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Background The demand for home healthcare is increasing in Japan, and a 24-hour on-call system could be a burden for primary care physicians. Identifying high-risk patients who need frequent emergency house calls could help physicians prepare and allocate medical resources. The aim of the present study was to develop a risk score to predict the frequent emergency house calls in patients who receive regular home visits. Methods We conducted a retrospective cohort study with linked medical and long-term care claims data from two Japanese cities. Participants were ≥ 65 years of age and had newly started regular home visits between July 2014 and March 2018 in Tsukuba city and between July 2012 and March 2017 in Kashiwa city. We followed up with patients a year after they began the regular home visits or until the month following the end of the regular home visits if this was completed within 1 year. We calculated the average number of emergency house calls per month by dividing the total number of emergency house calls by the number of months that each person received regular home visits (1–13 months). The primary outcome was the “frequent” emergency house calls, defined as its use once per month or more, on average, during the observation period. We used the least absolute shrinkage and selection operator (LASSO) logistic regression with 10-fold cross-validation to build the model from 19 candidate variables. The predictive performance was assessed with the area under the curve (AUC). Results Among 4888 eligible patients, frequent emergency house calls were observed in 13.0% of participants (634/4888). The risk score included three variables with the following point assignments: home oxygen therapy (3 points); long-term care need level 4–5 (1 point); cancer (4 points). While the AUC of a model that included all candidate variables was 0.734, the AUC of the 3-risk score model was 0.707, suggesting good discrimination. Conclusions This easy-to-use risk score would be useful for assessing high-risk patients and would allow the burden on primary care physicians to be reduced through measures such as clustering high-risk patients in well-equipped medical facilities.

This study aims to investigate the factors of care-level deterioration in older adults with mild and moderate disabilities using nationally standardized survey data for care-needs certification. We enrolled people aged 68 years or older, certified as support levels 1–2 (mild disability) or care levels 1–2 (moderate disability) with no cancer. The outcome was care-level deterioration after two years. The possible factors were physical and mental functions which were categorized as the following five dimensions according to the survey for care-needs certification: body function, daily life function, instrumental activities of daily living (IADL) function, cognitive function, and behavioral problems. A multivariate logistic regression analysis was conducted after stratifying the care level at baseline. A total of 2844 participants were included in our analysis. A low IADL function was significantly associated with a risk of care-level deterioration in all participants. In addition, low cognitive function was linked to care-level deterioration, except for those with support level 1 at baseline. Participants with more behavioral problems were more likely to experience care-level deterioration, except for those with care level 2 at baseline. Our study showed the potential utility of the care-needs certification survey for screening high-risk individuals with care-level deterioration.

Secondary prevention with medications is essential for the better prognosis of patients who have experienced cardiovascular events. We aimed to evaluate the use of guideline-based medications for secondary prevention in older adults in the community settings after discharge following percutaneous coronary intervention (PCI). A retrospective cohort study was conducted using anonymized claims data of older beneficiaries in a suburban city of Japan between April 2012 and March 2015. The prescriptions of antiplatelets, statins, angiotensin-converting enzyme inhibitors (ACEi)/angiotensin II receptor blockers (ARB), and β-blockers were evaluated for 3 months before and after the month in which the participants underwent PCI. Multivariable logistic regression analysis was conducted to evaluate the associations of age ("pre-old" group [63-72 years] vs. "old" group [≥ 73 years]) and sex with the prescriptions, adjusting for whether a participant was followed-up by the PCI-performing hospital. Of 815 participants, 59.6% constituted the old group and 70.9% were men. The prescription rates for antiplatelets, statins, ACEi/ARB, and β-blockers after discharge were 94.6%, 65.0%, 59.3%, and 32.9%, respectively. The adjusted analysis indicated that statins were less likely to be prescribed for the old group (adjusted odds ratio [aOR], 0.70; 95% confidence interval [CI], 0.51-0.95; p = 0.023) and for men (aOR, 0.64; 95% CI, 0.45-0.89; p = 0.008). β-blockers were more likely to be prescribed for men (aOR, 1.66; 95% CI, 1.17-2.33; p = 0.004). Our results suggest the potential for improvements in secondary prevention by increasing the prescription rates of guideline-based medications in this population.

To examine the effects of early postdischarge rehabilitation on care needs-level deterioration in older Japanese patients.Propensity score-matched retrospective cohort study.A secondary data analysis was conducted using medical and long-term care insurance claims data from a suburban city in Japan.We analyzed patients (N=2746) aged 65 years or older who were discharged from hospital to home between April 2012 and March 2014 and had care needs certification indicating functional impairment.The provision of early rehabilitation services by rehabilitation therapists within 1 month of discharge. Propensity score matching was used to control for differences in characteristics between patients with and without early rehabilitation services.Any deterioration in care needs level during the 12-month period after discharge. Cox proportional hazards analyses were conducted to identify the association between the exposure and outcome variables after matching.Among 2746 patients, 573 (20.9%) used early rehabilitation services. Care needs-level deterioration occurred in 508 patients (incidence: 18.3 per 1000 person-months), of which 76 used early rehabilitation services (12.3 per 1000 person-months) and 432 did not use early rehabilitation services (20.0 per 1000 person-months). One-to-one propensity score matching produced 566 matched pairs that adjusted for the differences in all covariables. In these matched pairs, the hazard of care needs-level deterioration was significantly lower among patients who used early rehabilitation services (hazard ratio=0.712, 95% CI, 0.529-0.958). A Kaplan-Meier survival analysis showed similar results (log-rank: P=.023).Early rehabilitation services provided by rehabilitation therapists after hospital discharge appeared effective in preventing care needs-level deterioration, and involving rehabilitation therapists in transitional care may aid the optimization of health care for older Japanese adults with functional impairment.

ObjectiveTo assess the association of coprescribed medications for chronic comorbid conditions with clinical dementia in older adults, as indicated by the initiation of a new prescription of antidementia medication (NPADM).DesignRetrospective enumeration cohort study.SettingA Japanese city in Tokyo Metropolitan Area.ParticipantsA total of 42 024 adults aged ≥77 years residing in Kashiwa City, a suburban city of Tokyo Metropolitan Area, who did not have any prscription of antidementia medication from 1 April to 30 June 2012.Main outcome measureThe primary outcome was NPADM during follow-up period until 31 March 2015 (35 months). Subjects were categorised into four age groups: group 1 (77–81 years), group 2 (82–86 years), group 3 (87–91 years) and group 4 (≥92 years). In addition to age and sex, 14 sets of medications prescribed during the initial background period (from 1 April 2012 and 31 June 2012) were used as covariates in a Cox proportional hazard model.ResultsIn a follow-up period of 1 345 457 person-months (mean=32.0±7.5 months, median 35 months), NPADM occurred in 2365 subjects. NPADM incidence at 12 months was 1.9%±0.1% (group 1: 0.9%±0.1%, group 2: 2.1%±0.1%, group 3: 3.2%±0.2% and group 4: 3.6%±0.3%; pConclusionsThis retrospective cohort study identified the associations of coprescribed medications for chronic comorbid conditions with NPADM in older adults. These findings would be helpful in understanding the current clinical practice for dementia in real-world setting and potentially contribute to healthcare policymaking.Trial registration numberUMIN000039040.

Background To evaluate the effects of prevention services provided by long-term care insurance (LTCI) for older adults who require support from LTCI in Kashiwa City, Japan. Methods We conducted an analysis using the following population-based longitudinal data in Kashiwa City between April 2012 and March 2015: Data of National Health Insurance and LTCI claims, the survey for certification of LTCI, the register, and premium tier classification. All data was linked using the pre-assigned anonymous identifying numbers. We analyzed the Cox regression model using the time for the deteriorations of levels of certified care need in LTCI as an outcome and the use of preventive care services as the primary exposure among participants aged 75 years or older, who had either support levels 1 or 2 at the beginning of this analysis. The study was further stratified by both age and initial support level. Results The final analysis included 1289 participants. The primary result showed, among all participants, that preventive service was not effective (hazard ratio 0.96, 95% confidence interval 0.78–1.19). In our sub-analysis, the preventive service was effective in avoiding deteriorations only among those aged 85 and older with support level 1 (HR 0.65, 95% CI 0.43–0.97) out of four groups. Conclusions The preventive services of LTCI in Kashiwa City showed a significant effect on the deterioration among subjects aged 85 or older, whose disability level were low (support level 1). Our results suggest that the prevention services provided by LTCI may not be effective for all older individuals; to provide these services efficiently, local governments, as insurers of LTCI, will need to identify the specified groups that may benefit from the preventive services. Additionally, it is necessary to re-examine what preventive interventions may be effective, or redesign the health system if necessary, for those who were not affected by the intervention.

Aim This study aimed to improve the understanding of the utilization rates and the characteristics of users of pulmonary rehabilitation (PR) among people with chronic obstructive pulmonary disease. Methods We used medical and long-term care claims data from between April 2012 and March 2013 from Kashiwa city in Chiba prefecture, Japan. The study participants included patients of ≥63 years of age, who had received outpatient treatment for COPD (ICD-10 codes: J41-J44) two or more times during the study period, and who had been prescribed two or more COPD-related drugs. We extracted data on inpatient and outpatient PR using respiratory rehabilitation fee (I) (II) codes, and on home-based PR using home-care rehabilitation or nursing codes from medical insurance or long-term care insurance data. Results The mean age of the patients was 76.8 years (total participation: n = 2,708). There were 61 (2.3%) inpatient PR users, 25 (0.9%) outpatient PR users, and 101 (3.8%) home-based PR users. The median duration of usage by the inpatient, outpatient and home-based PR users was 1 month, 2 months, and 11 months, respectively. The mean age of non-PR and outpatient PR users was 76 years, while that of the inpatient PR users and home-based PR users was approximately 80 years. Approximately 20-30% of non-PR users and outpatient PR users were certified for long-term care. In contrast, approximately half of the inpatient users and almost all of the home-based PR users were certified for long-term care. Conclusions Since the PR utilization rates were low in both hospital-based and home-based settings, it is necessary to take measures to disseminate each PR based on the characteristics of the intervention duration and service users.

Objectives Antipsychotics are used to manage the behavioral and psychological symptoms of dementia (BPSD), despite their association with greater risks for mortality and cerebrovascular events. Previous studies in Japan have estimated the prevalence of antipsychotics among older adults who took antidementia drugs. Using long-term care (LTC) data, we aimed to obtain more accurate estimates of the prevalence of antipsychotics and to determine factors related to their use in older adults with dementia. Methods Medical and LTC claims data and LTC certification data between April 2012 and September 2013 were obtained from a middle-sized suburban city. The 1-year prevalence of antipsychotic use was estimated among individuals with probable dementia aged greater than or equal to 75 years who were prescribed antidementia drugs and/or had dementia based on LTC needs certification data. Results Of 25 919 participants, 4865 had probable dementia and 1506 were prescribed antidementia drugs. The prevalence of antipsychotics among participants with probable dementia was 10.7%, which was lower than that in those who were prescribed antidementia drugs (16.4%). Among participants with probable dementia with LTC certification data available (N = 4419), lower cognitive function (vs mild; adjusted odds ratio 2.16, 95% confidence interval 1.63-2.86), antidementia drug use (2.27, 1.84-2.81), and institutional LTC services use (2.34, 1.85-2.97) were associated with greater odds of antipsychotic use, whereas older age (greater than or equal to 92 years) was associated with lower odds (vs less than 77 years; 0.42, 0.27-0.65). Conclusions These findings may be useful for estimating the burden of BPSD and for taking measures to reduce inappropriate antipsychotic prescription.

Background The occurrence of multimorbidity (i.e., the coexistence of multiple chronic diseases) increases with age in older adults and is a growing concern worldwide. Multimorbidity has been reported to be a driving factor in the increase of medical expenditures in OECD countries. However, to the best of our knowledge, there is no published research that has examined the associations between multimorbidity and either long-term care (LTC) expenditure or the sum of medical and LTC expenditures worldwide. We, therefore, aimed to examine the associations of multimorbidity with the sum of medical and LTC expenditures for older adults in Japan. Methods Medical insurance claims data for adults ≥75 years were merged with LTC insurance claims data from Kashiwa city, a suburb in the Tokyo metropolitan area, for the period between April 2012 and September 2013 to obtain an estimate of medical and LTC expenditures. We also calculated the 2011 updated and reweighted version of the Charlson Comorbidity Index (CCI) scores. Then, we performed multiple generalized linear regressions to examine the associations of CCI scores (0, 1, 2, 3, 4, or ≥ 5) with the sum of annual medical and LTC expenditures, adjusting for age, sex, and household income level. Results The mean sum of annual medical and LTC expenditures was ¥1,086,000 (US$12,340; n = 30,042). Medical and LTC expenditures accounted for 66 and 34% of the sum, respectively. Every increase in one unit of the CCI scores was associated with a ¥257,000 (US$2920); 95% Confidence Interval: ¥242,000, 271,000 (US$2750, 3080) increase in the sum of the expenditures (p

Little is known about hip fracture expenditure in Japan. Using claims data obtained from a core city near Tokyo, we estimated the mean healthcare expenditure and monthly long-term care expenditure post-hip fracture to be ¥2,600,000 (US$29,500) and ¥113,000 (US$1290), respectively.We aimed to estimate healthcare and long-term care expenditures post-hip fracture in Japan.Healthcare insurance claims data for adults aged ≥ 75 years were merged with long-term care insurance claims data. We analyzed the data of hip fracture patients who were admitted to non-diagnosis procedure combination/per-diem payment system (DPC/PDPS) hospitals in a core city near Tokyo between April 2012 and September 2013. We estimated healthcare expenditure, namely, the difference between total payments 6 months pre- and 6 months post-hip fracture, and monthly long-term care expenditure for those who did not use long-term care insurance pre-hip fracture, but who commenced long-term care insurance post-hip fracture. We also performed multiple linear regressions to examine the associations of healthcare or long-term care expenditure with various factors.The estimated mean healthcare (n = 78) and monthly long-term care (n = 42) expenditures post-hip fracture were ¥2,600,000 (US$29,500) and ¥113,000 (US$1290), respectively. In multiple linear regressions, healthcare expenditure was positively associated with longer duration of hospital stay (p = 0.036), and negatively associated with higher Charlson Comorbidity Index scores (p = 0.015). Monthly long-term care expenditure was positively associated with higher care-needs level post-hip fracture (p = 0.022), and usage of institutional care services (p 0.001).This is the first study to estimate healthcare and long-term care expenditures post-hip fracture using claims data in Japan. Further studies are needed that include healthcare claims data at both DPC/PDPS and non-DPC/PDPS hospitals to capture the lifelong course of long-term care required post-hip fracture.

Background This study aimed to determine whether there are disparities in healthcare services utilization according to household income among people aged 75 years or older in Japan. Methods We used data on medical and long-term care (LTC) insurance claims and on LTC insurance premiums and needs levels for people aged 75 years or older in a suburban city. Data on people receiving public welfare were not available. Participants were categorized according to household income level using LTC insurance premiums data. The associations of low income with physician visit frequency, length of hospital stay (LOS), and medical and LTC expenditures were evaluated and adjusted for 5-year age groups and LTC needs level. Results The study analyzed 12,852 men and 18,020 women, among which 13.3% and 41.5%, respectively, were categorized as low income. Participants with low income for both genders were more likely to be functionally dependent. In the adjusted analyses, lower income was associated with fewer physician visits (incidence rate ratio [IRR] 0.90; 95% confidence interval [CI], 0.87-0.92 for men and IRR 0.97; 95% CI, 0.95-0.99 for women), longer LOS (IRR 1.98; 95% CI, 1.54-2.56 and IRR 1.42; 95% CI, 1.20-1.67, respectively), and higher total expenditures (exp(β) 1.09; 95% CI, 1.01-1.18 and exp(β) 1.09; 95% CI, 1.05-1.14, respectively). Conclusions This study suggests that older people with lower income had fewer consultations with physicians but an increased use of inpatient services. The income categorization used in this study may be an appropriate proxy of socioeconomic status.

The present study aimed to examine the percentage of and risk factors for potentially avoidable hospitalizations (PAH), non-PAH and in-hospital deaths among residents of special nursing homes for the elderly (SNH) and geriatric health service facilities (GHSF).Long-term care and national health insurance claims data (April 2012 to September 2013) were obtained from a suburban city in Chiba prefecture, Japan. Study participants were aged ≥75 years and resided in either SNH (n = 1138) or GHSF (n = 885). The PAH were defined using 17 medical condition groups, and the percentage of PAH, non-PAH and in-hospital deaths was identified, and associated factors were compared using multilevel logistic regression models for SNH and GHSF, respectively.A total of 34.5% SNH residents experienced any hospitalization, and this was composed of PAH (16.3%), non-PAH (12.2%) or in-hospital deaths (6.1%). Of the GHSF residents, 23.8% experienced any hospitalization, and this was comprised of PAH (9.5%), non-PAH (10.6%) and in-hospital death (3.7%). More than 70% of the PAH were related to respiratory infections, urinary tract infections or congestive heart failure. In both SNH and GHSF, artificial nutrition was positively associated with PAH and non-PAHs, and male sex was positively associated with non-PAHs and in-hospital deaths. However, there were also discrepancies between SNH and GHSF in terms of risk factors for PAH.The percentage of PAH was higher in SNH than in GHSF, which might be related to their different personnel and managerial regulations. The linkage of health and long-term care claims data might facilitate data-based evidence on policy-making. Geriatr Gerontol Int 2018; 18: 1272-1279.

ObjectivesThis study aimed to identify factors associated with long-term urinary catheterisation (LTUC) in community-dwelling older adults and to evaluate the risk of urinary tract infection (UTI) among people with LTUC.DesignPopulation-based observational study.SettingMedical and long-term care insurance claims data from one municipality in Japan.ParticipantsPeople aged ≥75 years living at home who used medical services between October 2012 and September 2013 (n=32 617).Outcome measures(1) Use of LTUC, defined as urinary catheterisation for at least two consecutive months, to identify factors associated with LTUC and (2) the incidence of UTI, defined as a recorded diagnosis of UTI and prescription of antibiotics, in people with and without LTUC.ResultsThe 1-year prevalence of LTUC was 0.44% (143/32 617). Multivariable logistic regression analysis showed that the male sex, older age, higher comorbidity score, previous history of hospitalisation with in-hospital use of urinary catheters and high long-term care need level were independently associated with LTUC. The incidence rate of UTI was 33.8 and 4.7 per 100 person-years in people with and without LTUC, respectively. According to multivariable Poisson regression analysis, LTUC was independently associated with UTI (adjusted rate ratio 2.58, 95% CI 1.68 to 3.96). Propensity score-matched analysis yielded a similar result (rate ratio 2.41, 95% CI 1.45 to 4.00).ConclusionsWe identified several factors associated with LTUC in the community, and LTUC was independently associated with the incidence of UTI.

The financial interests of care management agencies can affect how care managers assist clients' use of long-term care insurance services. The present study examined the relationship between clients' service expenditures, and whether the home help and day care service agencies belonged to the same organization as the care management agency.Population-based data were obtained from a suburban municipality in Japan. We investigated 4331 persons with care needs certificates (levels 1-5), including those using home help (n = 1780) or day care (n = 2141) services. Data on the service expenditures, and clients' and agencies' characteristics were analyzed using multiple linear regression analyses controlling for potential confounders.Home help service users spent an average of US$558.1 ± 590.1 for home help service, and day care service users spent US$665.0 ± 415.9 for day care service. Living alone, living in a condominium/apartment, higher care needs, more severe cognitive impairment and lower use of other services were associated with higher home help service expenditure. Day care service expenditure increased with older age, female sex, higher care needs, more severe cognitive impairment and higher physical function. Clients whose service agencies and care management agencies belonged to the same organization had higher expenditures, even after adjusting for confounders (home help: β = 0.126, P = 0.007; day care: β = 0.085, P = 0.002, respectively).Financial interests of care management agencies might significantly influence clients' service expenditure. We should develop an effective system to minimize this influence. Geriatr Gerontol Int 2017; 17: 2224-2231.

Previous literature pointed out that the role of care managers is ambiguous. In 2000, Japan instituted a new policy for long-term care of the elderly (the National Long-Term Care Insurance Policy), within which the work of care managers was recognized as a new profession providing care management services for the elderly needing care. We conducted a random-sampled mail survey on 530 care managers in 268 organizations to clarify the association between role ambiguity and care managers’ work environments, including role clarification, organizational profit-seeking climate, and the utilization of professional and personal support. The results showed that fewer opportunities for role clarification and increased organizational profit-seeking climate were associated with greater role ambiguity for care managers. Furthermore, emotional and instrumental support from colleagues and external resources were positively associated with role ambiguity, while informational support from superiors was negatively associated with role ambiguity. Role clarification and the utilization of support within and outside of work organizations would be beneficial to reduce the role ambiguity of care managers.

Increasing service use under the long-term care insurance (LTCI) system in Japan requires a comprehensive understanding of how the services are actually used. This study aimed to identify patterns of LTCI service use and to examine the characteristics of the patterns.We analyzed data from a population of 4,339 older adults living in the community who were certified as "Needing Care" and were using at least one LTCI service in a suburban municipality of Japan. We identified six patterns of service use using cluster analysis based on the amount of fees for LTCI services and compared characteristics among the clusters.The clusters were: 1) light use of care services (n = 1,852); 2) day care-centered (n = 1,071); 3) day care with rehabilitation-centered (n = 616); 4) home help-centered (n = 365); 5) short-stay respite service-centered (n = 246); and 6) compound uses of visiting services (n = 189). "Home help-centered" and "short-stay respite service-centered" clusters used a large number of fees, whereas "compound uses of visiting services" clusters did not despite their severe conditions. The "day care-centered (with rehabilitation)" classification included few people who needed medical procedures, likely due to the lack of medical facilities in those agencies.The results show the impact of social and medical factors on LTCI service use, suggesting possible difficulties in the socialization of care. The clusters could be used as typical service use patterns, providing a framework for further studies, such as those evaluating the services' effects. Geriatr Gerontol Int 2017; 17: 753-759.

The present study investigated the association between the structure of catheter replacement services in home medical care settings and regional characteristics.An anonymous self-administered questionnaire was carried out from August to September 2013. Participants were physicians from 5338 clinics that provided medical care services at home, and nurses from 1619 home-visit nursing stations in Tokyo and three adjoining prefectures. The questionnaire covered catheter replacement (gastrostomy tubes, nasogastric tubes, tracheal cannulas) during home medical care, and the professions of those who replaced urethral catheters for male and female patients. Regions were divided into two groups (higher- and lower-density regions) based on the number of clinics, number of home-visit nursing stations and the ratio of the population aged ≥65 years. The rates of respondents that reported catheter replacement was usually executed, and those who reported catheters were replaced by "physicians in principle" were compared between the groups.Responses were received from 842 clinics (16.3%) and 499 home-visit nursing stations (31.4%). In the higher-density regions, the rate of physicians who reported urethral catheters for male patients were replaced by "physicians in principle" was significantly higher than in the lower-density regions (P 0.001). In the lower-density regions, the rate of nurses who reported urethral catheters for male patients were replaced by "nurses in principle" was significantly higher compared with the higher-density regions (P 0.016).In home medical care settings, urethral catheters for male patients are replaced by nurses in regions where physician resources are limited. Geriatr Gerontol Int 2017; 17: 628-636.

Social capital (SC) can be broken down into a number of aspects and dimensions, but few studies have differentiated between the effects of different components of SC on health. This study examined the relationship between contextual SC and health (self-rated health, and co-occurrence of lifestyle risk factors such as smoking, drinking, overweight/underweight and physical inactivity) among the general population in a Japanese suburban area. The specific research question was to explore which components of contextual SC had what effects on health. In 2009, we randomly selected 4123 residents, aged 20 years and over, from 72 districts in the city of Kashiwa, Chiba prefecture (a typical suburban city of Tokyo) to participate in a cross-sectional survey using mailed questionnaires. We used four indicators of SC: cognitive/horizontal (trust in neighbors), cognitive/vertical (institutional trust in the national social security system), structural/horizontal (participation in groups with egalitarian relationships) and structural/vertical (participation in groups with hierarchical relationships). District-level SC was calculated by aggregating the individual responses of each SC indicator within each district. The response rate was 42.1% (1716 questionnaires), 43.7% of the respondents were male, and the mean age was 54.8 ± 16.4 (ranging from 20 to 97). A multilevel analysis showed that higher district-level institutional mistrust was associated with self-rated poor health, but higher district-level mistrust in neighbors was inversely associated with it, after adjusting for individual-level covariates. There was no contextual effect of any SC components on co-occurrence of risk factors. Our findings showed that institutional trust has a beneficial effect on self-rated health, but trust among neighbors might negatively affect the health of the residents in a Japanese suburban city. These unique findings could suggest the advantage of breaking down SC to examine more specific relationships between SC and health, and the importance of accumulating the evidence in specific cohorts to develop customized health promotion strategies.

We have to create a new paradigm for home medical care system towards a historical increase of elderly population in Japan. Tokyo University and Chiba University have been collaborating to erect a home medical care support center in Kashiwa, Chiba prefecture. We have been constructing a support center as well as a home care doctor system, and also created a teaching course for GPs to learn a home care doctor activity. We have also been constructing a regional network system called IT Net in Chiba, which connects all the entire medical and care staff. We will expand this model in many places and to instruct medical students and residents there in the near future.

In order for community-based health promotion and prevention activities to be effective and efficient, it is important to assess the community consciousness among local residents. The purpose of this study was to review the reliability and validity of the Attitude toward Community Scale (ACS) and examine its association with health status among the general population.A cross-sectional survey was conducted in February 2009 using a mail-in self-administered questionnaire. The target population comprised 4,123 randomly-selected local residents aged 20 years and over living in Kashiwa city, Chiba prefecture, Japan. The questionnaire encompassed the ACS (the wording of some items was modified), an also included data to allow assessment of demographics and health status.Of 4,123 questionnaires, 1,735 could be analyzed (valid response rate: 42.1%). Confirmatory factor analysis supported the two-factor model of the original scale. The reliability of the scale was verified using the Cronbach's alpha coefficient. All item-total correlations were moderately or strongly positive. Logistic regression showed that a better attitude toward the community was associated with higher self-rated health, less anxiety about the future and less loneliness.Although the original scale was developed in 1978, the ACS still appears applicable for modern research following some wording modifications of the items. In future studies, it will be necessary to clearly establish relationships between health status and community consciousness and to develop methodology for enhancing the latter.

Homebound status is associated with poorer health and disability; however, the impact of community factors on the decision to remain homebound is unclear. We applied multilevel analyses to examine the association between neighborhood environment and homebound status among Japanese community-dwelling elderly. A cross-sectional survey was conducted in February 2009 using a mailed questionnaire. A total of 4123 participants aged 20 years and over living in 72 small districts of Kashiwa, Japan, were randomly selected for the survey. Of the 1735 returned questionnaires, the 588 that were completed by individuals aged 65 years and over were used for analysis. Frequency of going outdoors was assessed and respondents going outdoors once a week or less were defined as homebound. Neighborhood environment was assessed using three subscales of the Neighborhood Environment Walkability Scale (NEWS-A) (land use mix-access, aesthetics and crime safety). Multilevel logistic regression analysis indicated that the lower score of land use mix-access at the district level was associated with the elderly being homebound after adjustment for individual demographic data, physical, psychological and social factors and district prevalence of population aged 65 years or more. This finding could contribute to devising a successful community-based strategy for homebound prevention of community-dwelling elderly individuals.

Public health nurses (PHNs) played the major role in providing care management for the frail elderly before the Long-term Care Insurance started in 2000. Although the role of care management has now shifted to care managers, PHNs are still consulted by such care managers, service providers and families of the elderly about long-term home care. The purpose of this study was to explore the factors that make a case difficult to deal with from PHNs' viewpoint. This study focuses on the factors related to family living in the same household (living-together family).The informants of this study were seven PHNs who worked for a city with a population of 67,000 (proportion of elderly in the whole population is 19%) in Nagano Prefecture. First, a focus group interview (about 90 minutes) with the six PHNs was conducted to extract an outline of difficult cases. Next, semi-structured interviews (about 60 minutes each) with five PHNs were conducted to obtain detailed information on difficult cases. The interviews were tape-recorded and transcribed verbatim. KJ analysis was conducted by defining characteristics, finding similar factors, and grouping these together to form categories.Categories of family related problems emerged for each of two major categories: family characteristics and care related problems. Firstly, existing family characteristics, including the existence of mental or psychological disorders, low motivation towards providing long-term care, conflictual familial relationships, objections to having service providers in the home, and economic difficulties contribute to problems in providing long-term care with living-together families. These characteristics can lead to a second set of problems, relating to the actual provision of care by the living-together family to frail elderly patients. These care related problems include including insufficient care, rejection of formal care services, and deviation from care directives, including to the point of physical mistreatment.This study points to the need for care providers to consider the living-together family's background and the potential for the phenomena, indicated in this study, to negatively impact on the provision of care for the frail elderly.