Improving functions of the frail elderly

• Abstract
• Purpose of health policy or idea
• Characteristics of this policy
• Political and economic background
• Purpose and process analysis
• Expected outcome
• References

Featured in half-yearly report: Health Policy Developments 10

Abstract

The 2005 amendment of the Long Term Care Insurance created new service benefits intended to improve and maintain the physical, mental and social functions of the frail elderly. The changes and new benefits have been implemented since April 2006, and include e.g. a revision of fees for home care services, changes of eligibility rules, and the creation of comprehensive care centers managing the services.

Purpose of health policy or idea

Since the population of senior citizen is expected to increase up to thirty million, the long-term care system shall be modified to be more sustainable. To achieve a sustainable system, mechanisms to improve and maintain physical, mental, and social functions of the elderly shall be developed through revised rehabilitative benefits for those with slight disabilities, newly created services to prevent the frail elderly who have a risk from losing their health and abilities, and other measures developed by municipalities.

The rehabilitative benefits include services similar to existing services such as home help services, intensive physical training at home, physical training at a facility with modified fees that are intended to promote provision of more efffective rehabilitative services. The newly created services include exercise training, nutritional counselling, oral health counseling, and home visit. Also, municipalities have subsidies to develop various measures for promotion of active aging and/or support to the frail elderly.

Main points

Main objectives

The creation of new service benefits is intended to improve and maintain functions of the targeted frail elderly by providing specified services.

Type of incentives

Creation of new services for improving or preventing deterioration of functions of the elderly itself can be interpreted as a non-financial incentive for providers, municipalities and the public. Publication of additional information on service quality of providers, e.g. broad outcomes for maintaining functions of users, is another non-financial incentives.

Subsidies for municipalities will work as financial incentives. Revised benefits include some financial incentives, such as additional fees for additional training, for providers to promote rehabilitative services.

Groups affected

Providers, beneficiaries, insurers

Degree of Innovation	traditional		innovative
Degree of Controversy	consensual		highly controversial
Structural or Systemic Impact	marginal		fundamental
Public Visibility	very low		very high
Transferability	strongly system-dependent		system-neutral

Innovative - the policy is quite new in the sense that it intends to maintain functions of the frail eldery with structured intervention of general promotion of active aging, rehablitative services for those at risk, and rehabilitative benefits for those in need of support with financial and non-financial incentives.

Controversy - as metioned in section "stakeholder positions", the policy was quite controversial and arguments are underway.

Systemic impact - may be fundamental because it can change resource allocation according to beneficiaries' need though whether this re-allocation works or not shall be evaluated.

Visibility - was high because it relates to those using services at that time. There was much argument on the revision of the categories and newly created rehailitative services for those at risk.

Transferability - is system neutral in the sense that long-term care systems integrate rehabilitative services.

Political and economic background

This policy was developed between 2003 and 2005 when the ruling parties were still strong in the Diet with the Koizumi Administration. The government had to decrease the amount of accumulated deficit and declared to contain costs by reforming health care with regard to its basic policies for economic and fiscal operation and its structural organisation. Meanwhile, the Government has a general policy that stipulates the prolongation of the length of healthy life.

The government has promoted decentralization by increasing revenues of local governments from taxes, with a reduction of subsidies and by promoting mergers of municipalities. The administrative reform has been intended to increase efficient management of local governments with sufficient capacities.

As to the Long-Term Care Insurance, its expenditures and premiums as well as service utilization had increased rapidly over the last years; more people than expected were certified as eligible under the two lowest categories ("in need of support" and "level 1"); and demand for institutional services also grew rapidly, probably due to among other things social and demographic changes. Furthermore, there were critical disputes about opportunistic behavior of care managers who were employed by providers, which required some changes of care management .

Purpose and process analysis

Current Process Stages

	Idea	Pilot	Policy Paper	Legislation	Implementation	Evaluation	Change
Implemented in this survey?

Origins of health policy idea

Since the idea of achieving an active society with healthy aging has been prevalent during the last decade in Japan, there have been general ideas for promoting healthy aging through employment, social particpation, a physically active life, health promotion and other activities.

The unexpectedly increased number of those certified as those with slight disabilities may have resulted in revision of benefits for this group of beneficiaries. Also, some measures to control or mitigate cost inflation were desired to make the LTCI politically and financially sustainable. Although revision of benefits had been scheduled when the LTCI started, more sophisticated development of benefits for those with slight disabilities is politically and practically feasible and suited for controlling costs. Also, the fact that people with slight disabilities sometimes do not use long-term care and lose their functions led to the development of a screening test for evaluating risks to lose functions or abilities in the near future. The idea of providing specified rehabilitative services to targeted high-risk populations probably came from academics or experts in related disciplines such as rehabilitative medicine, sports medicine or public health.

Initiators of idea/main actors

• Government

• Providers

• Scientific Community

• Media : Some criticize the idea, others the insufficient resources for implementation.

• Others

• Political Parties : The Democratic Party has become critical in the process of implementation.

Approach of idea

The approach of the idea is described as:
new:

Innovation or pilot project

Local level - Local experiences with improving the functions of the frail elderly and screening for preventive services
Pilot project - Model projects were carried out to develop assessments, evaluations, and skills on exercise training to improve or maintain functions of the frail elderly.
Else - Scientific research

Stakeholder positions

The government and the ruling party strongly supported the policy, which was developed and made prevalent through two policy papers. In 2003 a research group organized by the director of the Health and Welfare Bureau for the Elderly of the Ministry of Health, Labour, and Welfare, developed a broad strategy on long-term care for the aged (Research Group on Long-Term Care for the Aged 2003). The group pointed out the necessity for developing effective services to improve or maintain the functions of the frail elderly, which were supposed to differ from services to the aged with disabilities.

Another research group, which was organized by the director as well, recognized research results that the eldery who used long-term care services were more likely to lose their physical and mental functions than the eldery who did not use those services. The group paid attention to inactive lifestyles as a cause of disabilities of the aged and proposed that the Government should develop screening tests for frailty and effective services to improve or maintain functions of the elderly through skilled management and of their needs and services they receive (Rehabilitation for the Aged Research Group 2004).

Finally, the Committee for Long-Term Care Insurance of the Social Security Council in 2004, which was in charge of formally reviewing LTCI scheduled by law (the long-term care insurance system has to be reviewed every five years), established the policy as a part of its review.

Since the policy described in this report (ie. improving the functions of the frail elderly) is a part of the larger revision of the LTCI, political arguments were constructed on the revision as a whole. The Democratic Party, the major opposition party, also supported the policy in the process of legislation, though its proposal for an amendment to the revision bill was successfully adopted. But in the process of implementation they became critical, arguing that revision of benefits for the elderly with slight disabilites were undermining access to long term care services. The media also maintains a similar position. Health and social care professions gave general support in the process of legislation and proposed specific issues relevant for them. The care workers association argued that exaggerating effectiveness of rehabilitation would decrease general support for the frail elderly.

Actors and positions

Government
Ministry of Health, Labour	very supportive		strongly opposed
Providers
Professionals concerned	very supportive		strongly opposed
Scientific Community
Rehabilitative specialists	very supportive		strongly opposed
Social workers	very supportive		strongly opposed
Media
Newspapers	very supportive		strongly opposed
Others
Care workers association	very supportive		strongly opposed
Political Parties
Liberal Democratic Party	very supportive		strongly opposed
New Komei	very supportive		strongly opposed
Democratic Party	very supportive		strongly opposed
Communist Party	very supportive		strongly opposed
Social Democratic Party	very supportive		strongly opposed

Influences in policy making and legislation

The amendment bill of the Long-Term Care Insurance was submitted by the Cabinet to the Diet (Japanese Parliament) in February 2005.

The Committee for Health and Welfare, the House of Councillors (upper house of the Diet) adopted an additional resolution, which includes the following requests to the Government as to the creation of new services:

• To carefully make arrangement so that beneficiaries who would be affected by changes in eligibility rules could use the same services they received before the enactment of the act;
• To consider a payment system, such as monthly block payment, for eneabling beneficiaries to use the services created according to their needs;
• To make efforts to investigate the situations of the elderly by public health nurses at comprehensive health centers in order to provide the appropriate services;
• To decrease disparities between municipalities in terms of amount of premiums, service provision, and processes of eligibility examination;
• To ask for the opinion of dental specialists in making individual plans for improving and/or maintaining functions;
• To coordinate the newly created services with health promotion activities.

After three months of debate, the bill was adopted in June 2005 with an amendment that obliges municipalities to find, treat, and prevent maltreatment of the elderly as well as advocate rights of beneficiaries.

Actors and influence

Government
Ministry of Health, Labour	very strong		none
Providers
Professionals concerned	very strong		none
Scientific Community
Rehabilitative specialists	very strong		none
Social workers	very strong		none
Media
Newspapers	very strong		none
Others
Care workers association	very strong		none
Political Parties
Liberal Democratic Party	very strong		none
New Komei	very strong		none
Democratic Party	very strong		none
Communist Party	very strong		none
Social Democratic Party	very strong		none

Positions and Influences at a glance

Adoption and implementation

The MHLW developed the details for implementing the new services:

Firstly, the MHLW revised criteria for classifying those "in need of support" and those "in need of care" and introduced additional items on functions of the elderly to the criteria. If person have more severe disabilites, they are categorized as those in need of care (higher categories). Those in need of support are divided into two categories: those in need of support in category 1 and those in need of support in category 2. Each category has estimated times for home help, training and medical services. For example, a person in need of support in category 1 is expected to use those services between 25 and 32 minutes per day; while a person in need of care in category 5 is expected to use services 110 minutes and over.

By the revision some beneficiaries have been downgraded after the revision of the long-term care insurance system. Some of those who had been classified as "in need of care" before the amendment have been classified after the revision as "in need of support". Those "in need of support" are eligible for rehabilitative services; while those "in need of care" for usual long-term care services.

Secondly, the MHLW determined remuneration fees and standards for newly created services with slight innovation. For example fees for day care services for those in need of support have basic, additional and incentive components. Additional fees are paid for physical trainings, services of nutritional improvement, services for oral health improvement, and group activities. Incentive fees are paid to service sites according to outcomes in terms of improvement of functions of those in need of support. Outcomes are broadly measured by changes in categories of beneficiaries. On the other hand, fees for home help services for those at risk are not counted on an hourly basis, which was the case before the enforcement of the amendment, but on a monthly basis for facilitating more flexible and efficient delivery of services. In the process of implementation, concerned professional organizations, such as the association for nutritionsts or occupational therapists, requested the MHLW to make a guideline for delivering the services that explicitly involve them.

Thirdly, municipalities shall make efforts to identify those "at risk" through health check-ups and/or other measures. Those "at risk" are frail senior citizens who have larger risks to lose thier functions and may need support or care in the near future. Thus those who has been categolized as those in need of care or of suppor are excluded from those "at risk". Comprehensive support centres shall examine functions of the elderly to determine whether they are at risk, in need of support, or not. A screening test for that purpose is being developed and shall be used from April 2008. Comprehensive support centres also shall manage services of improving or maintaining functions of those at risks.

Forthly, a new program, Community Support Program, has been introduced to develop allied services by each municipality. The program includes rehabilitative services to those at risk and other activities for promoting active aging and developing support network there. Rehabilitative services are financecd by tax (municipality, prefecture and national) and the LTCI fund; Other programs by tax and premiums collected from senior citizens.

Finally, the MHLW published circulars on comprehensive support centres in October 2006. These centres shall have more skilled and experienced staff in both health and social care, particularly in community care for complex tasks: to manage the newly created services, to handle issues on abuse and maltreatment, to support those at risk or at need and their carers and to deal with difficult cases. Each centre in a municipality shall be supervised by a council established by the municipality government consisting of representitives from providers, service professional, experts for advocacy, users or beneficiaries, and other experts on the LTCI. Municipalities are expected to establish a centre for every 6,000 senior residents and can contract management of centres out. The Government subsidises operation of comprehensive support centres.

In April 2006 the amendment came into force and delivery of the new services started. More than eighty percent of local governments have established comprehensive support centres so far. The MHLW organized training courses for staff at comprehensive support centres.

Monitoring and evaluation

The MHLW organized several meetings for discussing problems and solutions on implementation of the revision of the LTCS with several local governments.

In September 2006 the MHLW conducted surveys on the implementation of the newly created services at the local level. The surveys showed that the identified number of those at risk was far lower than expected. Also, the MHLW requested local governments to co-operate with the concerned entities, such as health centres, physicians, social workers and long-term care providers, to reach those at risk in addition to identification through health check-ups. Furthermore, it widened and modified the criteria for those at risk, which had been requested by some local governments.

On the other hand, the MHLW also has begun to collect data for analysing processes, outcomes and costs of the revised benefits for rehabilitative services for those in need of support with selected municipalities.

As in the case of the revision in 2006, formal revision shall be done in five years.

Expected outcome

Though the idea of improving or maintaining functions of the frail elderly is brilliant, problems exist on how to achieve it. The policy is intended to achieve this purpose by a professionally managed mix of personal services to those identified by screenings and other methods, and with financial incentives to providers. Whether the policy works or not is to be empirically evaluated, but the evaluation itself may be controversial at least in terms of methodology. One problem is that it seems difficult to clearly differentiate those at risk from those in need. Another is that current procedures are much too complicated.

If the new services actually improve or maintain functions of the frail elderly for a significant period of time, impacts of the policy at the macro level can be still marginal because the rapid increase of the aged population may increase the real number of  those in need of care and some elderly become in need because of acute diseases from a healthy state. In this sense, more development of broader public policies to promote active and healthy aging may supplement the policy.

Impact of this policy

Quality of Health Care Services	marginal		fundamental
Level of Equity	system less equitable		system more equitable
Cost Efficiency	very low		very high

Since the policy introduced are so innovative, It's too early to rate the impact of this policy in terms of quality, eqity, and cost efficiency. The policy is controversial in terms of: quality because of the question if rehabilitative services work or not; equity because it may decrease equity by excluding some people formerly categorized as those in need of support but increase equity by developing community network for providing long-term care; efficiency because it may increase by allocating resources according to needs but decrease if services do not work.

References

Sources of Information

Research Group on Long-Term Care for the Aged. Long-Term Care for the Aged in 2015. 2003.

Rehabilitation for the Aged Research Group. Future direction of rehabilitation services for the aged. 2004.

Committee for Long-Term Care Insurance, Social Security Council. Review of the Long-Term Care Insurance and Its Future Directions. 2004.

MHLW. Papers to the National Conference for Heads of Long-Term Care Insurance and Health and Welfare for the Aged Section. 2007.

Author/s and/or contributors to this survey

Matsuda, Ryozo

Ryozo Matsuda is professor in community health and health policy at the College of Social Sciences, Ritsumeikan Univerisity. This report was written when he was a visiting fellow at LSE Health, London School of Economics and Political Science.

Suggested citation for this online article

Matsuda, Ryozo: "Improving functions of the frail elderly". Health Policy Monitor, October 2007. Available at http://www.hpm.org/survey/jp/a10/1