Prof. Takako Tsutsui. Education and Degrees. Research Areas. Professional Societies

Transcription

1 Prof. Takako Tsutsui Present title: Chief Institute: Administration, Department of Social Services and Public Health, National Institute of Public Health, Ministry of Health, Labour and Welfare, Japan Education and Degrees Department of Public Health, School of Social Medicine Faculty of Medicine, The degree of Ph.D. in Medical Graduate School of Science and Technology Faculty of Architecture, The degree of Ph.D. in Engineering Master's Program in Education, Faculty of Social Science, University of Tsukuba etc. The degree of MSc in Sociology and The degree of MSc in Education Research Areas Clinical Evaluation in Health and Social Service Area Public Health Applied Physics Applied statistics Social Science Professional Societies The Gerontological Society of America The American Geriatrics Society American Physical Society Sleep Research Society Architectural Institute of Japan Japanese Society of Public Health The Japan society of Healthcare administration Japanese Society of Epidemiology Japanese Society for the Study of Social Welfare Japan Socio-Gerontological Society

2 Overview of Payment Systems in Japan s Long-Term Care Insurance System and Development of an Assessment Tool for Care Needs Certification as an Essential Part of Insurance Prof. Takako Tsutsui, Ph.D. I will address mainly two issues in today s speech. The first concerns the funding and allocation of the resources of the long-term care insurance system. The second concerns an assessment tool developed specifically for Japan and used in the long-term care needs certification system. First, I will explain how funds are raised, who is managing the system, and the mechanism behind this management. Second, I will speak about the assessment tool and, more specifically, the peculiarities of long-term care needs certification, a system different to that of other countries. This unique system, having gained a positive international reputation, will be the focus of this speech. I will also explain how the level of long-term care needs is assessed in Japan and the logic behind how computers are used to estimate the quantity of long-term care services. Such a method was implemented due to a strong desire in the government to administer the system on the basis of a scientific approach, and the same desire is probably shared within the Taiwanese government. Since this method might be useful not only for Taiwan but also for other Asian countries, I will explain the Japanese system in detail. Finally, it is important to note that both Japan and Taiwan have a common cultural background regarding Confucian thought and that both are facing issues due to a rapid increase in the elderly population. Japan has established a long-term care insurance system before other Asian countries, and I will address a few key points for designing such a system.

3 Today s topics Ⅰ. How insurers secure a source of revenue, and how they allocate the resources 1. How insurers secure a source of revenue 2. Who pays insurance premiums 3. How they allocate the resources 1 Today s topics Ⅱ. Development of Assessment Tools in Japan s Long Term Care Insurance System 1. The necessities of the long term care need certification system 2. The three times revised assessment tool and its items 2

4 Difference between the Previous System and Long-Term Care Insurance System from the Users Point of View Previous system (1) Apply at the administrative office contact point, and municipalities determine the service. (2) Apply separately for medical care and welfare services. (3) Services provided mainly by municipalities and public organizations (Council of Social Welfare, etc.). (4) For middle and high income earners, services are hard to use due to an expensive cost to bear. e.g. In the case where the householder s annual employment income is 8 million yen, and his or her elderly parent receives a pension of 200,000 yen per month: Special nursing home for the elderly will cost 190,000 yen per month Home helper service will cost 950 yen per hour. Long-term care insurance system (at the time of revision) Users can choose the type of service and facilities they use. Users will make a long-term care service usage plan (care plan) and use medical care and welfare services comprehensively. Services provided by various organizations such as private companies, agricultural cooperatives, consumers cooperatives, and NPO, etc. Users will pay 10% charge for the service regardless of their income. e.g. In the case where the householder s annual employment income is 8 million yen, and his or her elderly parent receives a pension of 200,000 yen per month: Special nursing home for the elderly will cost 50,000 yen per month Home helper service will cost 400 yen every 30 to 60 minutes. 3 How does insurance work? Social insurance is a system of persons helping each other in order to manage various crises that can happen in life and lead to loss of income. Japan s long term care insurance system was built to face the increasingly serious problem of providing long term care to the elderly. The main difference between social insurance and private insurance is the obligatory nature of the participation in social insurance. 4

5 1.How insurers secure a source of revenue 5 Resource of Long Term Care Insurance/System DE Premium FR Tax JP Exclusive self payment Premium:Tax=1:1 6

6 Insured of Long Term Care Insurance DE Insured under medical insurance (All affiliates, regardless of their age) JP Category 1 insured: 65 years and over Category 2 insured: Persons aged 40 to 64 who are insured by health care insurance (In this category, actual beneficiaries of the LTC insurance are only people suffering from specific deceases) 7 2. Who pays insurance premiums Category 1 Insured Persons :aged 65 and older Precisely speaking, we can say that persons participating in insurance programs are local residents aged 65 and older. 8

7 How the Category 1 Insured Persons premiums are collect The Category 1 Insured persons are divided into six different sub groups according to premiums paid, each fitting a different level of residence tax imposition. The institution in charge of managing pensions (Japan Pension Organization and Federation of Mutual Association) notifies each Category 1 Insured Person of the premium amount. 9 How premiums are collected from the Elderly (Category 1 Premium) From the standpoint of having people bear the cost in response to their ability to pay and giving special consideration to low-income earners, the Category 1 premiums are divided into 6 levels according to municipal residence tax, etc., imposed on each insured person. Premiums from the Category 1 insured 20% (average) State 25% Premiums: multiplication 1.5 of the standard amount (level ) Insured person being exempted from municipal residence tax 1,501 TWD per month (national average) Insured person paying municipal residence tax Premiums from the Prefectures Category 2 insured contribution 12.5% 30% Municipalities contribution 12.5% 0.5 Level 1 Level 2 Level 3 Level 4 Level 5 Level 6 Income Level 1 Welfare recipients Level 2 All members of a householdbeing exempted from municipal inhabitant taxes, and only if annual pension of the insured person is less than 293,527 TWD (and other conditions) Level 3 All members of a householdbeing exempted from municipal inhabitant taxes, and only if the annual pension benefit of the insured person exceeds 293,527 TWD (and other conditions) Level 4 The insured personbeing exempted from municipal inhabitant tax but at least one municipal inhabitant tax payer is in the household. Level 5 The insured person paying municipal inhabitant tax and having an income of less than 733,818 TWD. 1 TWD =2.72 JPY Level 6 The insured person paying municipal inhabitant tax and having an income of733,818 TWDor more 10

8 Category 2 Insured Persons :aged People aged from 40 to 64 who already pay for medical care insurance are known as the Category 2 Insured Persons aged Furthermore, as most people under 64 are employed, their long term care insurance premiums can be collected at the same time as their medical insurance premiums. This also means that participation in medical care insurance is another necessary condition to be considered a Category 2 Insured Person. 11 How the Category 2 Insured Persons premiums are collected <step1> The amount that the medical insurers have to collect is a percentage of the total expenses for all the municipalities longterm care insurance benefit (30 % for the term ), and this amount is divided between the Category 2 Insured Persons of the whole country. 12

9 How the Category 2 Insured Persons premiums are collected <step2> This amount is collected by medical insurers together with the medical insurance premiums and with the same procedure. The amount collected by medical insurers is then put into the Social Medical Fee Payment Fund, a fund that will be used to equally deliver an amount equal to 30 % of the insurance expenses of each municipality. 13 How the Category 2 Insured Persons premiums are collected <step3> If municipalities total expenses for the long term care insurance benefit exceed the provision, the amount that medical insurers collect from the Category 2 Insured Persons will be insufficient. 14

10 System of insurance premiums for the Category 2 Insured Persons Calculation of the insurance premium per person of the Category 2 (30% of insurance expenses divided by the numbers of persons in category 2 equals premium amount per person) Financial burden matching the number of insured Japan Health Insurance Association Mutual Aid Health Insurance Mutual Aid Association National Health Insurance Organization Premiums are collected uniformly with the medical insurance premium Pooled in the Social Medical Fee Payment Fund Municipalities allocate the fund to each insured person of the Long term care insurance How they allocate the resources a) Who manages long term care insurance b) How much users have to pay c) How the long term care insurance benefits are financed 16

11 a) Who manages long term care insurance DE Insurers of Long Term Care Insurance Private Insurance FR Mainly Prefecture JP Insurers = Municipalities Private Insurance represents a very small scale 17 The Long-term Care Insurance Scheme is operated in three-year cycles. Municipal governments formulate a long-term care insurance service plan where three years are regarded as one phase (the first and second phase actually lasted five years) and review it every three years. Insurance premiums are set every three years based on projected service costs specified in a service plan so that financial conditions can be balanced throughout the next three years. (Insurance premiums are not changed during such three years.) Operation period (FY) Service plan Benefits Insurance premiums The first phase The second phase The third phase The first phase The second phase The third phase 1,068 TWD (National average) 1,208 TWD (National average) 1,501 TWD (National average) 18

12 b) How much users have to pay The insurance benefit pays for 90 % of the expenses; the remaining 10 % being paid by the user. 19 The insurance benefit pays 90% 100% 10% Care service expenses Food expenses accommodation expenses daily life expenses Expenses paid by the user benefits 20

13 c) How the long term care insurance benefits are financed 21 Tax 50% Premiums 50% Financial structure of Long-Term Care Insurance System Premiums Municipalities (Insurer) Municipalities Prefectures 12.5% Finance Stabilizing Fund 12.5% 20% 30% Decided based on the population ratio Individual municipality State 25% (JFY ) National pool of money Pay 90% of costs Application National Health Insurance, Health Insurance Society, etc. Housing and food expenses 10% copayment Service providers In-home service - Home-visit care - Day service for care, etc. In-facilities service - Welfare facilities for the elderly - Health facilities for the elderly, etc. Use of service Care needs certification Insured persons Category 1 Insured Persons - aged 65 or over Category 2 Insured Persons - aged (27.27 million people) (42.76 million people) 22

14 Policyholders contribution to the insurance expenses (in percentage of total expenses) 1Long-term care expenses (all expenses minus copayment) are financed one-half by taxes and one-half by premiums. 2As for premiums, 20% of them would be paid by Category 1 insured persons and 30% by Category 2 insured persons. 3As for taxes, the state bears 25%, and prefectures and municipalities bear 12.5% respectively. (As for facilities expenses, however, the state bears 20%, and prefectures and municipalities bear 17.5%.) 4Of 25% of expenses borne by the state, 5% is provided as adjustment grants which aim at adjusting insurance finance of municipalities 23 Expenses variation 30 % 50 % Expenses expectations Actual expenses Premiums of the 2 nd group of policyholders (30%) Each medical insurer collect the premium along with the usual medical insurance premium and this constitutes the Social Medical Fee Payment Fund Public funds State: 20%of the expense forin home benefits (15%of the expense forin facility benefits) Prefecture: 12,5%of the expense forin home benefits (17,5%of the expense forin facility benefits) Municipality: 12,5% Adjustment on last year 20 % State adjustment subsidies (average of 5%) Premiums of the 1 st group of policyholders (average of 20%) Special collection from pension credit Normal collection Compensation/Loan Fund for Fiscal Stability Premiums actually collected Fiscal deficient due to unpaid premiums 24

15 However, regarding premiums paid by the Category 1 Insured Persons, deficits will occur due to an unexpected increase in insurance expenses or a lower percentage of the amount collected. It is impossible to change the amount of the premium in the middle of a fiscal year, prefectural and city governments can borrow the deficient amount from the fund to maintain fiscal stability. They can also be compensated for half of the deficit occurring due to a low collected amount. These were respectively referred to as loan and compensation in the last slide. The amount borrowed is reimbursed the next year by the Category 1 Insured Persons,when the amount of premiums for the group is calculated at the beginning of the next term, the amount that has to be reimbursed is added to this premium amount. The Fund for Fiscal Stability comprises contributions from the state, the prefectural and city governments, and the municipalities. 25 Today s topics Ⅱ. Development of Assessment Tools in Japan s Long Term Care Insurance System 1. The necessities of the long term care need certification system 2. The three times revised assessment tool and its items 26

16 Institution Determining the Care Level DE FR Judgment by MDK Jointly established by the health insurance funds in each state Judged by the prefecture JP Certification examination committees established in the municipalities 27 The requirments of the long term care need certification system Setting a scale that can measure the level of need regarding long term care (LTC) conditions requires both objective standards and procedures in order to decide above which level a person has access to LTC services and how much services fit this level. These standards for the certification of LTC and the procedure that goes along is referred to as the LTC need certification system. 28

17 Procedures for the Use of Service Users Municipality s window for application Investigation for certification Doctor s opinion Certification of long-term care need Bedridden or demented persons requiring long-term care services Care level 1-5 Persons who might be in need of longterm 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 Long-term care utilization plan (care plan) Care plan for care prevention In-facility service Special nursing home for the elderly Health care facilities for the elderly requiring long-term care Sanatorium type medical care facilities for the elderly requiring care In-home service Home-visit care Home-visit nursing Day service Short-stay service, etc. Community-based service Small-scale multifunctional in-home care Nighttime home-visit long-term care Daily-life group care for the elderly with dementia, etc. Long-term care prevention service Day care for care prevention Day rehabilitation service for care prevention Home-visit care for care prevention, etc. Community-based long-term care prevention service Small-scale multifunctional in-home care for care prevention Daily-life group care for the elderly with dementia for care prevention, etc. Long-term care prevention projects Services which cope with municipalities needs Preventive benefits Community support program Care benefits 29 Method of research Time Sampling Survey Ⅰ Ⅱ Ⅲ Ⅳ Elderly Caregiver Researcher We were able to collect data on some 10 million minutes of in-home services provided. 30

18 public sector (51 nursing care facilities) What types? Ⅱ eg. Move from bed to Take off one s Help patient sit up in wheelchair seconds shoes seconds bed seconds Dress seconds Help move in to Help move in Help move in wheelchair seconds wheelchair wheelchair seconds seconds We measured the specific amounts of time that caregivers spent performing various types of services for these seniors, each of whom had his own unique characteristics. 31 An efficient needs assessment program There was a question of assessment standards.?? Full assistance for daily living? You need care???? Is he Independent??? You don t need care Once a decision has been made regarding eligibility, it would be necessary to devise a system to rank the eligible people according to their long-termcare needs. 32

19 Initial Decision Assessment-data put into computer 73items +12items Initial assessment outcome Result of Basic questions(73 items) + Result of Medical care received during 14days (12 items) past =85-item 7scores (Aging Indicator for 7status Quo) (1)Paralysis, joint constriction;(2) Movement; (3) Complex Actions;(4) Special care;(5) Personal care;(6) ommunication/understanding; and (7) Problem behavior. Estimate nursing care times (1) Grooming;(2) elimination;(3) eating; (4) bathing;(5) moving;(6) Indirect living assistance; (7) Assistance for behavioral problem;(8) Rehabilitation activities;and (9) Medical care activities questions NO ITEM NO ITEM 1 1 Paralysis, left arm 5 7 putting on and taking off bottom wears 1 2 Paralysis, right arm 5 8 putting on and taking off socks 1 3 Paralysis, left leg 5 9 room cleaning 1 4 Paralysis, right leg 5 10 self-management of medication 1 5 Paralysis, other parts 5 11 handling money 1 6 Limitation of mobility, shoulder 5 12 serious forgetfulness 1 7 Limitation of mobility, elbow 5 13 indifference to surroundings 1 8 Limitation of mobility, hip 6 1 eye sight 1 9 Limitation of mobility, knee 6 2 hearing ability 1 10 Limitation of mobility, ankle 6 3 communication ability ability to understand caregivers' instructions 1 11 Limitation of mobility, other(s) Turns over in bed 6 5 understanding daily routine 2 2 Sitting up in bed 6 6 recognizing date of birth 2 3 Sitting with feet on floor 6 7 memory just before the interview 2 4 Sitting without feet on floor 6 8 remembering one's own name 2 5 standing upright on both feet 6 9 Recognizing the current season 2 6 Walking 6 10 Recognizing where he/she is 2 7 locomotion 7 1 Feeling persecuted 3 1 Standing up from a sitting position 7 2 Making up stories 3 2 Standing on one foot 7 3 hallucination 3 3 getting into and out of the bath tub 7 4 emotionally unstable 3 4 bathing 7 5 Reversal of day and night 4 1 bedsore 7 6 Verbal/ physical violence 4 2 other skin problems 7 7 Repeating the same story 4 3 Lifting one arm to chest height 7 8 Shouting 4 4 Swallowing 7 9 Resisting care 4 5 desire to urinate 7 10 moving around 4 6 desire to defecate 7 11 Restlessness 4 7 clean-up after urination 7 12 getting lost on one's way home 4 8 clean-up after defecation 7 13 need of observation 4 9 Taking meals 7 14 Collecting things inappropriately 5 1 Oral hygiene 7 15 unable to manage fire 5 2 Face Washing 7 16 damaging things or clothes 5 3 Hair dressing 7 17 Playing with feces 5 4 Nail cutting 7 18 Putting inedible things into mouth 5 5 bottoming and unbuttoning 7 19 Troublesome sexual behavior 5 6 putting on and taking off 7 20 Treatment 12 questions related to medical treatment ITEM 1 Management of Drip Infusion into Vein 2 Intravenous hyper alimentation 3 Dialysis 4 Care for artificial anus 5 Oxygen therapy 6 Artificial ventilator 7 Care for incised trachea 8 Pain care 9 Tube feeding Monitoring (blood pressure, palms, oxygen 10 saturation,etc.) 11 Bedsore care Catheter (condom catheter, indwelling 12 catheter, etc.) outcome 0.01sec Assessment Initial assessment system Initial Decision 34

20 Assessment of Care Needs Certification in the Long Term Care Insurance System * What is focused when certifying elderly people? The applicant s Standardized scores for the dimensions of physical and mental status Inability to act (disability) Cannot stand up Cannot eat Cannot turn around in bed Has difficulties walking, etc. Impairment of physical and mental functions (impairment) Hearing loss Blindness Mental impairment Cut off extremities etc. Care is provided for compensating the inability Social disadvantages (handicaps) Cannot work in a paid job Cannot deal with people etc. Necessary time for caring (calculated by time study) Used as an indicator for determining the quantity of care Required quantity of the services (The time index for Care Needs Certification) 35 Development of assessment tool 36

21 Revision of 2003 Adjustment of the criteria regarding the demented elderly who have mobility In order to be able to adjust the final decision of the care need level (final decision) for the demented elderly (whose wanderings can have no purpose), the reform of 2003 introduced two checkboxes, allowing an upgrade of the care need of one or even two level. (The initial decision) (The initial decision) (Care level 2) (Care level 4) (mins) (The time index for Care Needs Certification) 37 Revision of 2006 Care level 1 Former category Preventive care benefit A new distinction in the care need certification to introduce the Preventive care benefit The initial decision made by computer could only distinguish care level from 1 to 5. In order to allow the distinction between support level and care level, we started to take into consideration both dementia and ADL during the final decision. Care benefit Category after 2006 s revision Support level1 Support level2 Care level2 Care level5 Care level4 Care level5 Care level1 Category before revision in 2006 : Support level Care level1 Care level2 Care level3 Care level4 Care level5 38

22 Revision of 2009 A new method of distinction within the former category Care level 1 The new method of distinction is based on two approaches. 1) Cognitive Function decreasing A tool to assess the degree of autonomy of the elderly with dementia is used, even now, during the final decision process. 2)Instability of Function Following the logic of a discriminant analysis, we were able to distinguish support level from care level during the initial decision process. Method used:we looked at the data gathered until 2008, and isolated the persons who had gone through the certification process twice until now and were assessed care level 1 or support level 2 at their first certification (126,231 persons). Then, we proceeded to a discriminant analysis to distinguish the elderly whose condition got worse at their second certification from those whose condition improved or stayed the same. 39 Revision of 2009 Regarding demented the elderly who have mobility Before the revision:the adjustment that occurred during the final decision process regarding the demented elderly who have an ability to move was not homogeneously made in every municipality. Countermeasure:Instead of an automatic upgrade of care level, we added the necessary time of care to the total given by the Time index, leading eventually to an upgrade of level. Notation in investigation format before 2009 s revision (care level 1) (care level 2) (The initial decision) (mins) (The time index for Care Needs Certification) (The initial decision) After 2009 s revision (care level 1) (care level 2) (mins) (mins) (mins) (The time index for Care Needs Certification) Support level1 Care level 2 Care level 4 the check mark for the certification examination committee Time added to the Time Index for people with dementia who have mobility. Support level 2 / Care level 1 Care level 3 Care level 5 40

23 Certification Assessment Items(2000) (1)Paralysis and limitation of joint movement Paralysis,the left arm Paralysis,the right arm Paralysis,the left leg Paralysis,the right leg Paralysis,other parts Limitation,shoulder Limitation,elbow Limitation,hip Limitation,knee Limitation,ankle Limitation,other(s) (2)Movement and balance Turns over in bed Sitting up in bed Sitting with feet on floor Sitting without feet on floor Standing on both feet Walking Transferring (3)Complex movement Standing up from a sitting position Standing on one foot Standing over the rim of the bath tub bathing (4)Conditions requiring Special assistance Bedsore(decubitus) Other skin diseases Lifting one arm to his/her breast Swallowing(Deglutition) Feels for voiding Feels for defecation Management after voiding Management after defecation Taking meals(dietary intake) (5)Conditions requiring assistance with activities of daily Oral hygiene(tooth brushing) Face Washing Hair dressing Nail cutting Putting on and takes off buttons Putting on and takes off a jacket Putting on and takes off trousers Putting on and takes off socks Cleaning rooms Taking medication Financial management Serious failing memory Indifference to circumstances (6)Communication and cognition Vision (acuity) Hearing (audibility) Sending will Responding to instructions Understanding a daily schedule Answering date of birth and age Immediate memory Remembering own name Recognizing the season Recognizing the place (7)Behavioral problems Feeling persecuted Making up stories (fabulation) Visual or auditory hallucination Unstable emotional state Reversal of day and night Verbal or physical violence Repeating same story Shouting Resisting advice or care Wandering Restlessness Being lost out of one's residence Insisting on going out alone Collectionism Inability to manage the fire Destruction of things or clothes Dirty behavior Putting inedible things into mouth Troublesome sexual behavior 41 Revision of 2003 Items removed Sitting without feet on floor Feels for voiding Feels for defecation Management after voiding Management after defecation Putting on and takes off buttons Putting on and takes off socks Cleaning rooms Revision of 2006 Items removed None Revision of 2009 Items removed Limitation,elbow Limitation,ankle Pressure sore cutaneous disease drinking Resisting advice or care Shouting Restlessness Verbal or physical violence Indifference to circumstances Troublesome sexual behavior Reason for the removal: The decision was made by the Certification committee, which means that data were no longer objective, leading to Heterogeneous results. Insisting on going out alone Inability to manage the fire Dirty behavior Putting inedible things into mouth Tolerance of changing Environment Using telephone Responding to instructions Unstable emotional state Repeating same story Daily life frequency of going out Items added Moving around Defecation Urination Drinking Using telephone Reason for the addition: allowing estimation of the elderly condition through an analysis Making everyday decisions of data gathered until now. Items added Daily life frequency of going out frequency of social participation Items added Talks without coherence, no conversation possible Buying Cooking Acts as he/she likes Speaks and laughs to himself/herself without sense Non adaptation to groups 42

24 Revision of 2009: Certification Assessment Items Group 1 Body functions / standing and sitting movements Group 2 Daily life functions Group 3 Cognitive functions "1 1 Existence of paralysis, etc. (5)" "1 2 Contraction of joints (4)" "1 3 Turning in bed" "1 4 Rising up" "1 5 Remaining in sitting position" "1 6 Standing with both feet" "1 7 Walking" "1 8 Standing up" "1 9 Standing with one foot" "1 10 Body washing" "1 11 Fingernail clipping" "1 12 Power of vision" "1 13 Power of hearing" "2 1 Transfer" "2 2 Moving around" "2 3 Swallowing" "2 4 Taking meals" "2 5 Urination" "2 6 Defecation" "2 7 Oral hygiene" "2 8 Face washing" "2 9 Hair washing" "2 10 Dressing/undressing of tops" "2 11 Dressing/undressing of trousers, etc." "2 12 Frequency of going out" Group 4 Mental / behavioral impairments "4 1 Inflicts damage saying, for example, that something was stolen" "4 2 Makes up stories" "4 3 Emotions are unstable, crying and laughing" "4 4 Day and night are reverted" "4 5 Says the same things over and over" "4 6 Speaks with a loud voice" "4 7 Resists care" "4 8 Is restless, saying "I want to go home", etc." "4 9 Wants to go outside on his/her own and cannot be left unobserved" "4 10 Collects various things, and brings them without permission" "4 11 Breaks things and rips up clothes" "4 12 Serious memory loss" "4 13 Speaks and laughs to himself/herself without sense" "4 14 Acts as he/she likes" "4 15 Talks without coherence, no conversation possible" "3 1 Communication of intentions" "3 2 Understanding of daily tasks" "3 3 Can say birthday and age" "3 4 Short term memory" "3 5 Can say own name" "3 6 Understands current season" "3 7 Understands location" "3 8 Wandering" "3 9 Cannot return when going out" Group 5 Adaptation to social life "5 1 Taking of oral medicine" "5 2 Management of money" "5 3 Making everyday decisions" "5 4 Non adaptation to groups" "5 5 Shopping" "5 6 Easy cooking" "Regarding special medical treatment (12)" 43 Certification logic at the time of the system revision in Physical and mental condition indices Body functions / standing and sitting movements Attribute data of the research items (74 basic attributes of the elderly person) Time study data 3488 sets (Data on the time) Daily life functions Mental / behavioral impairments Cognitive functions Sociallyadapted life Power of hearing Power of vision Paralysis H001: Bathing preparations 250 items Give scores (standardization of category scores) to the selection branches of the research items from the results of the research items (74items) Use the dual scaling method as the statistical method to integrate the attributes of the elderly person Tree regression Primary model project data from fiscal 2007 (data from 34,000 elderly persons) Tree model 44

25 We have succeeded in maintaining the principle of "universality" in the nursing care needs assessments made throughout the country. Village Central government Care Needs Certification Support Center in Tokyo Township Village Village City Township Village City City Village Township The amount of care needs time all over Japan can be calculated by using the accumulated information in our governments data base. This information can also be used to make budgets for future years,and help us to predict the number of people who will be needing long term care services in the future. 45 Certification in the long term care insurance system in Japan reached the system as presented above after considering the following three elements Health insurance system: The quantity of services provided to the patient are decided by the medical doctor upon medical assessment. Long term care insurance system: Initial assessment (using a computer) on the basis of the certification research results Final certification to determine the care level by LTC certification committee, which consists of experts including medical doctors Research Initial assessment Final certification *Based on objective data from the research, a computer is used to estimate the time required for care *Determine the care level on the basis of the Initial assessment result and physicians' statement Feasibility Currently, million persons are certified as requiring long term care (support) (as of September 2008). The total number of valid applications is million (April 2008 to December 2008) Cost The cost of the clerical work for the care requirement certification was 61.6 billion Yen (estimated) in fiscal 2003, which corresponds to about 1% of the costs for the long term care benefits. A large amount of additional costs are anticipated if all applicants are certified by medical doctors. ObjectivityCheck the condition of the applicant by comparing it with standards. Certification procedures do not depend on personal quality of the certification research staff. 46