Abstract
This paper elucidates issues concerning support for reconstructing assistance systems by examining the circumstances of transitioning from hospitalization to living at home for an ALS patient living alone. Research methodology: I conducted participant observation of support for a male ALS patient in his sixties transitioning from hospitalization to living alone at home and documented the progress of this support using records from June 12th to July 13th, 2008. Results: the care plan submitted one month after hospitalization was almost unchanged from the plan prior to hospitalization and used only nursing care insurance. Support providers provided information on disability welfare services and assistance in connecting with relevant institutions in order to formulate a care plan and obtain access to intensive visiting nursing care. It took two months to receive the judgement of the disability grade certification situation survey, and during this time the symptoms of the ALS patient progressed. Disability welfare services were deemed unnecessary because he had not undergone a tracheostomy, and the care plan that had included intensive visiting nursing care during the night was deemed impossible as there was no institution to take it on. With discharge from the hospital approaching, through support providers looking for a nursing care office and helpers to provide intensive visiting nursing care a care plan incorporating disability welfare services became more realistic and was accepted with a doctor's written opinion, but reconstructing the assistance system took three months.
