Services in public long-term care insurance in Japan

ABSTRACT

In Japan, a public long-term care insurance system was launched in 2000. Residents can receive long-term care according to their care needs, as determined by a nationally standardized certification system. The present report describes the details of the long-term care services covered by public insurance. The Long-Term Care Insurance Act categorizes services into three major types: in-home, nursing-home, and community-based long-term care services. In-home care services include visiting, commuting, short-stay, and other services. Welfare, health, and medical facilities provide nursing-home care services for the elderly. Community-based care services were categorized into visiting, commuting, nursing-home, and composite services.

INTRODUCTION

In Japan, the government implemented mandatory public long-term care insurance in 2000 [1–3]. Residents aged ≥65 years are regarded as primary insured candidates, and residents aged 40–64 years who need care due to one of the 16 pre-determined diseases (e.g., end-stage cancer, Alzheimer’s disease, and stroke) are regarded as secondary insured candidates. Of these candidates, residents who meet the eligibility criteria can receive long-term care insurance services according to their care-need level.

Care-need level is evaluated by the nationally standardized certification system, irrespective of the income level and availability of informal care provided by the family [3]. First, a trained local government official visits a candidate (at home or hospital) to assess the need for nursing care. The official uses a questionnaire of approximately 90 multiple-choice questions on the current physical and mental status of the individual and investigates the daily use of medical services with detailed notes [4]. Concurrently, the attending or outpatient primary care physician fills out a paper-based statement on the condition of the candidate using a standard format consisting of both multiple-choice and free-text items. Based on the questionnaire and part of the statement, the candidate is temporarily allocated to one of seven care-need levels according to the total daily estimated care minutes: support levels 1–2 and care-need levels 1–5 (Table 1). Candidates judged to be independent are classified as non-applicable. Finally, the Nursing Care Needs Certification Board (consisting of physicians, nurses, and other experts in health and social services appointed by the mayor) determines the final care-need level after considering the notes by the officer and the statement by the primary care physician. The care-need level is valid for six months to two years and is generally re-evaluated once or twice a year.

Table 1 Details of care-need levels in Japan’s long-term care insurance system

Care-need levels	Total daily estimated care minutes (minutes)	Maximum benefits covered by LTCI per month (Japanese yen)	Nursing-home service
Support level 1	25–32	50,320	Not covered
Support level 2	32–50	105,310	Not covered
Care-need level 1	32–50	167,650	Covered
Care-need level 2	50–70	197,050	Covered
Care-need level 3	70–90	270,480	Covered
Care-need level 4	90–110	309,380	Covered
Care-need level 5	≥110	362,170	Covered

Abbreviation: LTCI, Long-term care insurance

Previous articles have explained the care-need level [1–3] and reported that the level was highly associated with the Barthel index [5]. This allows for clinical research using the information of care-need level recorded in administrative claims databases [4, 6, 7]. However, few studies have demonstrated the nationally standardized categorization of services covered by the Japanese long-term care insurance. Therefore, to accelerate large-scale research using real-world data on long-term care, we aimed to summarize the categorization of long-term care insurance services in Japan.

CATEGORIES IN LONG-TERM CARE INSURANCE SERVICES

The Long-Term Care Insurance Act categorizes care services into three major types: in-home, nursing-home (sanatorium), and community-based long-term care services (Table 2) [8]. In-home and nursing-home services were founded with the enforcement of the Long-Term Care Insurance Law in 2000. These services are under the jurisdiction of the prefectural governments. Community-based services were added in 2006 to provide services for residents requiring moderate care (e.g., residents with dementia) in their immediate community. Thus, each municipality controls community-based care services, and the content of community-based care services can differ between municipalities. In-home and community-based care services are provided for users with any care-need level; that is, users with support levels 1–2 can receive some of the same services as preventive long-term care services. Nursing-home care services that allow admission to a care facility are covered only in care-need levels 1–5 (Table 1). Among the 24 million residents aged ≥65 years recorded in the national data on Japanese long-term care from 2007 to 2016, 7 million (28%) used nursing-home care services [9].

Table 2 Three major types of long-term care insurance services

Types of LTCI services	Established in	Administration	Targeted care-need level
In-home service	2000	Prefectural governments	Any level
Nursing-home service	2000	Prefectural governments	Care-need levels 1–5
Community-based service	2006	Local municipality	Any level

Abbreviation: LTCI, Long-term care insurance

Users can request a care manager to evaluate the situation of the user and their family, formulate a plan for the services to be used (mainly in-home and community-based care services), and coordinate with service providers. This service is called “care management” or “in-home care support.”

IN-HOME CARE SERVICES

The Long-Term Care Insurance Act defines 12 services as in-home care services [8]. In-home care services are categorized as visiting, commuting, short-stay, and other services (Table 3).

Table 3 Contents of in-home care services

	Contents of service
Visiting services	Home-visit care*
	Home-visit bathing
	Home-visit nursing
	Home-visit rehabilitation
	Management guidance for in-home care
Commuting services	Commuting care*
	Commuting rehabilitation
Short-stay services	Short-term stay for care
	Short-term stay for recuperation
Other services	Rental service for welfare equipment
	Sale of specified welfare equipment
	Care in a specified facility

* These services are not provided to users at support levels 1–2.

Visiting services include “home-visit care,” “home-visit bathing,” “home-visit nursing,” “home-visit rehabilitation,” and “management guidance for in-home care.” Home-visit care supports daily activities such as bathing, toilets, meals, and cleaning at the user’s home. In a bathing service, the provider takes a bathtub to the user’s home and supports the user’s bathing. Home-visit nursing and rehabilitation are performed under the instruction of an attending physician. Home-visit nursing includes medical care and assistance (e.g., symptom observation, sputum suction, bladder catheter replacement, bedsore care, and nutritional guidance) provided by a nurse, whereas home-visit rehabilitation is conducted by physical, occupational, and speech therapists. In management guidance for home-based care, attending staff (such as physicians, nurses, and pharmacists) visit users’ homes to provide medical management (e.g., prevention, diagnosis, and treatment of diseases) and make decisions regarding the use of short-term stay services for recuperation.

Commuting services include “commuting care” and “commuting rehabilitation.” Users visit a facility for one day to receive care (e.g., bathing and meal services), functional exercise, rehabilitation, and management guidance.

Short-stay services include “short-term stay for care” and “short-term stay for recuperation.” These services are supposed to temporarily reduce the physical and mental burden on users and their families. During a short-term stay for care, users stay in a facility to receive support for daily activities such as bathing, toilets, and meals. Short-term stays for recuperation provide care, functional exercises, and treatment under medical and nursing management in certified healthcare facilities. The maximum length of stay allowed in a facility per month is determined by the care-need level: approximately one week for support level 1, and almost one month for care-need levels 4–5.

As other in-home care services, users can rent or purchase welfare equipment. Rental services provide welfare equipment such as wheelchairs, care beds, anti-decubitus seat cushions, handrails, walkers, and motion sensors to prevent falls or wandering. Users can receive allowances for minor renovations such as installing handrails and eliminating steps. Some equipment regarding bathing and toilets (e.g., chairs for bathing, bathtubs, toilet seats, and colostomy devices) should be purchased because the equipment does not fit the rental service. Additionally, users living in a specified facility can receive care (e.g., bathing, toileting, and meal services), functional exercises, and rehabilitation based on a facility service plan. Specified facilities provided by private businesses, such as fee-charging homes and nursing homes for the elderly, are defined in ministerial ordinances.

NURSING-HOME CARE SERVICES

Nursing facilities defined by Long-Term Care Insurance Act are categorized into “welfare facilities,” “health facilities,” and “medical facilities” for the elderly [8]. These facilities all provide care (e.g., bathing, toilet, and meal services). Welfare facilities provide lifelong care for users with care-need levels of 3–5. Health facilities mainly provide nursing and rehabilitation for several months to users with any care-need level aiming to return home. Users with care-need levels 1–5 who require life-long medical care (e.g., suction, parenteral nutrition, and wound care) can be admitted to a medical facility for the elderly, which is called “integrated facility for medical and long-term care.”

COMMUNITY-BASED CARE SERVICES

The Long-Term Care Insurance Act defines nine services as community-based care services [8]. Community-based care services are categorized as visiting, commuting, nursing-home, and composite services (Table 4). The services provided differed among the municipalities.

Table 4 Contents of community-based care services

	Contents of service
Visiting services	Round-the-clock home-visit care and nursing*
	Night-time home-visit care*
Commuting services	Community-based commuting care*
	Commuting care for patients with dementia
Nursing-home services	Community-based nursing-home care in a welfare facility*
	Community-based nursing-home care in a specified facility*
	Nursing-home care for patients with dementia
Composite services	In-home care by a multifunctional small facility
	In-home care and nursing by a multifunctional small facility*

* These services are not provided to users at support levels 1–2.

Visiting services include “round-the-clock home-visit care and nursing” and “night-time home-visit care.” Round-the-clock home-visit care and nursing provide regular and as-needed visits to a user’s home for home-visit care (e.g., bathing, toilet, meal services) and nursing. Users can contact the provider throughout the day to request the service. Night-time home-visit care provides regular and as-needed visits only for home-visit care at night.

Commuting services include “community-based commuting care” and “commuting care for patients with dementia.” Community-based commuting care is provided in small facilities with a capacity of 19 users or fewer. For commuting care for patients with dementia, a user with dementia can receive specialized care and exercise from staff familiar with dementia.

Nursing-home services provide care (such as bathing, toilet, and meal services) based on community-based facility service plans in welfare or specified facilities with a capacity of 29 or fewer users, or nursing-home care for patients with dementia. In nursing-home care for patients with dementia, a small group of five to nine users live together with care staff and participate in household chores, such as cooking and shopping, with 24-hour professional assistance.

Composite services include “in-home care by a multifunctional small facility” and “in-home care and nursing by a multifunctional small facility.” Multifunctional small facilities provide visiting, commuting, and short-stay services, coordinated by a single office. Therefore, users can easily receive services that match their situation with that of their families.

CONCLUSION

Long-term care insurance services are categorized into three major types according to the relevant laws. In-home care services include visiting, commuting, short-stay services, etc. Nursing facilities are categorized as welfare, health, or medical facilities for the elderly. Community-based care services include visiting, commuting, nursing-home, and composite services as determined by each municipality. Users can receive these services according to their care-need levels.

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