As Japan looks forward to becoming a hyper-aging society, the government has begun encouraging the elderly to "live out their years at home," integrating medical treatment and long-term care to forge environments preferable to old age homes.
"Ganbatte! Ganbatte! Ganbatte!"
Rarely is Sendan no Oka this boisterous. At this geriatric health care center affiliated with Tohoku Fujushi University in Sendai, Japan, inspiring music from the film Chariots of Fire is playing, as five licensed care workers lead 22 elderly wheelchair-bound people in their monthly "sports day."
That's right. Sports day.
Some of them have had mild strokes, some have heart problems, and all of them are in wheelchairs. The care workers help split them into the Red team and the White team. Over a period of 20 minutes they play three different games, first passing a ball, then passing a ring on a bat, and finally picking a card and trying to perform the action written on it faster than the other contestants.
"Putting out an effort in front of other people is an important component of rehabilitation," says life counselor Miura Kou.
Sendan no Oka is an elderly care center that has attracted a great deal of attention lately. Unlike in the past, when medicine and long-term care were two separate systems, Sendan no Oka is experimenting with how to set up a single interface to integrate medical treatment and long-term care. Following the physician's diagnosis, a team of care managers, occupational therapists, care workers, and social welfare workers facilitates the seniors' rehabilitation with the ultimate goal of helping them return home.
Taking on 2025
The integration of medical treatment and long-term care, the promotion of long-term community care and treatment, and having old people live out their lives at home, are all elements of Japan's recent reforms following its transition into a "hyper-aging society."
On June 25 the Ministry of Health, Labour and Welfare announced that it would raise revenue through a new consumption tax in every community large and small with a junior high school district, so as to establish a system of in-home treatment and in-home long-term care.
The harsh aspect of this plan is that in the future long-term care insurance institutions will only accept elderly people that "need help in their lives and are unable to manage their own affairs and take care of themselves." Japan's National Health Insurance system will also clamp down tightly, and hospitals will not easily add beds.
Japan is anxious to encourage elderly people to use home treatment and hospice care because Japan is about to become "a hyper-aged society the likes of which the world has never seen before."
In 2025 Japan's post-war baby boom generation will reach 75 years of age, at which time one out of every five Japanese will be 75 years old or older. Over the next decade Japan will enter a critical period of transition from an early aging society to an advanced aging society. Insurance company payments have increased tenfold over the past 12 years, so that if no changes are made, it will take the insurance companies down.
Japan happens to be the most serious country in the world about tackling the problem of its aging society.
Dr. Shyh-Dye Lee, senior attending physician in the Department of Community and Family Medicine at National Taiwan University Hospital Bei-Hu Branch, relates that as early as 1994 Japan's cabinet secretary tasked a committee to develop a strategy to address the society's aging trend. In addition to the Ministry of Health, Labour and Welfare and other departments directly related to the issue, the Ministry of Education, Culture, Sports, Science and Technology took on responsibility for designing the training and certification of related professionals. For instance, content was added to elementary school textbooks to help students understand various aspects related to Japan's entry into the ranks of aging societies. "Society must establish long-term care as a social value," stresses Dr. Lee.
Rallying at the Grass Roots
In Japan, the social values of long-term care are rooted in a foundation of "self-help, community assistance, institutional assistance, and public assistance." The elderly are aware of their responsibility to be self-reliant, which makes them take personal health management seriously. Community assistance stresses the power of local interpersonal networks. Institutional assistance involves promoting the insurance system, and public assistance is meted out in line with the government's budget.
Since 2005, these values have defined Japan's approach as a "long-term care system with prevention at the core."
Doctor Lee notes that each local administrative office, from village to county and city level, has a long-term care window. These windows can process applications for long-term care services and assist elderly people within the jurisdiction to take "disability tests," which could involve oral history, games, cooking, or flower arrangement classes for high-risk groups to try and keep them active.
In the fitness center at Tohoku Fukushi University in Sendai, CommonWealth Magazine met 73 year-old Sasaki Masayuki. With power in his voice and a spring in his stride, he works here and is the best "living advertisement" for the facility.
Eight years ago Sasaki suffered cracked vertebrae in a fall while working. Despite surgery and rehabilitation, he was tormented by debilitating back pain for three years.
The care manager suggested he try exercises, once per week at first for a period of three months. The fitness center's occupational therapist designed a customized program for him, and progressively over a four-year period his back fully recovered. Today he comes to work each morning, offers living proof of the center's work, and assists other elderly people in the community.
Prior to traveling to Japan to cover this story, we were under the impression that under its long-term care insurance program, Japan's elderly people either live at assisted living institutions or go to care centers during the day each day, similar to kindergarten students attending class. However, upon investigating for ourselves we found that most of Japan's white-haired population does not leave home, but stays rooted firmly in their communities.
Living Out Life at Home Preferable to Institutionalization
At the Dream Lake Village Urayasu Daycare Center on the outskirts of Kyoto, Hashiguchi Kyoko puts on just a little makeup, looking as elegant as always.
What sets Dream Lake Village apart is that it issues its own currency, "Dreams," for use within the center. Anyone that gives rehabilitation exercises a try can accrue dream currency, which can be redeemed for such activities as massages or karaoke singing. One example of a contest would involve memorizing the names of all the stations on Tokyo's Yamanote Line, which fetches 50 Dreams.
Hashiguchi Kyoko baked some red bean buns at the institution's cooking classroom in exchange for some Dreams, and traded her Dreams in for the buns.
Kyoko lives with her daughter's family. Suffering from Parkinson's, she must take medication regularly. She visits Dream Lake Village on Wednesdays and Fridays, and attends karaoke gatherings two days per week. The rest of the time she stays at home, where she cooks dinner for herself, buys her groceries at the supermarket herself, and shops for cosmetics.
Japan's latest reforms aim to return elderly patients to their communities, allow the elderly to live out their days at home whenever possible, and reduce reliance on hospitals and old age homes.
Doi Katsuyuki, director of Sendan no Oka and executive council member of the Japan Occupational Therapists Association, notes that while previously many stroke victims remained hospitalized for rehabilitation following surgery, and quite a few went to live in assisted living centers, Sendan no Oka seeks to effect a transition, whereby assisted living centers are just halfway houses for stroke victims, who can return home to live after rehabilitation work and recovering their daily living skills.
Follow-up work can include community home visitations, regular return visits to the rehabilitation center, or the lending of assistive devices to ascertain that stroke sufferers recover their capacities for living. Certain tasks, like taking out the rubbish or delivering meals, can be handled by community volunteers or nursing assistants.
Sendan no Oka was the first to adopt the "Instrument Activity of Daily Living" evaluation method.
When patients are admitted from the hospital, a social welfare worker or occupational therapist speaks with the patient or family member(s), and asks what the patient would most like to do if they could get better – like going fishing. If the occupational therapist deems fishing a feasible goal, a course is designed with that in mind. As this is something the patient desires to do, he will be motivated to work harder.
"Hospital rehabilitation is targeted at treating you, whereas our goal is for elderly people to get their daily lives back," says Doi Katsuyuki. More and more hospitals have begun to use this method, pioneering the integration of hospital and long-term care systems.
Japan's 4000 assisted living institutions are only able to serve around 400,000 people at the moment. If these institutions only serve as halfway houses, they could help more people. A deposit must be paid before one is admitted into an assisted living complex, as well as a monthly fee. If they can return home to live out their days, the burden on their children can be lessened.
Integrating Treatment and Long-term Care Resources
In line with the home living policy, Japan is working on establishing more community clinics and care centers for home treatment, providing round-the-clock services.
Consider the example of Fumio Yamazaki of Kodaira City outside Tokyo. A medical treatment pioneer, he is one of Japan's most renowned hospice doctors, and is the author of a book on life and death.
In 2005, he established a home visit clinic in Kodaira, making consultations by appointment. Once someone has become a patient, they can get in touch with the facility at any time around the clock. Currently, there are three doctors on the staff, who always visit patients as a group, to get to know each one individually. This way, when they work in shifts, they can all provide seamless patient support.
NHK did a special on Yamazaki. His clinic is a Japanese-style longhouse, next door to which is the home care nurses' office, followed by the home helpers' station. Just like in a hospital, each day the doctors, nurses and care workers meet together to go over patients' conditions.
"In the future, Japan must integrate the two separate treatment and long-term care systems," asserts Professor Koichi Ogasawara, Ph.D. of the School of Comprehensive Welfare Studies, Tohoku Fukushi University.
Many aspects of what Japan has experienced and done are worth thoughtful consideration in Taiwan.
Translated from the Chinese by David Toman