Decision making in clinical practice has shifted from paternalism to the patient’s self-determination, and then to shared decision-making (SDM) which appears to be the standard currently． When patients’self-determination was the standard in the late 20th century, they had the right to make decisions on their own． However, this resulted in patients not making the best choices in many cases． SDM allows the patient, family members, and medical and care professionals to talk together, provide information to each other, and share any concerns in order to realize the best for the person, without leaving the person alone to take the role of exclusive decision maker． The patient and those involved in their treatment and care discuss what is best for the person, using evidencebased choices whenever possible, in terms of the person’s narrated life． These changes have implications for how to prepare for medical and social care at the end of life when the person is often in an uncommunicative condition． Advance care planning (ACP) has developed to compensate for the limitations of advance directives, which were devised in the era of patients’self-determination, and emphasize the importance of the dialogue process． Home medical care is carried out where the person spins their life narratives with their family, and appears to be the optimum location to conduct ACP． If ACP is performed appropriately, it can also help to care for the family, and also increase job satisfaction among healthcare professionals．

COVID-19, a severe respiratory disease caused by the new coronavirus SARS-CoV-2, resulted in a worldwide pandemic that is still expanding. Although COVID-19 is primarily transmitted by droplet and contact routes, airborne transmission by aerosols also needs to be considered. The condition of approximately 20% of COVID-19 patients becomes severe and complicated by acute respiratory failure and multiple organ failure. Thrombus formation due to injury to vascular endothelial cells in each organ or tissue was recently shown to markedly increase disease severity. The cytokine storm caused by the activation of various immune cells due to SARS-CoV-2 infection and the direct invasion of vascular endothelial cells by SARS-CoV-2 through surface ACE2 as a receptor have been proposed to cause vascular endothelial cell injury. Elevated blood D-dimer, FDP, PT prolongation, and elevated blood IL-6 are useful markers for predicting aggravation.

When we think about the relationship between home medical care and emergency medical care, it is most significant that nurses do joint operation with medical doctor, especially for the nurse belonging to visiting nurse association serving for 24 hours.　In our home medical care service, we can realize immediate medical care for the patient having sudden change by using the system of home care medical social worker. We report our providing emergency system for our home care patent.

After acute phase diseases and its’treatments，physical and psychological disorder often occur in patients， especially in the elderly because of their declined resiliency. These dysfunction and injury have been treated as post-intensive care syndrome or hospital acquired associated disability for the limited population. We propose the concept of post-acute care syndrome PACS to discuss the dysfunction after broad acute medicine. PACS contains physical injury，cognitive dysfunction and psychological disorder，which can be evaluated with appropriate evaluation batteries. In the super aging society，it is urgent need to consider and take measures for PACS and to start up the informative cooperation between acute care hospitals and primary care including home healthcare.

The purpose of this study is to understand the structure of the issues related to use of ambulance services by the elderly，and to obtain insights for strategies for solving the issues. Semi-structured individual or focus-group interviews were conducted on 216 healthcare professionals from 31 institutions in Kobe，including 68 physicians，59 nurses，6 policy makers. Thematic analyses were performed. The　major themes identified included： 1） unclear preferences of patients about future medical care，2） barriers to ACP implementation，3） unavailability of sharing health information about ACP preference and physical conditions of patients，4） lack of cooperation among emergency department，community medical services，and long-term care facilities，and 5） insufficient local resources and public involvement． The proposals for solving these issues included; 1） clarification of the definitions，components，and evaluation methods of ACP suitable for the Japanese ，2） establishment of electronic sharing system about medical information including ACP of patients ，3） reduction of unwanted or unnecessary emergency transportation and hospitalization through cooperation of emergency department，primary care services，and long-term care facilities，and 4） fostering culture and system to think together with the residents and work toward a better society.

Vital signs are usually used as indicators which tells health status easily but it is hard to say that they are enough used for the judgement of medical intervention. In this study, ICT remote health care system “Anshin-net” sets normal ranges of vital signs based on its data as mean ± 2σ, then determines “abnormal value” which is off the normal range. Abnormal values are put on “the scoring table” then calculated the score. We use Anshin-net for remote monitoring of the home care patients, then extract the its issues and did questionnaire survey.As results, most of cases home care patients could continue to measure their vital sings with the smartphone and measurement device with transfer function by cooperation of their family, and it could be confirmed that effect for changes the awareness of health care. There were many benefits for the primary doctors, too. The doctors can monitor high blood pressure patients remotely. They are able to use the result as a reference to do telephone interview, and visit patient’s house to care. Additionally, they can know patient’s condition worsens during blanc period of medical interview, and confirm the condition before and during visiting.

Emergency transfers and hospitalizations of nursing home residents to acute care hospitals should be avoided if possible. Our study aimed to provide a broad overview of research on nurse-led interventions to reduce avoidable transfers and hospital admissions from nursing homes to acute care hospitals and to examine future research questions. Methods: We conducted a scoping review using three electronic databases （MEDLINE, CINAHL, Cochrane Library）. Results: Thirty-nine papers met the inclusion criteria and were categorized as follows: （1） interventions related to improving the quality of primary care, （2） interventions related to improving the quality of end-of-life （EOL） care, and （3） complex interventions that included elements of both primary and EOL care. Hospitalization were reduced by implementing care pathways, as well as interventions related to EOL decision support and those for care staff and by advanced practice nurses. The present study also suggests that complex interventions that combine multiple interventions might be useful. Conclusions: Given that many studies indicated that effectiveness includes multiple intervention elements, reducing avoidable transfers and hospital admissions from nursing homes would be better served by complex interventions.

Aims: We established “One Hospital Coordination of home-visiting physicians and emergency physicians” to overcome confusion at the emergency care site for elderly. The goal of this system is to develop a close relationship between home-visiting physicians and emergency physicians. Methods: A prospective observational study, and the effectiveness of this system considered. Results: Out of 98 cases which were referred to an emergency hospital from a home-visit facility, and 97 cases were accepted. 66 cases were admitted to a hospital for treatment (hospitalization rate 68%), the average number of days of hospitalization were 21.6±1.8 days, and the rate of patients returning to the referral facility was 91%. 13 patients (20%) were hospitalized for several times within a year A questionnaire interview was given to 10 home-visiting physicians who referred patients to a hospital. Features of emergency medical care desired by home-visiting physicians included “quick response (50%)” and “ease (25%).” By connecting the “One Hospital Coordination,” results such as “stress when referring patients was reduced (70%),” and “referrals are carried out smoothly (60%).” Conclusions: “One Hospital Coordination” is considered to promote the smooth referral to emergency care for elderly patients, and contribute to a higher rate of returning home and receive care.