Act for Partial Revision of the Long-Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure

Transcription

1 Act for Partial Revision of the Long-Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure 0

2 1 The status of aging in Japan 1

3 International comparison of life expectancy Japan s life expectancy is 79 for males and 86 for females, the highest in the world. Life expectancy (years) Life expectancy (years) Country Males Rank Country Femal es Rank Males Rank Brazil France Canada Germany USA Italy China Netherlands India Norway Israel Portugal Japan Russia South Korea Spain Malaysia Sweden Singapore Switzerland Pakistan UK Finland Australia Fema les Rank Source: WHO, "The World Health Report 2006" "Rank" is the order of the 24 countries listed, from longest to shortest life expectancy. 2

4 International comparison of aging Japan is aging at a pace unparalleled in other countries. Country Years required for Percentage of population p 65 and older (year attained) attainment 7% 14% 21% 7% 14% Japan China Germany UK USA Sweden France Until 1950, figures are according to UN, "The Aging of Population and Its Economic and Social Implications" (Population Studies, No. 26, 1956) and Demographic Yearbook; since 1950, they are according to UN, World Population Prospects: The 2006 Revision (median estimates). For Japan, however, figures are population (median values for births and deaths) according to Statistics Bureau, Ministry of Internal Affairs and Communications, "Census Return" and National Institute of Population and Social Security Research, "Japan s Future Estimated Population" (December 2006 estimate). For years before 1950, figures are interpolated from years for which data are known. Years indicated are the first in which the percentages were exceeded. "-" indicates that the percentage will not be reached by Number of years required for doubling are the period needed to move from either 7% to 14% or from 10% to 20%. Countries are listed in order from fewest to most years required to move from 7% to 14%. 3

5 Changes in the population pyramid Age Age (11%) Total population M Baby Boom generation (60 62) 62) (12%) 6.64 M Total population M Total 100 Total population population M M 90 Age (18%) Age 75 Age 75 Baby Boom Baby Boom (12%) generation (13%) generation (62 64) (66 68) 6.56 M 6.36 M (14%) (12%) (12%) Baby Boom generation (76 78) 5.47 M (59%) Secondary Baby Boom generation (35 38) M (59%) 65 - Basic pension payments begin - Long-term care Category 1 insured persons Secondary Baby Boom generation (37 40) 7.87 M (56%) 75 - Healthcare system for the latter-stage elderly Secondary Baby Boom generation (41 44) 7.83 M (55%) Secondary Baby Boom generation (51 54) (18%) (18%) (17%) (14%) Million persons Pct. 65 and older 22.7% 23.4% 26.9% 30.5% (Pct. 75 and older) (10.8%) (11.6%) (13.1%) (18.2%) Note: Japan s Baby Boom generation was born in , and its Secondary Baby Boom generation was born in Sources: For 2009, Ministry of Internal Affairs and Communications, "Population estimate"; for , National Institute of Population and Social Security Research, "Japan s Future Estimated Population: 2006 median Estimate" 4

6 Changes in social security benefit expenditures (trillion) (ten thousand) (budget basis) National income (trillion yen) A Total benefit expenditures (trillion yen) B 3.5(100.0%) 24.8(100.0%) 47.2(100.0%) 78.1(100.0%) 105.5(100.0%) (Breakdown) Pensions 0.9( 24.3%) 10.5( 42.2%) 24.0( 50.9%) 41.2( 52.7%) 53.2( 50.4%) Healthcare 2.1( 58.9%) 10.7( 43.3%) 18.4( 38.9%) 26.0( 33.3%) 32.1( 30.4%) Welfare, other 0.6( 16.8%) 3.6( 14.5%) 4.8( 10.2%) 10.9( 14.0%) 20.2( 19.1%) B/A 5.77% 12.15% 13.61% 21.01% 31.36% Pensions Healthcare Welfare, other Per capita social security expenditures Pensions Per capita social security expenditures (right-hand scale) Healthcare Welfare, other Sources: National Institute of Population and Social Security Research, "FY 2007 Social Security Benefit Costs"; FY 2010 (budget basis) is from Ministry of Health, Labor and Welfare statistics; FY 2010 national income is from 2010 Economic Outlook and Basic Stance on Economic and Fiscal Management (Cabinet decision of January 22, 2010) Note: Figures in the chart are social security benefit expenditures (trillion yen) for fiscal years 1950,1960,1970,1980,1990, 2000, 2007, and 2010 (budget basis). For reference: Per capita social security expenditures were 716,000 in FY 2007 and 828,000 in FY (budget basis). (Budget base)

7 2 History of the establishment t of the long-term care insurance system 6

8 Flow of welfare policies for the elderly Decade 1960s Beginning of welfare policies for the elderly 1970s Expansion of healthcare expenditures for the elderly Elderly population pct. 5.7% (1960) 7.1% (1970) 1980s Social hospitalization and 9.1% bedridden elderly become (1980) social problems 1990s 12.0% Promotion of the Gold Plan (1990) Preparation for adoption of long-term care insurance system Major policies 1963 Act on Social Welfare Service for Elderly passed Intensive care homes for the elderly created Legislation on home helpers for the elderly 1973 Free healthcare for the elderly 1982 Passage of the Health and Medical Service Act for the Aged Adoption of payment of copayments for elderly healthcare, etc Establishment of the Gold Plan (10-year strategy for the promotion of health and welfare for the elderly) Promotion of urgent preparation of facilities and in-home welfare services 1994 Establishment of the New Gold Plan (new 10-year strategy for the promotion of health and welfare for the elderly l Improvement of in-home long-term care 1996 Policy agreement by the three coalition parties 14.5% Coalition party agreement on creation of a long-term care insurance (1995) system 1997 Passage of Long-Term Care Insurance Act 2000s Implementation of longterm care insurance system 17.3% (2000) 2000 Implementation of long-term care insurance 2005 Partial revision of the Long-Term Care Insurance Act 7

9 Problems with the system for long-term care of the elderly before adoption of the long-term care insurance system Welfare for the elderly Covered services Intensive care homes for the elderly, etc. Home help services, day services, etc. (Problems) Because municipalities decided types of services and their providers, users could not choose services. Because income verification was required, people felt reluctant to use services. Because municipalities generally provided services directly or via commission, there was no competition and services tended to be uniform. Because copayments were based on the income of the individual and persons with a duty of support (ability to pay), burdens on people with mid-level and high incomes were heavy Healthcare for the elderly Covered services Health facilities for the elderly, convalescent wards in hospitals, general hospitals, etc. Visiting nurses, day care, etc. (Problems) Because medical care was cheaper than welfare service for medium and high-income people and because welfare services infrastructure was insufficient, extended hospital admissions for long-term care became a problem. Compared with intensive care homes for the elderly, costs were higher and healthcare expenditures increased Systems S for the extended recuperation of persons needing long-term care were inadequate in terms of staff and living environments at hospitals intended for patient treatment t t (living i spaces were small, dining i rooms and bathing facilities were lacking, etc.) There were limits on the ability of the systems for elderly welfare/healthcare to respond before adoption of the long-term care insurance system 8

10 The history and significance of the introduction of long- term care insurance As society ages, long-term care needs are increasing in terms of more elderly persons requiring long-term care, longer periods of care, etc. Meanwhile, due to factors such as the trend towards nuclear families and the aging of caregivers, situations are changing for the families that have supported elderly persons needing long-term care. The creation of a mechanism by which society as a whole can provide long-term care to the elderly (long-term care insurance) Support for independence: Beyond simply providing personal care to elderly people who need long-term care, the principle is to support the independence of elderly people. User orientation: A system in which users can receive comprehensive health, medical, and welfare services from diverse agents based on their own choices Social insurance system: Adoption of a social insurance system in which the relationships of benefits and burdens are clear 9

11 Differences in the welfare system for the elderly from the user perspective before and after introduction of the long-term care insurance system Before introduction (1) Apply at a government office; services decided by municipality After introduction Users choose types of services and vendors themselves (2) Apply for healthcare and welfare services separately (3) Services provided mainly by municipalities and public institutions (social welfare councils, etc.) (4) Expensive and hard to use for people with medium or high incomes Example: In the case of a head of household with income of 8 million yen and an elderly parent with a monthly pension of 200,000 yen Intensive care home for the elderly: 190,000 yen/month Home helper: 950 yen/hour Al long-term care services care plan is created, and comprehensive use is made of medical and welfare services Services are provided by diverse vendors, including private-sector firms, agricultural and other cooperatives, non-profits, etc. Regardless of income, users pay 10% Example: In the case of a head of household with income of 8 million yen and an elderly parent with a monthly pension of 200,000 yen Intensive care home for the elderly: 50, yen/month Home helper: 400 yen/30 60 minutes 10

12 3 Basic structure t of the long-term care insurance system 11

13 Structure of Long-Term Care Insurance System Tax 50% Premiums 50% Municipalities Fiscal Stability Funds Municipalities i i (Insurer) Prefectures State 12.5% 12.5%(*) 25%(*) * As for benefits for facilities, the state bears 20% and prefectures bear 17.5%. 20% 30% Premiums Withheld from pensions, in principle Decided based on the population ratio Individual municipality (JFY ) National pool of money Pay 90% of costs Application Users pay 10% of long- term care services in principle, but must pay actual costs of residence and meals National Health Insurance, Health Insurance Society, etc. Service providers In-home service - Home-visit care - Outpatient Day Long-Term Care, etc. Community-based service - Home-Visit at Night for Long-Term Care - Communal Daily Long-Term Care for a Dementia Patient, etc. Facility Service - Welfare facilities for the elderly - Health facilities for the elderly, etc. Use of service Certification of Needed Long-Term Care Insured persons Secondary Insured Primary Insured Person - aged 65 or over Person - aged (28.38 million people) (42.40 million people) Note: Primary Insured Person is from Report on Long-Term Care Insurance Operation (provisional) (April, 2008), Ministry of Health, Labour and Welfare Secondary Insured Person is a monthly average for JFY2008, calculated from medical insurers reports used by the Social Insurance Medical Fee Payment Fund in order to determine the amount of long-term care expenses. 12

14 Matrix of Long-term Care Insurance Services Private Home Home-visit Services Home-visit Care, Home-visit Nursing, Home-Visit Bathing Long-Term Care, In-Home Long-Term Care Support etc. Day Services Outpatient Day Long-Term Care, Outpatient Rehabilitation etc. Short-stay Service Short-Term Admission for Daily Life Long-Term Care etc. Residential Services Daily Life Long-Term Care Admitted to a Specified Facility and People with Dementia etc. Long-term Care Facility In-facility service Facility Covered by Public Aid Providing Long- Term Care to the Elderly, Long-Term Care Health Facility etc. 13

15 Procedures for the Use of Service Use ers lication Municip pality s wind dow for app Invest tigation for cert tification pinion Doctor s o certifica ation Care needs *Community General Support Centers are the core institution for the implementation of prevention benefits and community support projects (see p. 15) Bedridden or demented persons requiring long-term care services Care level 1-5 Persons who might be in need of long-term care and require daily living support Support level 1 and 2 Persons who might be in need of daily living support or long-term care Not applicable ong-term ca are utilizatio on plan (ca are plan) L Care p lan for care pre evention Facility Service Special nursing homes for the elderly Health care facilities for the elderly requiring long-term care Sanatorium Medical Facilities for the Elderly Requiring Long-Term Care In-home service Home-visit care Home-visit nursing Outpatient Day Long-Term Care Short-stay service, etc. Community-based service Small-scale multifunctional in-home care Home-Visit at Night for Long-Term Care Communal Daily Long-Term Care for a Dementia Patient, etc. Long-term care prevention service Outpatient Preventive Long-Term Care Day rehabilitation service for care prevention Home-visit care for care prevention, etc. Community-Based Service for Preventive Long-Term Care Small-scale multifunctional in-home care for care prevention Daily-life life group care for the elderly with dementia for care prevention, etc. Long-term care prevention projects Services which cope with municipalities needs Care benef fits Prevent tive benefit ts* Commun nity suppo rt program m* 14

16 (For reference) Community General Support Centers Abuse prevention and early detection, rights advocacy Comprehensive consultations and support Provides a wide variety of consultations and cross-section support to residents Development of multifaceted support (across systems) Connects with necessary services, from government agencies, public health centers, medical institutions, child consultation offices, etc. Long-term care services Volunteers Comprehensive, ongoing care management support business Daily individual guidance and consultation for care managers Guidance/advice on difficult cases Building of community care manager networks Chief care manager, etc. Certified social worker, etc. Team approach Preventive long-term care support Creation of care plans for persons requiring support Public health nurse, etc. Health services Community rights advocates Medical services Long-term care consultants Adult guardianship Social workers Abuse prevention Prevention of long-term care Care management business Care management for subjects of long-term care prevention projects (creation of care plans, etc.) 15

17 Status of implementation of long-term care insurance system (1) Number of insured persons age 65 and older The number of insured persons age 65 and older increased by about 7.30 million (34%) over 10 years. End of April 2000 End of April 2003 End of April 2010 No. of insured persons million million million (2) Number of persons requiring long-term care (or support) The number of persons certified as requiring long-term care increased by about 2.69 million (123%) over 10 years. End of April 2000 End of April 2003 End of April 2010 No. of persons certified 2.18 million 3.48 million 4.87 million (3) Number of applications for certification of need for long-term care (or support) The number of applications for certification of need for long-term care increased by about 2.31 million (86%) over 9 years. Note: Renewals of certification of needed long-term care were made valid for two years in 2004, so the number of applications was lower in 2008 than in FY 2000 FY 2003 FY 2008 No. of applications 2.69 million 5.47 million 5 million 16

18 4 Act for Partial Revision of the Long- Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (passed June 15, 2011) 17

19 Issues in community-based long-term care and long-term care insurance finances Issues Long-Term Care Insurance Subcommittee, Social Security Council, "Opinion on revision of the long-term care insurance system" (abstract; November 30, 2010) [Issues in community-based long-term care] There are many elderly people requiring long-term care who want to remain in their homes There is a lack of support for elderly-only households and persons needing a high degree of long-term care Demand for human resources in the long-term care field will increase; securing human resources to meet healthcare needs is necessary [Issues in long-term care insurance finances] Increased long-term care costs accompanying expanded service (projected to reach trillion yen in 2025) Long-term care insurance premiums are expected to reach a national average of 5,000 yen during the fifth stage ( ) 2014) Securing the necessary funds in order to continue improving caregiver compensation Basic concept of the revision [Achievement of an integrated community care system] Seamless, organic, and unified provision of healthcare, long-term care, prevention, housing, and livelihood support services Balance between benefits and burdens Balance benefits and burdens by prioritizing benefits and making them more efficient <Spheres of daily life> Livelihood support Housing Longterm care Healthcare Prevention * "Integrated community care system" A community-based system that can appropriately provide, based on need, various livelihood support services, including welfare services as well as healthcare, long-term care, and prevention in spheres of daily life in order to ensure safety, security, and health, it is founded on the principle of provision by the home Generally, areas accessible within 30 minutes; in concrete terms junior high school districts 18

20 Overview of the Act for Partial Revision of the Long-Term Care Insurance Act, Etc., in Order to Strengthen Long- Term Care Service Infrastructure Promotion of the realization of an "integrated community care system" that seamlessly provides healthcare, long-term care, prevention, housing, and livelihood support services so that senior citizens can live independently in their communities 1 Enhanced collaboration between healthcare and long-term care, etc. (1) Promotion of integrated support (integrated community care) incorporating healthcare, long-term care, prevention, housing, and livelihood support services for persons requiring long-term care (see p. 21) (2) Setting of insured long-term care service plans for each sphere of daily life based on a grasp of community needs and issues (see p. 22) (3) Creation of 24-hour regular home visitation and as-needed visitation services and combined services in order to meet the needs of persons requiring long- term care who live alone or require extensive care (see pp ) (4) Enable comprehensive implementation of prevention benefits and livelihood support services based on insurer judgment (see p. 26) (5) Extend the date for elimination of sanatorium long-term care beds (March 31, 2012) (designate no new beds) (see p. 27) 2 Securing human resources for long-term care and improving services (1) Enable the suctioning of phlegm and so on by long-term care public aid workers and long-term care workers with a certain amount of education (see pp. 29 and 30) (2) Extend the revision of the licensing method for long-term care public aid workers (scheduled for April 2012) (see p. 31) (3) Strictly enforce labor regulations at long-term care establishments and add violations of the Labor Standards Act to grounds for disqualification for or revocation of establishments legal designation (see p. 32) (4) Carry out revision of the information disclosure system for long-term care services by eliminating the requirement to carry out surveys before disclosure, etc. (see p. 33) 3 Improving housing for the elderly Add regulations to protect users regarding refunds of advance payments for fee-based homes for the elderly (see p. 35) For reference: Promotion of service-added housing for the elderly through collaboration between the Ministry of Health, Labor and Welfare and the Ministry of Land, Infrastructure and Transport (content of revision of Act on Elderly Person s Housing passed April 27, 2011) (see p. 36) 4 Promotion of measures against dementia (1) Promote advocacy for senior citizens rights in municipalities by training and utilizing citizen guardians, etc. (see p. 39) (2) Incorporate dementia support measures based on community conditions into municipal insured long-term care service plans (see p. 39) 5 Promotion of independent initiatives by insurers (1) Ensure coordination among insured long-term care service plans, healthcare services, and housing (see p. 42) (2) Enable designation of community-based services through public recruitment and selection (see p. 43) 6 Mitigation of insurance premium increases Eliminate each prefecture s fiscal stability fund and use them to mitigate long-term care insurance premiums, etc. (see p. 46) [Date of implementation] Implement 1(5) and 2(2) on their date of promulgation; implement the rest on April 1,

21 4 Act for Partial Revision of the Long- Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (1) Enhanced collaboration between healthcare and long-term care 20

22 The integrated community care system Promotion of integrated support (integrated community care) for persons requiring long-term care through cooperation among healthcare, long-term care, prevention, housing, and livelihood support services [Integrated community care s five perspectives for action] In order to realize integrated community care, it is essential that action be taken from the following five perspectives in an integrated (provision of services through combinations of (1) (5) appropriate to user needs), ongoing (seamless provision of services throughout hospitalization, discharge, and return home) fashion. (1) Enhanced collaboration with healthcare Improvement of in-home healthcare, home-visit nursing, and rehabilitation available 24 hours per day Carrying out of healthcare actions, such as suctioning of phlegm, by long-term care workers (2) Improvement and enhancement of long-term care services Urgent preparation of special nursing homes for the elderly and other sites for long-term care (FY 2009 supplemental budget: enough for 160,000 people over three years) Enhancement of in-home services through the creation of 24-hour regular home visitation and as-needed visitation services, etc. (3) Promotion of prevention Promotion of prevention activities to avoid the condition of need for long-term care to the extent possible and of long-term care that supports independence (4) Ensuring diverse livelihood support services, such as watching, delivering food, and shopping, and rights advocacy In light of the increased number of elderly persons living alone, or in in households with only an elderly couple, or with dementia, promotion of various livelihood support services (watching, food delivery, etc., as well as asset management and other rights advocacy services) ( (5) Maintenance of elderly people s housing so that they can remain in their homes even as they age (collaboration with the Ministry of Land, Infrastructure, Transport and Tourism) Fee-based homes for the elderly and rental housing for the elderly that meet certain standards are set forth as service-added housing for the elderly in the Act on Elderly Person's Housing *Th The "integrated t community care system" "is a community-based system that t can appropriately provide, based on need, various livelihood lih support services, including welfare services as well as healthcare, long-term care, and prevention in spheres of daily life in order to ensure safety, security, and health. It is founded on the principle of provision by the home. Integrated community care areas are "Generally, areas accessible within 30 minutes; in concrete terms junior high school districts." (From the "Report of the Study Group on Integrated Community Care") 21

23 Setting of insured long-term care service (support) plans* that include collaboration between healthcare and housing *Municipalities set three-year insured long-term care service plans and revise them every three years. They began in FY 2000; FY 2011 falls in the fourth three-year period. Aiming for the realization of integrated community care, the fifth plan (FY ) will promote the following initiatives. Performance of a survey of needs in spheres of daily life in order to accurately grasp community issues and needs Plan content will include dementia support policies, in-home healthcare, housing maintenance, and livelihood support Survey of needs in spheres of daily life (Survey by mail and visits to non-responders) In what communities With what needs Do how many seniors live? Grasping and analyzing community issues and needed services Survey categories (examples) Activities of daily living and instrumental activities of daily living (ADL/IADL) Housing situation Dementia symptoms Illness situation Insured long-term care service (support) plans Major areas covered to date Setting of spheres of daily life Projections for each type of long-term care service Necessary capacity for facilities Community support projects (municipalities) Measures to secure human resources for long-term care (prefectures), etc. New content based on actual community conditions Improved dementia support measures Promotion of in-home healthcare Systematic maintenance of housing suitable for the elderly Diverse livelihood services such as watching and food delivery 22

24 Creation of 24-hour regular home visitation and as-needed visitation services (image) In order to support in-home living by elderly people who require long-term care, including those who need extensive care, "regular home visitation and as-needed visitation services" will be created to conduct short regular home visits and as- needed home visits, day or night, with close collaboration between home-visit long-term care and home-visit nursing. Conduct short-hour regular home visits with integration and close collaboration between home-visit long-term care and home-visit nursing care services. Responses to telephone calls from users and home visits on an as-needed basis (Use of ICT devices) Responses on an as-needed basis Telephone calls Short-hour regular home visits Operators(#) Short-hour hour regular home visits * This is to be carried out through close collaboration between home-visit long-term care and home-visit nursing, either through unified provision of home-visit long-term care and home-visit nursing by a single enterprise or performance of home-visit long-term care in close collaboration with an external enterprise providing home-visit nursing. * Collaboration with community healthcare institutions such as in-home treatment support clinics is also important. * They will be positioned as community-based services, with municipalities (insurers) as the actors, and services prepared in each area. # Actual distribution of operators is currently be studied. Conceivably, they might be located in a single site, or respond uniformly from multiple sites, or be part of facilities that already work round the clock, or workers with mobile phones from a single location might respond. 23

25 Creation of combined services Combined services will be created that integrate and provide multiple in-home and community-base services, such as multifunctional long-term care in a small group home (see p. 25) and home-visit nursing. *Community-based services help persons requiring i long-term care to continue living i in the communities to which h they are accustomed. They are provided by familiar municipalities. They comprise community-based services (services for persons requiring long-term care) and community-based service for preventive long- term care (services for persons requiring support). This will enable users to receive flexible multifunctional small group services in accordance with their medical and other needs. Additionally, it will provide enterprises with the advantage of enabling flexible staffing, making it easier to build care systems. Before implementation of revised law Establishment a Establishment b After creation Establishment A (combined establishment) Multifunctional longterm care in a small group home Home-visit nursing Multifunctional long-term care in a small group home + Home-visit nursing *Positioned as communitybased services (to be set by municipalities) Users Because different services are provided by different establishment, coordination and flexible provision of services are difficult. Multifunctional long-term care in a small group home is an important service supporting integrated t community care, but in their current form such homes cannot adequately handle persons requiring long-term care who have extensive medical needs. Users Combining services from a single establishment makes it easier to combine services and provide them more flexibly. Creation of a combined establishment that provides integrated multifunctional long-term care in a small group home and home-visit nursing enables fuller support for persons requiring long-term care who have extensive medical needs. 24

26 (For reference) Overview of multifunctional long-term care in a small group home Multifunctional long-term care in a small group home was created to support continued in-home living even for those requiring moderate to heavy amounts of care. It is centered on "commuting commuting, but in accordance with the conditions and wishes of persons requiring long-term care, it combines services to provide as-needed "visitation" or "overnight stays." (Created April 2006) User home Multifunctional long-term care in a small group home establishment "Visitation" based on condition and wishes "Visitation" Staffing is not fixed, so work can be performed flexibly. No matter which services are used, they are received from a familiar caregiver. Support for in-home living i Use centered on "commuting" "Overnight stays" based on condition and wishes <Users> No more than 25 registered users per location "Commuting" users can be up to half of registered users, or 15 persons "Overnight stay" users can be up to one third of commuting users, or 9 persons <Staffing> Long-term care/nursing staff Daytime: 1 per 3 commuting users + 1 for visitation Nighttime: 2 for overnight stays and visitation (1 may stay overnight) 1 long-term care support specialist <Facilities> Living and dining areas have appropriate space to function adequately For overnight stays, rooms are the size of a 4.5 tatami mat room, and must ensure privacy Users pay a fixed monthly fee depending on the degree of long-term care required 25

27 Comprehensive projects on long-term care prevention and daily livelihood support (image) Systems to comprehensively implement long-term care prevention and daily livelihood support services for persons requiring support and persons targeted by long-term care prevention projects are created based on the judgments of municipalities. In municipalities that adopt projects, municipalities and Community General Support Centers decide whether to respond to pictures of user situations ti and ideas with prevention benefits (see p. 14) or with the new comprehensive services of long-term care prevention and comprehensive daily life support projects (enabling flexible selection of prevention benefits and community support projects [see p. 14]). In accordance with their pictures of user situations and ideas, municipalities are the actors in the provision of diverse services, including long-term care prevention, livelihood support (food delivery, watching, etc.), rights advocacy, and participation in society. Pictu ure of us sers Provision of comprehensive, seamless services to elderly persons who move between requiring support and not being covered Smooth introduction of services for elderly persons who are frail, shut-ins, or otherwise not connected to use of long-term care insurance Provision of opportunities for participation in society and other activities for people with a high desire for independence and participation Community General Support Center Integrated care management Long-term care prevention (visitation/outpatient) Livelihood support (food delivery, monitoring, etc.) Rights advocacy Participation in society The entire community supports the lives of the elderly through comprehensive, diverse services Utilization of diverse workforce Utilization of diverse community Promotion of initiatives that utilize Promotion of services other than social resources community ingenuity long-term care insurance Long-term care insurance providers, nonprofits, volunteers, social workers, etc. Community centers, civic centers, Public health centers, etc. Use of "volunteer point systems," etc. Promotion of food delivery, watching, and other livelihood support services 26

28 Handling of sanatorium long-term care beds [Regulations before implementation of the revised law] Regarding sanatorium long-term care beds, chronic-stage beds were to be reorganized by March 31, 2012, and divided by function according to healthcare needs. In order to provide services suited to user situations, they were to be converted to long-term care facilities such as long-term health care facilities and intensive care homes for the elderly, and the system was to be eliminated. [Situation as of June 2010] In 2006, there were about 120,000 beds. In June 2010, there were still about 86,000, so the conversion from sanatorium long-term care beds was not making good progress. [Response through the revised law] 1. While maintaining the existing policy direction, it extends the conversion period by six years for existing beds. 2. From FY 2011 on, no establishment of new sanatorium long-term care beds will be permitted. 3. Necessary additional policies will be devised in order to promote a smooth transition from sanatorium long-term care beds to long-term health care facilities, etc. 27

29 4 Act for Partial Revision of the Long- Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (2) Securing human resources for longterm care and improving services 28

30 Suctioning of phlegm, etc., by long-term care workers Based on Cabinet decision i and the Prime Minister s i instructions ti on regulatory and system reform, the required legislation l will be passed to enable long-term care public aid workers and other long-term care workers to perform the suctioning of phlegm for people for whom such medical procedures are necessary, enabling safer provision of such services. * In order to utilize human resources in the long-term care field, study of the legislation needed to enable long-term care public aid workers and other long-term care workers to carry out everyday medical care such as suctioning of phlegm and tubal feeding in homes, facilities covered by long-term care insurance, schools, etc., will be promptly undertaken. (Prime Minister s instructions, September 26, 2010) [Situation before implementation of the revised law] Suctioning of phlegm and tubal feeding are considered medical procedures and under the Medical Practitioners Act and other laws may only be performed by physicians or nurses. In exceptional cases, they may be performed by helpers under some circumstances (written consent of the patient, appropriate medical supervision, etc.). Suctioning of phlegm Tubal feeding (4) Gastrotomy (5) Duodenostomy (Jejunostomy) (6) Nasotracheal tubal feeding [Issues] Because they are immediate and compelling necessities, (1) Their legality is uncertain and carrying them out causes anxiety (2) They cannot be performed at group homes, fee-based homes for the elderly, etc. (1) Nasal cavity (2)Oral cavity (3)Tracheal cannula Trachea [Image of system] Revision of the Certified Social Workers and Certified Care Workers Act such that long-term care public aid workers and other long-term care workers who complete additional training can carry out the procedures 29

31 Intent System for long-term care workers to carry out the suctioning of phlegm, etc. (Partial revision of the Certified Social Workers and Certified Care Workers Act) Long-term care public aid workers and other long-term care workers who complete additional training shall be able to perform procedures such as suctioning of phlegm under certain conditions. Suctioning of phlegm and tubal feeding are considered medical procedures and are currently permitted under certain conditions based on justifiable noncompliance with the law. Permitted actions Suctioning of phlegm and other actions required to conduct daily life, when performed under a doctor s instructions * Despite the provisions of the Act on Public Health Nurses, Midwives and Nurses, suctioning of phlegm, etc., can be performed as work supplementing treatment. Concrete actions will be designated by ordinance Suctioning of phlegm (oral cavity, nasal cavity, tracheal cannula) Tubal feeding (gastrotomy, duodenostomy, nasotracheal tubal feeding) The scope of long-term care workers Long-term care public aid workers A concrete training curriculum will be designated by ordinance Long-term care workers other than long-term care public aid workers Prefectural governors will approve those completing specific training Prefectural governments will be able to commission licensing offices Registered training institutions Registered businesses Enterprises that include the suctioning of phlegm, etc., as part of their business shall register each place of business with their prefectural governor (those meeting all conditions may register) Conditions for registration Securing the collaboration of doctors, nurses, and other healthcare personnel Mechanisms for record keeping and other elements of safe and appropriate operation Concrete items will be specified by ordinance * Regulations for notifications and collections of reports necessary for the guidance and supervision of registered businesses will be prepared. <Examples of target facilities/businesses> Facilities for long-term care (intensive care homes for the elderly, long-term health care facilities, group homes, fee-based homes for the elderly, Outpatient Day Long-Term Care, short-term admission for daily life long-term care, etc.) Support facilities for persons with disabilities, etc. (outpatient facilities and care homes, etc.) In-home services (home-visit iitlong-term care, intensive i home-visit iitlong-term care [including travel and destinations], etc.) Special-needs schools *Medical institutions are not targets Source: Study Group on the Proper System for Implementing the Suctioning of Phlegm by Long-term Care Workers, "Interim Summary" Institutions providing training in suctioning of phlegm, etc., will register with prefectural governors (those meeting all conditions may register) Conditions for registration Carries out basic and practical training Engages in training with doctors, nurses, and others as instructors Meets criteria for appropriate and sure provision of training Concrete items will be specified by ordinance * The necessary renewal system, notifications, improvement orders, etc., for the guidance and supervision of registered training institutions will be issued. Date of implementation and transitional measures Implementation April 1, 2012 (Implemented April 1, 2015 for long-term care public aid workers. Even before that, t however, it will be possible with specific training.) Necessary transitional measures so that those currently performing the suctioning of phlegm, etc., under certain conditions can continue under the new system. 30

32 Extension of the revision of the licensing method for long-term care public aid workers [2007 law revision] From the perspective of enhancing the qualifications of long-term care public aid workers, unification of the licensing method through sitting for a national examination following a specific course of education (to have been implemented in FY 2012) (1) Persons with practical experience: in addition to at least 3 years experience, practical training (6 months training) was to be required (2) Persons graduating from a training facility: required to take national exam [Responses through the revised law] With a shortage of personnel in the long-term care field, the revision will make it easier for current workers to undertake practical training. A preparatory period is needed d in order to facilitate t the receipt of training i while working and provide concrete educational support and sufficient publicity directed at current workers, and to smooth implementation of the suctioning of phlegm, etc., by long-term care public aid workers. Therefore, implementation of the revision of licensing methods for long-term care public aid workers will be extended by 3 years (from 2012 to 2015). Practical experience route Training facility route Welfare-education high school route *No change in licensing meth Before 2007 revision 3+ years experience National exam License obtained Graduat ion from training facility License obtained Graduation from a welfareeducation high school National exam License obtained 3+ After years 2007 experi- + revision ence On-the-job training National exam License obtained Graduat ion from training facility Graduation License from a welfare- exam obtained education high school National exam National exam License obtained Extended by 3 years through this bill 31

33 Ensuring strict vendor compliance with labor regulations Promotion of work environment improvements by vendors is important in order to secure human resources in the long-term care field. The rate of violations of the Labor Standards Act by social welfare related businesses, including long-term care businesses, is higher than the average for all industries. In order to promote work environment improvements by businesses, those newly fined for violating the Labor Standards Act will be denied designation as a approved businesses. Cases sent to a prosecutor for violation of the Labor Standards Act (social welfare facilities) cases 15 cases 11 cases Note: About 50% of cases sent to a prosecutor each year are prosecuted (all industries) Comparison of rate of violations of the Labor Standards Act (2008) Social welfare facilities All industries Rate of workplaces in violation 77.5% 68.5% Labor Standards Act Article 24 58% 5.8% 32% 3.2% (failure to pay wages) Labor Standards Act Article 37 (failure to pay extra wages) Minimum Wages Act Article 4 (failure to pay minimum wage) 35.8% 18.1% 4.7% 2.8% * Social welfare facilities include intensive care home for the elderly long term care health facility long term care day service centers short Social welfare facilities include intensive care home for the elderly, long-term care health facility, long-term care day service centers, shortterm admission facilities, home-visit long-term care businesses, and other in-home service businesses, group homes, and fee-based homes for the elderly, as well as daycare centers and welfare centers for people with disabilities. Source: 2008 Annual Labor Standards Inspection Report 32

34 Revision of the long-term care services information disclosure system The long-term care services information disclosure system will be revised from the perspectives of (1) easing the burden on businesses and (2) making it easier for users to understand. [Mechanism before revision of the law] [Content of revision] Businesses were required to report to the prefectural governor any information that would help users make decisions. That information was surveyed and regularly made public. From the perspective of easing the burden on businesses, the operating method will be reorganized. The annual survey requirement will be eliminated. i Prefectures will conduct surveys when they consider it necessary. The mechanism will be able operate without collecting fees. Office work related to disclosure will be made more efficient. Efficiency will be increased through unified national operation of information disclosure servers currently located in each prefecture. Disclosure methods will be devised to make disclosure easier to understand. Search functions and screen displays will be devised. More complete information will be disclosed. In accordance with the wishes of long-term care businesses, prefectures will establish regulations with the intent of disclosing information related to quality of long-term care services and workers in long-term care. 33

35 4 Act for Partial Revision of the Long- Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (3) Improving housing for the elderly 34

36 Addition of regulations to the Act on Social Welfare Service for Elderly in order to protect users of fee-based homes for the elderly Rules on refunds when contracts are cancelled after a short time [Response through revision of the law] In order to protect users, rent, service fees for long- term care and so on, and security deposits may be accepted, but receipt of "rights fees" will be prohibited. [Before implementation of the revised law] The guidelines on establishment and operation of feebased homes for the elderly specify that when contracts t are cancelled within 90 days, all advance payments, minus actual expenditures, should be refunded. However, this is not mandated by the Act on Social Welfare Service for Elderly, so some businesses do not follow this system. [Response through revision of the law] In order to protect users, when contracts with feebased homes for the elderly and group homes are canceled within a certain period after admission, a full refund of any advance payments must be refunded in full, minus actual costs such as rent and service fees. *The problem of lump-sum payments upon admission to fee-based homes for the elderly was discussed by the Consumer Commission, which issued a proposal on December 17, Prohibition of the receipt of "rights fees" [Before implementation ti of the revised law] Regarding advance payments, even today the basis of their calculation must be presented in writing. Unlike rent or service fees, however, the purpose of "rights fees" is unclear to users, which can make it a source of conflict. When a prefecture believes that a fee-based home for the elderly has violated user protection regulations, it will be able to order the business to correct the situation. Noncompliance with such an order shall be punishable by up to six months imprisonment or a fine of up to 500,000 yen. 35

37 (For reference) service-added homes for the elderly Single elderly people or elderly couples living alone who face difficulties in daily life or with long-term care do not have to enter facilities such as intensive care homes for the elderly. They can continue living with peace of mind in their accustomed communities by combining longterm care services from newly established service-added homes for the elderly (Act on Elderly Person s Housing, passed April 17, 2011, joint jurisdiction by the Ministry of Land, Infrastructure and Transport and the Ministry of Health, Labor and Welfare) and 24-hour regular home visitation and as-needed visitation services (Long-Term Care Insurance Act, Ministry of Health, Labor and Welfare). Dissemination of these services will be undertaken. 24-hour home-visit long-term care and nursing Regular home visitation and as-needed visitation services Created by revision of the Long-Term Care Insurance Act Service-added homes for the elderly (joint jurisdiction by Ministry of Land, Infrastructure and Transport and Ministry of Health, Labor and Welfare) Created by revision of the Act on Elderly Person s Housing Clinics, home-visit nursing stations, helper stations, ti day service centers, People can continue living in their accustomed environments while receiving necessary services Regular home visitation and as-needed visitation services (new) 36

38 4 Act for Partial Revision of the Long- Term Care Insurance Act, Etc., in Order to Strengthen Long-Term Care Service Infrastructure (4) Promotion of measures against dementia 37

39 Changes in the number of persons with dementia disorders (patients with vascular or unspecified dementia or Alzheimer s disease as primary complaint) The number of patients with vascular or unspecified dementia or Alzheimer s disease as a primary complaint is increasing. 1,000 persons , アルツハイマー Alzheimer s disease 病 383,000 血 Vascular 管 性 及 or び unspecified 詳 細 不 明 の dementia 認 知 症 321, , , Source: Patient Survey 38

40 Utilization of citizen guardians (see p. 40) Promotion of measures against dementia The number of people with difficulty finding family members and so on to become guardians of adults is expected to increase. The role of the public in serving as guardians of adults mainly in support of contracts for use of long-term care services is likely grow. Municipalities will therefore promote rights advocacy by training citizen guardians and working to use them. *1 Estimated number of people with II or over with daily life dependency level of the elderly with dementia of level II or higher: 2.08 million (2010) 3.23 million (2025) *2 The number of claims related to guardians of adults are increasing annually (2009: 27,397 cases) Number of claims by heads of government: 1,564 cases (FY 2007) 1,876 cases (2008) 2,471 cases (2009) Promotion of research on dementia The national and local governments will work to promote research on dementia, prevention, diagnosis, and treatment, as well as methods of long-term care that accord with the physical and mental characteristics of people with dementia. Inclusion of dementia support measures in municipal i insured long-term care service plans Municipalities will work to incorporate dementia support measures based on community conditions into their insured long-term care service plans. (Image of how citizen guardians could be used) Municipality (4) Recommendation of candidates (5) Appointment of citizen guardians Citizen guar rdians ty of ship, etc. Dut guardian Adult (Senior with dementi a) (3) Sending of list of people who have completed training (1) Commission Family court (6) Specialist support Implementing organization [(2) Performance of citizen guardian training] 39