care, palliative care, and instructions tolong-term care staff. Nurses also observe day-to-day conditions of each resident,and, in the event of acute change or abnormality in conditions, make decision onmoving the resident to a local hospital in collaboration with the physician.19Japanese Nursing Association
Challenges Unclear scope of work Training opportunities for nurses Collaboration with other professionsinside and outside the facility, andlocal networksAs increasing number of people live in long-term care facilities, needs are rising forindividual long-term care and health care. Needs for end-of-life care are also onthe rise. Unfortunately, nurses are not able to provide sufficient care in responseto these needs. As factors for these insufficient care , it has been pointed out thatthe number of nurses allocated to long-term care facilities is small, and theposition of nursing in the organization is not clear. It has also been uncovered thatfew new graduates are employed as nursing staff, and nurses do not have manytraining opportunities, resulting in difficulty of acquiring nursing knowledge andskills required at long-term care facilities. At the same time, collaboration withother professionals is indispensable to fully exercise the functions of nursing.In order to improve the quality of nursing, it is required to strengthen thefunctions of nursing, to provide training opportunities for acquiring knowledgeand skills, and to bolster local networks.20Japanese Nursing Association
Home-based Nursing21Japanese Nursing Association
History of home-based nursing1982The Law of Health and Medical Services for theElderly was enacted, providing the legal groundfor home-based nursing for the first time. Thelaw was revised in September 1991,establishinga home-visit nursing system for the elderly.1994The Health Insurance Act was partially revised.In response to nursing needs of from children toolder people, nursing activities were promotedin collaboration with medical care and welfare athome.1997Home-based nursing was incorporated into thebasic nursing education curriculum.2000Gold Plan 21 was set, in prospect ofestablishment of 9,900 visiting nursing stationsin 2006.2006Medical fees and long-term care fees wererevised. The scope of home-visit nursing wasexpanded to special nursing home for the elderly,group shared residence, etc.22Japanese Nursing Association
Nurses are involved in a variety ofservices covered by the long-term careinsurance system Facility Service Home-based ServiceHome visit nursing, home visit long-term care, home visitbathing, day rehabilitation, day care service, short termstay, rental service/ purchase of equipment for long-termcare, etc. Community-based ServicesCombined services, periodical round, multifunctionallong-term care in a small group home, home-visit at nightfor long-term care, etc.Nurses are involved in providing home-visit nursing and other variety of servicescovered by the long-term care insurance system, aimed at supporting living ofolder people at home.23Japanese Nursing Association
Nurses work on various settings tosupport living of older people at homeFTE staff per facility or establishmentHome-visitsHomevisit longterm serviceOthersDaycare rehabilitationWelfarefacilitiesfor sShortterm stayfor longterm 40.60.50.60.9Source: "Survey of Institutions and Establishments for Long-termCare", 2011, Ministry of Health, Labour and WelfareNurses are involved in a variety of home-based services. Their main tasks arehome-visit nursing services.24Japanese Nursing Association
Home-visit nursing supportingcontinued medical care at homeUsersCare managersHealthinsuranceRequestsLong-term instructionsVisiting nursing stations, hospitals and clinicsProfessions that support medical care at homePhysiciansOTsDentistsSTsPublic d socialworkersIn-home helpersPTsCertified careworkersLong-term caremanagerHome-visit nursing is provided by visiting nursing stations, hospitals and clinics,based on the long-term care insurance system and the health insurance system. Awritten instruction issued by the physician is required to start home-visits.Manager of a visiting nursing station should be a dedicated public health nurse,midwife, or nurse. At least 2.5 FTE nurses should be allocated to a visiting nursingstation.In home-visit nursing, nursing personnel should support the maintenance,promotion and restoration of the client's health, while minimizing impact ofdiseases and/or disorders if any, thereby facilitating the client's long-term care athome. In doing so, nurses must align with many other professions engaging in themedical care at home.25Japanese Nursing Association
Users of visiting nursing stations areincreasing(number of 00150400030001002000501000002001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013visiting nursing stationsHospitals and clinicsUsers of visiting nursing stationsSource: Based on data of May every year, "Survey of Long-term Care BenefitExpenditures", Reports, Ministry of Health, Labour and WelfareUsers of home-visit nursing are on the rise under the long-term careinsurance system. The focus of institutions providing home-visit nursingseems to be shifting from hospitals and clinics to visiting nursing stations.The number of visiting nursing stations has been slightly increasing.26Japanese Nursing Association
Some aged users of home-visit nursinghave unstable health conditionsHealth aspects of users of home visit nursingn 5,028Up to 64 years oldLowModerate65 to 74 years oldHighSerious75 years and overN/ANo answer0%LevelConditionsLowConditions arestable, thoughrequiringoccasional vitalsigns ns are stable,though relapse ispossible. Vital signschecks should bedone whennecessary.Conditions arerelatively unstable.Periodic vital signschecks arerequired.Conditions areunstable. Constantvital signs checksare required.Source: "Report of the Basic Survey on Home Visits and Home-Visit Nursing", FY2006, JapaneseNursing Association and Japan Visiting Nursing FoundationAmong people aged 65 and over who live at home, more than 60% have moderate tohigher needs for medical care. Many people with unstable conditions and high needsfor medical care also continue to live at home.27Japanese Nursing Association
Providing a broad range of care toenable continued life of aged people athome, from medical services to supportand consultation for caregivers Medical interventions under the direction of physicianManagement of oxygen therapy, prevention and treatment of bedsores,provision and management of injection and IV, provision and management ofcentral venous hyperalimentation at home, provision and management ofnasal tube feeding, enema and stool extraction, etc. Observation of and advice on health conditionsSupport to daily lifeBed bath, shampooing, oral care, meal care, etc. Advice for improvement of in-home recuperationenvironmentRehabilitation at homeSupport and consultation for informal caregivers such asfamiliesMental and psychological supportEnd-of-life careCoordination of different services (social resources)Consultation on hospitalization and dischargeIn order to enable continued living of older people at home, nurses provide a broadrange of services in a limited time frame, including advanced medical interventionsthat are required due to reduced days of hospitalization, terminal care requiredthrough promotion of end-of-life care at home, care for people with dementia, etc.In providing these types of care, collaboration with other professions related to lifeof older people at home is indispensable.28Japanese Nursing Association
Current situation of nursing staff atvisiting nursing stationsNurses’ ealth centersMunicipal governmentsHospitals2.1%ClinicsMaternity homesHealthcare facility for the elderly requiringlong-term careVisiting nursing stations20.7%Social welfare facilities62.0%Welfare facility for the elderly requiringlong-term careIn-home services, etc.IndustriesNursing schools, InstitutesSource: Statistical data on Nursing service in Japan 2012, JapaneseNursing Association Publishing CompanyResearched by the Nursing Division, Health Policy Bureau, Ministryof Health, Labour and WelfareWhile the number of visiting nursing stations has been slightly increasing, theshare of nurses who work at visiting nursing stations has remained at the samelevel over the past ten years.29Japanese Nursing Association
The majority of visiting nursing stationsare small-sizedSize of visiting nursing stations2009, n 211218.70%47.320%40%20.760%7.9 2.780%2.5 to fewer than 33 to fewer than 55 to fewer than 77 to fewer than 99 to fewer than 1111 to fewer than 1515 to fewer than 2020 or more100%Source: Japanese Nursing AssociationGrant for Promoting Elderly Health care Services, Ministry of Health, Labour and Welfare,FY2009, "Survey and Research Project to Analyze the Causes for the Declining Trend of Homevisit Nursing Establishments and Measures to Cope with the Trend"It has been specified that at least 2.5 FTE nurses should be allocated to a visitingnursing station.According to the survey by JNA, the majority of visiting nursing stations aresmall sized, with only fewer than five FTE employees.* FTE Total work hours of employees per week / Weekly work hours specified by theestablishment30Japanese Nursing Association
Challenges Users of home-visit nursing have increasingly diverseand complicated needs.Increasing patients with cancer, intractable neurological diseases, psychiatricdiseases, etc.Increasing users who require medical interventions Because of the visiting nursing stations are small sized,operations tend to be inefficient, resulting inincreased burden on staff.Smaller sized visiting nursing stations are in poorerbusiness conditions compared to larger stations, andare unable to provide services around the clock.Because home-visit nursing is provided under the two separate systems of long-termcare insurance and health insurance, it takes a long time for complicated clerical work,causing difficulty in increasing the case of home-visit nursing. This has a negativeimpact on business efficiency and management.Because opening of a visiting nursing station is approved with the allocation of atleast 2.5 FTE nurses, most establishments are small sized. Because of their small scale,efficiency is poor at these facilities, causing great burden on staff. Neither can theyincrease users because of inability to fulfill their needs, nor can stabilize or reinforcetheir management. It is also difficult for these facilities to provide services around theclock.In order for users and their families to continue life at home, stable and seamlessservice provision is essential.31Japanese Nursing Association
Informal Caregivers32Japanese Nursing Association
Families as principal care givers at homeRelationship of principal caregivers with older people whorequire long-term careSpouseChildChild’s spouseParentOther relativeService providerOtherUnknownSource : National Livelihood Survey, 2010, Ministryof Health, Labour and WelfareAs indicated on Slide 10, many older people use long-term care service athome. However, their families serve as principal caregivers at home, becausethere is a ceiling on the use of services under the long-term care insurancesystem.33Japanese Nursing Association
Current conditions of care time ofprincipal caregiversCare time of principal caregivers who live with older peopleSupport level 1Support level 2Care level 1Care level 2Care level 3Care level 4Care level 50%Almost all day10%20%About half day30%40%2 to 3 hours50%60%70%When necessary80%Other90%100%UnknownHalf of principal caregivers who live with older people requiring high-level carespend almost all day on providing care.34Japanese Nursing Association
Increasing people leave or change theirjobs to provide care to their families(Persons)People leaving or changing their jobs for caregiving120,000100,00080,000Leaving jobs, Female60,000Changing jobs, FemaleLeaving jobs, Male40,000Changing jobs
Home-based services for prevention of dependence on long -term care Community -based prevention of dependence on long -term care services (1,000 people) * The Long-Term Care Insurance Law was revised in 2005, introducing preventive services. Increased number of population are using the long-term care insurance system.
