Health Promotion activity for the aged in Japan

1
Health Promotion activity for the aged in Japan

• Yoshihisa Fujino, MD, MPH, PhD, and Shinya
  MATSUDA, MD, PhD, FFPHM
• Department of Preventive Medicine and Community
  Health
• University of Occupational and Environmental
  Health, Japan

2
Topics

• General scheme of LTCI in Japan
• Health inequality among elderly regarding to
  living arrangement and income

3
Social insurance benefits for the aged in Japan
Medical care
ADL care
Income
Pension
Long Term Care Insurance
Medical Insurance
4
System of Long-Term-Care Insurance in Japan
LTCI fund Insurer (municipal government)
The first category of insured (65)
Deduction from pension or direct payment
Premium (19)
General tax (50)
Withheld with Premium of Medical insurance
The second category of insured (40 64)
Premium (31)
Reimbursement
In the case of the second category, only aging
associated disability is eligible.
Request for eligibility assessment
Two step of assessment On-site assessment by
standardized questionnaire with 79 items
and Assessment conference
Benefits in kind (10 of co-payment) 1)
Institutional services 2) Home care services
(home helper, Visiting nurse,, etc) 3)
Respite care (Day care, etc), etc
Accepted
Request for service
Establishment of the care plan according to the
eligibility status
Service supply
5
Care need certification

• Application for a certification
• Care need certification
• Investigating by the visit
• First judgments
• computer programme
• Second judgment
• The need certificate committee
• Notice to the judgment result

6
Levels of the certified care need and service
available
Tokyo Metropolitan Government
7
LTCI service

• Service given at home
• Home help service
• Home-visit nursing
• Home-visit rehabilitation
• Service given at a facility, etc.
• Day service
• Day rehabilitation
• Short-stay service
• Group care service
• Service for assistive devices

8
Dependency level and place of care (2004)
(person base )
Higher the dependency, more the users of
institutional care.
Source MHLW (2005)
9
Rapid increase in LTCI payment?(Chronological
changes in the beneficiaries)
(Thousands)
Source MHLW (2005)
10
Changes in dependency level between 2000 and 2002
(Matsue, Izumo and Mizuho town)
()
Source JMA (2003)
There is a considerable deterioration of ADL
level for the slightly frail aged.
11
What are diseases responsible for dependency ?
Results of analysis of medical comment report by
home doctor
(Source Matsuda, 2007)
12
Follow-up study of slightly dependent elderly
for mobility (three years)
Independency level of mobility
Independency level of toileting
Independency level of mental activity
OMA Disease (-)
Cumulative intact rate
OMA Disease ()
TIME(Year)
TIME(Year)
TIME(Year)
(Source Matsuda, 2001)
Statistically significant declines in
independency level were observed for the elderly
with OMA diseases (Log rank test plt0.01).
13
When intervene?

• Elderly ADL deteriorate in early stage
• The cause of disease in early stage are mainly
  Osteo Muscular Disease

14
Brief Overview of 2006 Reform

• Issue
• With a rapidly aging society with continuous
  increases in social insurance expenditures, is
  the Japanese universal health insurance system
  sustainable in future?
• Reform
• 2006 Health care reform (the biggest during the
  past 30 years)
• Basic concepts
• securing safe and reliable health care and
  valuing prevention,
• comprehensively promoting an appropriate system
  of medical expenses,
• realizing a new medical insurance system for the
  super-aging society.

15
Flow of frail elderly under the new LTCI scheme
Aged people
Revised LTCI eligibility assessment Assessment
of LTCI eligibility level Assessment
of possibility for improvement by preventive
programs
Screening program of frailty
Community Health Program
Benefit for prevention
Benefit for ADL care
High risk group
Assistance required
Care required
CCSC
Care management office
Community Health Program Physical fitness
class Community restaurant, etc
Preventive services Physical fitness
class Oral care, etc
ADL care Home help services Visiting nursing
services, Day services, etc
16
Physical fitness class by group exercises for the
frail elderly
17
Physical fitness class by machine exercises for
the frail elderly
18
Physical fitness class for the frail elderly
(Kochi city)
This kind of class is organized in about 700
community centers. Instructors are volunteers
aged who received a special training.
19
Physical fitness class for the frail elderly
(Kochi city)
20
Change in Physical fitness level
Yano, et al (2007)
21
Preliminary results of community physical fitness
program

• Statistically significant improvements are
  observed for
• Physical activity level
• ADL level
• VO2 max
• Mental status (depressive emotion, etc, evaluated
  by SF36)
• Social activity
• General health

22
Change of dependency level stratified by the
prevalence of dementia
(Source Matsuda, in submitting)
The aged with dementia have become worse in
dependency level compared with the non-dementia
elderly.

• Social and Biological Researches for
• Prevention of dementia
• Treatment of dementia
• Appropriate ADL care for the dementia person

23
Effect of depression to change in mobility of the
aged(YAL data 2004-2005,)
Independent variables Age category 0
65 - 74 years old, 1 75 years old and more CVD
(Cerebro-vascular diseases) 0 No disability
due to CVD, 1 Disability due to CVD MCD
(Musculo-Skeltal diseases) 0 No MSD, 1
Existence of MSD Other diseases 0 No other
diseases, 1 Existence of oteher
diseas Depression score 0 lowest level of
depression, 4 highest level of
depression Depndent variable Change in
Mobility score Mobility score 0 lowest , 5
highest
(Source Matsuda, in submitting)
24
Can long-term care insurance system reduce health
inequality among Japanese elderly ?

• Yoshihisa Fujino, MD, PhD, MPH, and Shinya
  Matsuda, MD, PhD, FFPH

Department of Preventive Medicine and Community
Health University of Occupational and
Environmental Health, Japan
25
Health inequality

• Living arrangements and health among elderly
• Income inequality and health among elderly
• How dose long-term care insurance service affect
  these terms?

26
The increased life expectancy of Japanese

• The increased life expectancy of Japanese
• 83 years (male 79, female 86) in 2006
• The aging of the population becomes social
  problems
• Japan introduced long-term care insurance in 2000
• elderly certified to receive long-term care
• from of 1.5 million in 2000 to 3.2 million in
  2005

27
Declining fertility rate

• A declining fertility rate has increased the
  ratio of nuclear families among the elderly
  population
• families of two among elderly increasing
• from 20 in 1988 to 30 in 2006
• elderly people living alone of all elderly aged
  65 or over
• from 15 in 1988 to 22 in 2006

28
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productive age
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29
LTCI and informal care

• Despite increasing the elderly who lives alone or
  with elderly, care for elderly assume informal
  care from immediate family.
• Living arrangement may be a good proxy of
  informal care for elderly
• Living arrangement may affect health of elderly

30
Methods

• Setting Yukuhashi City, Fukuoka
• Sampling randomly identified from resident
  registry data
• Subjects 3000 elderly at home
• 2773 (1178 males and 1595 females)
• 27 subjects declined participation
• 200 subjects were excluded owing to extended
  hospitalization or stay in a nursing home.
• Period 2002-2007

31
Measurements

• face-to-face interview
• Living arrangement
• Mobility status
• Medical status
• the municipal office data
• the use of long-term care insurance
• the vital status
• Income level (taxation base)
• Information was collected annually from 2002 to
  2007

32
Living arrangement categories
33
Mobility status

• Mobility status (Typology of the Aged with
  Illustrations)
• level 5, able to climb stairs without aid or
  assistive devices
• level 4, cannot climb stairs without aid but can
  walk on flat surfaces without aid or assistive
  devices
• level 3, cannot walk on a flat surface without
  aid, but can move around using assistive devices
  and change position independently while seated
• level 2, cannot move around or transfer while
  seated using an assistive device or aid from
  others, but can sit up and maintain a seated
  position
• level 1, cannot sit up or maintain a seated
  position but can roll over on bed without aid
  and
• level 0, cannot roll over on a bed while lying
  without aid.

34
Example of TAI (Typology of the Aged with
Illustrations)
35
Medical status

• Medical status
• not receiving medical care
• receiving periodic outpatient treatment
• hospitalized

36
Income levels
Income levels were adopted from taxation base for
long-term care insurance premiums for those aged
65 and over
37
Follow up

• 5 years of follow-up (2002-2007)
• 11639 person-years
• 4830 males and 6810 females
• 381 deaths
• 225 males and 156 females

38
Main Findings

• Living arrangement as classified by the ability
  to receive informal care affects survival among
  elderly men
• Higher mortality were seen among
• Elder-to-elder care
• Men living with others who cannot provide
  sufficient care
• Men living alone without support
• LTCI did not reduce the difference in mortality
  between the groups of living arrangements

39
HRs of living arrangement for mortality among men
40
Living alone without support
41
Living alone without support
42
Confoundings
Income
Marital status
Occupation
Education
Character
Living arrangements
Health
Pathway
Social participation
Alcohol
Mental health
Smoking
Diet
Informal care
?
LTCI
43
Adjusted for use of Long-term care insurance
44
Discussion Who is a responsible for care of
elderly?

• LTCI is initially assumed that elderly receive
  informal care at home
• LTCI is designed to support family member who is
  involved in care at home
• Short stay and Day service aim not only to
  support elderly but also to reduce burden of
  family members.
• However, elderly living alone or two family of
  elderly is rapidly increasing.
• There will be a huge demand from elderly who dose
  not have a principle carer at home.
• Unfortunately, benefits from informal care cannot
  substitute for those from current LTCI service.

45
Income and Health
46
Income and Health

• It is believed that income inequality is
  relatively narrow among Japanese society
• However, recent evidence shows that income
  inequality among Japanese is increasing
• Gini coefficient is 0.25 to 0.4
• Income is a significant determinants of health
• Very few evidence about Japanese elderly

47
Income levels
Income levels were adopted from taxation base for
long-term care insurance premiums for those aged
65 and over
48
Income and Health

• No association was found in women
• The highest mortality in the poorest men

49
Income level and use of LTCI
People with low income are more likely to use LTCI
50
Income and Health
51
Stratified by mobility status
52
Adjustment of use of LTCI among men with good
mobile
53
Discussion

• Very few evidence that LTC can improve elderly
  health
• LTCI dose not reduce health inequality in regard
  to living arrangement and income
• The role of LTCI is an open question
• Improve/maintain independency?
• Improve elderly health/QOL?
• Reduce health inequality?

54
What is Aim of LTCI ?

• LTCI may improve and maintain independency of
  elderly compared with not using LTCI.
• It is difficult to examine this because LTCI has
  already implemented in Japan.
• LTCI can never satisfy needs
• LTCI must follow infinite needs
• LTCI creates needs People feel LTCI service is
  convenient
• LTCI can improve elderly health
• There is social anticipation, but far more
  ambitious.
• Is this possible? Aging is inevitable.
• LTCI can reduce health inequality related to
  individuals capacity of receiving care.
• Income, living arrangement, marital status,
  education,
• However, current LTCI can not reduce health
  inequality in these terms.
• The 3rd aim is the most promising if LTCI is
  designed appropriately.

55
Conclusion

• After the introduction of LTCI scheme in 2000,
  the ADL care for frail aged has been ameliorated
  both for quantity and quality.
• With fewer children and more aged, however, there
  is a doubt if the current system will be
  sustainable in future.
• There is very few evidence that LTCI can improve
  health/ADL nor reduce health inequality among
  elderly

56
Conclusion

• In order to make our universal social insurance
  system sustainable, we have to reconstruct the
  system
• Strengthen the preventive activity, esp. for the
  slightly frail elderly with OMA disorders
• Strengthen the researches concerning effect of
  dementia and depression for change in ADL level
  of aged
• Strengthen the approach to reduce health
  inequality regarding to capacity of receiving care