Home medical care using long-term care insurance--centered on home oxygen therapy

About two-thirds of the patients undergoing home oxygen therapy apply for the Long-term Care Insurance. Most of them are aged 75 or over but the degree of necessity of care is relatively low. Two-thirds of them apply for the insurance for the medical care-related reason, which are twice as many as those apply for the insurance because for the medical care-related reason. Medical cares covered by the Long-term Care Insurance include disease control by the visiting nurse, the assistance for the hospital visit using visiting care or day service/day care and respiratory rehabilitation using day care. Special elderly nursing homes are the good place to accept elderly people living alone. The merit of the Long-term Care Insurance is rapid information supply from various professionals to doctors. Since it is also possible to disseminate the doctor's instruction to each staff, it is possible to carry out disease control at home as if they were admitted to the hospital. For these reasons, the Long-term Care Insurance is extremely effective to prolong the period when patients undergoing oxygen therapy are treated at home or to improve their QOL.     

Assistance for improving QOL of patients using artificial respirator--a case of the very aged

The recent reform of the health insurance/Long-term Care Insurance resulted in the introduction of healthcare technology to home and patients can use even an artificial respirator in home medical care. However, both patients and family members have significant mental/physical burden, and in many cases, it may often be impossible to provide care to improve ADL/QOL. This time, a very old patient aged 88, who underwent artificial respiratory management, HOT, tracheotomy, tubal feeding, balloon catheterization and decubitus treatment among other medical cares, was discharged from the hospital and QOL was successfully improved by the care of family members and other various services. The success was mostly attributed to the endeavors of caregivers. In this article, we review the visiting nursing and assess what cares contributed to the improvement of QOL and discuss future assistance.     

Home medical care and long-term care insurance

The difference in medical care at home before and after the introduction of the Long-term Care Insurance is discussed and reported on the basis of my 20 years of experience in the home medical care. I appreciate the introduction of the Long-term Care Insurance in terms of its effect in making the general public interested in nursing as well as in those who need care. On the other hand, since emphasis was placed only on the degree of demand for the care in evaluating the qualification of the users of nursing facilities under the Long-term Care Insurance, public interest was focused simply on the degree of demand for the care. In the meantime, the fundamental problem of how to institute medical care at home appears to be neglected. As a result, many of those whose demand for the care have been assessed low make claims and request re-assessment, which results in a lot of personnel and financial waste in office procedures. Moreover, the families of those with the care necessity grade of 1 or more tend to falsely feel that they have been given the right to use the facilities, which decreases their motivation toward the home care. In reality, most facilities are crowded with users and improvement of the facility does not catch up with the rapid increase of users. Needless to say, the present situation is attributed to the inadequate governmental policies taken at the time of introduction of the Long-term Care Insurance. Immediate measures for improving the situation are required. In the case of elderly insurance facilities, in particular, in addition to evaluation of the conditions for using the facility solely on the basis of the degree of demand for the care, their positioning as the rehabilitation facilities aiming at achievement of home care should be clarified like before the introduction of the Long-term Care Insurance. A certain limitation is necessary regarding the duration of the use of the facility. Other than that, various problems have been proposed. We hope to examine these problems as well and report the results. We believe the most important thing is to exercise our ingenuity in creating a system enabling medical care at home in each community.     

An experimental weekly visit of the ward at Higashi Yamato Hospital--a holistic cooperation

The city of Higashi Yamato is located in the northern part of Tama, Suburbs of Tokyo, and the population of Higashi Yamato is approximately 80,000. The Higashi Yamato visiting nursing station was opened in April 1998. As of April 2006, we have over 100 patients, and the aggregate visiting nursing services have provided more than 600 cases. Our station's uniqueness is that forty percent of the patients have malignant neurological disorders and are terminal stage patients, and that they are all covered by medical care insurance. We also provide nursing services to patients who are expected to be dying peacefully at home averaging 4 patients per month. Higashi Yamato Hospital, attached to the visiting nursing station, is an acute phase hospital and has 274 beds. The average hospital stay for our patients was 13 days in 2005. We promote an early discharge from the hospital for patients who have a high need of medical and nursing care and for the patients who are at the terminal stage. However, there were many cases where visiting nursing care services were provided because of a local care manager's request rather than a visiting nursing care need for patients who will be discharged soon from the hospital and for those expecting to have the service. In reality, we have observed a family being felt that his or her patient was pushed out from the hospital, a family who has no confidence in taking a nursing task at home, and a family who could not cope with the patient's changing condition. Therefore, we wanted resolve these observed problems urgently to create close cooperation with the hospital in order to provide continued nursing care after a patient is discharged from the hospital and to have home medical care safely. As a result, we planned a visit to the ward on a weekly basis starting on February 2006. We report here because we had a good result.     

Formulation of policies for promoting home medical care by a university hospital--report of planned and convened case review sessions

It is no exaggeration to say that the linkage among the persons in various specialties, medical staff including the home doctors and visiting nurses, and those related to social welfare is essential for supporting and promoting the terminal care at home of the patients heavily dependent on medical care, as well as the patients and their families with problems in the nursing ability. Good understanding of other specialties and compensation for each other are considered to enable effective service to the patients. At our hospital, we have planned and convened case review sessions for the past two years. The sessions were proved to have the following merits that helped creation of teamwork for smoothly promoting medical care at home: 1. Persons in each specialty became able to play respective roles properly; 2. Measures to be taken were revealed, thereby inducing changes in the subsequent care; 3. The efforts made in the community could be understood and the problems to be wrestled within the hospital were suggested; 4. Smooth cooperation with visiting nurses and home doctors was achieved; 5. Nursing from a broader point of view became possible; and 6. A place for identifying problems and tasks under the present situation was provided.     

Roles of nursing counseling room in home medical care

The hospital inaugurated the service of visiting nursing in 1985 and the scope of the service was subsequently expanded to patients at the terminal stage and patients under artificial respiratory management. At present, however, the service of visiting nursing is restricted to the assistance to visiting medical care as a result of the diversification of the services of Nursing Counseling Room and the provision of better services at the visiting nursing station established in the city. The author reviewed the roles of the Nursing Counseling Room based on the experiences of discharge arrangements made in 2000 and 2001 in a patient with terminal disease, a patient with neurological refractory disease under artificial respiratory management and a child also under artificial respiratory management. Experiences in these patients made us realize the necessity of acting on the department of welfare of the municipal government, coordinating with the visiting nursing station, effectively holding conferences to discuss discharge and the necessity of the home doctor. We are determined to work to find solutions for these challenges.     

Contribution of the rehabilitation approach for home medical care--a case study of a patient with higher cortical dysfunction

Although the main theme of this meeting is the continuous care process from acute phase to chronic phase, it is also strongly emphasized on rehabilitation medicine. However, most of the patients who really need rehabilitation have not followed such a process. We will show you a patient with traumatic brain injury, who returned home directly from an acute phase hospital, who had difficulties in ADL and QOL. We took initiatives in medical and care services in order to support the patient and his family to alleviate his difficulties in ADL and QOL. Thereafter, he was able to continue living at home with more comfort. We must offer adequate medical rehabilitation and other necessary support providing medical services and welfare before a patient returns home.     

Present situation of home care and roles of nurses at Tokyo Women's Medical University Hospital--through the 5-year home care support activities

Diseases, details of interventions, medical cares provided and the condition of use and services of local medical institutions were investigated in the home care support activities during the period from November 1997 to March 2003. We intervened in 1,309 patients. 70% of them were terminal patients with malignant tumor. Interventions were mostly consultations about the life under medical care, guidance about HPN/tube feeding, consultations about nursing and coordination with local medical institutions. 422 of them were under care of family doctors. 502 of them used visiting nursing. 70% of the patients under care of the hospital required high-tech home care and home hospice care. The 5-year activities indicate that nurses who support home care at the hospitals providing acute medical care are expected to 1. serve as the consultation contact for patients and families, 2. support the life under medical care in consultation with internal and external related professionals, 3. use social resources, 4. serve as the contact for providing the logistic support under an emergent situation or under the lack of care-giving capabilities, 5. provide guidance for the safe use of high-tech home medical care by patients/families at the discharge, 6. communicate or coordinate with local medical institutions for continued care/nursing and 7. develop/support the flexible and convenient distribution system of medical equipment and medical materials/drugs or the 24-hour healthcare support system jointly with private enterprises.     

Examination of an after-hour emergency telephone consultation by Kizuna visiting nurse station

From inception, Kizuna visiting nurse station has been giving a 24-hour service because it is highly regarded as being most dependable in providing medical care service to a patient and family members since we started doing this service. Since an introduction of home care insurance system started, we provided telephone consultation as well as dispatching emergency visiting nursing service under an agreement with a fee that was named as "added emergency visiting nursing service fee". We examined and analyzed the emergency visiting nursing service contents based on the after hour telephone consultation given to patients and family members.     

The roles of a visiting nurse for a terminal stage patient with chronic renal failure: a case study

A visiting nursing service was provided for an 87-year-old male patient with terminal stage of chronic renal failure. Although his primary doctor told us that the patient's prognosis is no good with general prostration, the patient was cared at home because his family strongly wanted him in a home care environment. The patient, who is having a right nephrostomy catheter and urethrovesical indwelling catheter and is in an unstable condition due to dehydration caused by an aggravation of renal failure, left the hospital in the end of August in 2005. Meanwhile, a family care giver was feeling uneasiness due to a lack of experience in giving medical treatment and to care for the patient. Therefore, a visiting nurse provided support to reduce the caregiver's anxiety and taught how to observe the patient's conditions, to give medical treatment and a method to care the patient at home. As a result, the patient's symptom was little improved to a lesser degree of stable condition. The family caregiver's anxiety was also reduced as well. The roles of a visiting nurse for a terminal stage patient are: (1) to urge the family care giver to obtain basic self reliant home care techniques, (2) to create a division of clear roles among the family members, (3) to execute an individualized life for the patient and family, (4) to try to establish a system to cooperate with a medical support group.     

Clinical clerkship of home care for medical students

A clinical clerkship of home care has been introduced in our program for third-year medical students since 1998 at this university. In our clinical clerkship of home care, medical students are not only dispatched to visiting nursing stations, but they also participate in home care service activities with visiting nursing people at patients' homes. Through these experiences the students have an opportunity to study the policy of community medicine and home care, and to gain the knowledge of teamwork. OBJECTIVE AND METHOD: The clerkship of home care (1 week program) was introduced to all of the third-year medical students. The students were dispatched to visiting nursing stations and they had to take part in home care service activities at patients' homes with community care visiting nurses. After this program was finished, questionnaires were given to all the students and visiting nurses to examine the necessity and scheduling of this program and to evaluate the students by the visiting nurses, etc. RESULT: A total of 621 students participated in our program for the past 6 years since 1998, and 90 visiting nurses from 30 visiting nursing stations gave actual trainings to our students every year at patients' homes. 98% of the students as well as 97% of the home care nurses returned questionnaires. After the program, 95.1% of the students and 97.8% of the visiting nurses agreed that this program was meaningful for both sides and it should be continued. Furthermore, regarding a question of the suitability of the third-year medical students to be in the program, 70% of the students and 48% of the visiting nurses agreed. As to a question of the training duration, 80% of the students and 87% of the visiting nurses also agreed. Both students and visiting nurses were in agreement that this home care clerkship was important. Meanwhile, both students and visiting nurses also expressed a degree of some difficulty for this clinical clerkship training. These results suggested that there were some factors to be resolved in order to carry out the clinical clerkship as a success. The clinical trainings for community-based home care are not carried out sufficiently under present medical education because clinical clerkships are always performed at a bedside of a university hospital. It is hard for the students to learn community-based home care and the time related progression of a patient's disease. Therefore, clinical clerkship of home care is a good and effective method to educate the students in those areas.     

Home visiting nursing care for a terminal stage cancer patient with bed sore--coordination through exchanging of advice request memo as a useful tool

Visiting nursing care service was provided to a 40s female patient, who had a terminal cancer with bed sore around the sacred bones. We started the nursing service when the patient was still cared at hospital. The nursing service we provided was coordinated by the certified nurse specialized in skin and excrement care and home visiting nurse. A smooth home care transition was resulted because of the coordination provided by the two nurses. We started coaching the family while the patient was still at the hospital with a home care instruction manual until the patient was discharged. All in all, the patient and her family were at ease with two nurses' coordinated efforts. Since the patient was cared at home, her bed sore problem got worse due to an absence of caregiver. In order to solve the bed sore problem, the visiting nurse took pictures of peeled adhesive patch and the bed sore around the sacred bones to show and consult with the certified nurse. With the advice from the certified nurse, the home visiting nurse was able to care the bed sore problem manageable in size. From this experience, we learned that a proper communication channel, in this case an advice request memo exchange, between the certified nurse and visiting nurse was a useful tool for both sides in order to properly assess the patient's medical care needs.     

Home care in Sapporo

We established a clinic specialized in home care in Sapporo in July 2001. In these 2 years we have provided medical home care service to 160 patients, and 97 are still receiving regular service. At first we accepted any patients living within 16 km from the clinic. However, bad traffic conditions in winter made it difficult to visit patients living in districts far away from the clinic. Therefore, we planned a network of home care physicians in Sapporo. Now 12 home care physicians hold monthly meetings. In Sapporo, meetings of home care related workers are organized in each ward, as suggested by the Sapporo Medical Association. There is a relatively good supply of home care related services and resources, including availability of an important number of visiting nurses. Patients being taken care of at home who present an acute exacerbation of symptoms are relatively easily accepted by acute hospitals. But those who have difficulties in continuing home care due to a sudden change in family conditions are not easily accepted by nursing hospitals. Recently, the number of group homes and lodging houses for elderly persons has markedly increased in Sapporo. It might have some problems in medical support in the near future.     

"My tiny windows"--a nurse's point of view--case study from a home palliative care meeting

In visiting nursing care for home palliative care, nurses should take medical care with a holistic viewpoint. Nurses are not only a daily care provider to clients, but nurses are also necessary to think of themselves as being a person because they are in contact with clients' lives every day. In this home palliative care case, nurses had a chance to intervene with a woman with end-stage-cancer. Once in a while, the client had refused visiting nursing care with no reason. So it was necessary to have meetings frequently to discuss the problem. One of the things we thought was that we had to listen to the client and to watch her expression and behavior very carefully. This case study suggested that nurses should reconsider their practices to improve and to establish their original methods of nursing along with their clients.     

Involvement of Daikou Sunabashi Clinic in home care to home death

Daikou Sundabashi Clinic provides continuous advanced medical treatment and visiting nursing services for patients with serious diseases till their death at home. The clinic has been involved in home care of 72 patients in total during the period from April 2002 to July 1 of 2003. Of the patients, 40 patients died to date and 71% (32 patients) of them died at home. 49 of the 72 patients (70%) had terminal cancer and mostly required advanced home care. The clinic provides services according to the following principles till the death of the patients: 1. All of our medical staff pool their information and stay in very close communication with one another. 2. The attending physician gives a complete explanation of the patient's condition to his/her family. 3. The staffs respond to emergency calls around the clock using 2 cell phones. Under this very meticulous and fast-response system, seriously ill patient can receive continuous and high-quality treatment at home and die at home even if the family is not adequately capable of providing care.     

Key issues in death at home

After our facility was first opened, we provided terminal care for one patient with terminal stomach cancer. In this case palliative care, so important in terminal care, and care for the family was insufficient, and in the end we had to abandon the process assuring the kind of death the patient wished for at home. Learning from this experience, we have provided terminal care to about 150 patients based on each patient's outlook on life and view of life and death. These patients have included terminal cancer patients and patients informed of their cancer who chose to coexist with the cancer and live together with their families. At home, the words and facial expressions of the patients and their families are clear expressions of their humanity. At times, such, feelings are also directed frankly and unaffectedly toward us, the visiting nursing staff. When considering the early case in which we were unable to continue home care, we could see various problems: on the part of the medical staff including primary physician and nurses, the welfare service, the patient and family, and neighboring informal social resources. These included problems in informing the patient of his cancer and his remaining days. In home treatment of patients with terminal cancer, death at home assisted by a physician from the same medical facility is not emotionally all it might appear to be. Nurses, for example, do not provide religious comfort; therefore, they can not provide home hospice services. Or so it is said. However, in supporting community home care, there is an exchange between humans and the communication of genuine feelings; thus, the nurturing of warm care makes possible the kind of death the person wishes. In fact, we can not deny that that is the path we are taking. In the present report, we explore the issues that make home terminal care possible from the viewpoint of visiting nurses.     

Home medical support at Jikei Medical University

A clinical clerkship of home care has been introduced to third-year medical students since 1998 at our university. Visiting nurses from the regional visiting nursing stations would give actual trainings at patient's home to a lot of medical students every year. For the improvement of medical education, it is not sufficient to give actual trainings to the students from visiting nurses. Then what we can do for visiting nurses about the role of the medical University was to offer and introduce the programs of cardiac and respiratory assessment as lifelong learning for the visiting nurses. After these programs were finished, two kinds of questionnaires were given to all participants to examine the necessity and scheduling of these program: 1 ) The first questionnaires after the programs was of cardiac and respiratory assessment, 2 ) The second questionnaires was for the participants with the experience of these programs, 3 ) Last questionnaires was for all visiting nurses about our 41 regional visiting nursing stations to promote the new programs(eight programs: home hospice care and opioids, PEG for the nutrition, ICLS, management of respirator at home, management of IVH port, ECG, foreign body of the airway, and the anatomy of organs)for lifelong learning. 1 ) A total of 7 2 visiting nurses participated in our programs for about one year recently, and 100% of these attendants returned questionnaires. After the programs, almost all of visiting nurses agreed that these programs were meaningful for them and it should be continued. 2 ) A total of 2 10 visiting nurses participated in our programs for the past 5 years. Fifty seven percent(57. 1%)of visiting nurses returned questionnaires. After the programs, a lot of visiting nurses agreed that these programs were meaningful for them and it should be continued. 3 ) Nearly 50 percent (47. 8% or 213/446)of visiting nurses from 41 visiting nursing stations returned questionnaires. A lot of visiting nurses expressed that they would like to participate in the subject of hospice care and opioids, PEG for the nutrition, ICLS and management of respirator at home as new programs. For the role of the medical University to promote a home care, it is necessary to support a community-based home care with educational issues at the university and to offer the new program mentioned previously as lifelong learning with practical and essential issues for medical staffs at patients' homes.     

Home medical care network in the community supporting hospital--nursing consultant acting for community coordination

Tama Nambu-Chiiki Hospital is a secondary medical institution providing the acute short-term care centered on cancer treatment and emergency medical service, which few other medical institutions in the region provide. The hospital, which has no system to directly support home medical care by house visit or visiting nurses, needs to coordinate home medical care with other community medical institutions. 2 nurses serve as the Nursing Consultants who provide consultation services over the issues related to home medical care and other issues face to face or by phone and coordinate home medical care with other community medical institutions. Medical coordination based on trust and understanding of home medical care by hospital staffs are essential for the smooth transfer to home medical care. Activities of the hospital are studied to cope with the changes in healthcare trend.     

Assistance for improving QOL of patients with terminal disease cared at home

A visiting nursing service was provided for a female patient with the terminal stage of transverse colon cancer. The patient, who strongly wanted to stay at home, was discharged from hospital under continuous subcutaneous injection of morphine hydrochloride in late April 2001. The visiting nurse supported her life including the procedures for the continuous subcutaneous injection for attenuating pain as the main symptom. As a result, her fear of pain was reduced and she became able to control pain by oral medication. She became able to walk to the rest room and take a shower and have increased ADL while regaining the strength of will. Family members were concerned with the potential sudden change in her conditions or intensification of pain at home but the worry was contained by understanding the procedures to follow in such cases. QOL can be improved even at the terminal stage if: 1. the patient understand the pathological condition; 2. the patient discloses his/her worry; 3. the patient can choose the way of living; 4. caregiver can cope with the change; 5. caregiver can maintain the nursing capability; 6. the medical provider's assistance system is established.     

Method for home parenteral nutrition (HPN) at Daikou Sunadabashi Clinic

In recent years many patients who have become heavily dependent on medical care live at home. At Daikou Sunadabashi Clinic, we take care of many patients who have malignant tumors, at their homes. They need many medical treatments, so HPN has become a common practice. Here we show our circumstances of HPN. And we introduce our method for HPN. Our method is as follows: 1. Before the patient is discharged from the hospital, we go to the hospital and confirm the patient's condition. 2. We assess the level of training regarding HPN, and select the best way (instruments, circuits, administration) in consideration of the patients' or their families ADL. 3. We select a visiting nurse station 4. and train the visiting nurse in HPN using our manuals. 5. We use an HPN pump. 6. We select a simple way of infusion and adjust it to the patient's condition. In this way, we use HPN easily at home with the aid of a visiting nurse, visiting pharmacist, families, and us.