In Japan, towards 2025, when the baby boomers will be 75 years or older, a full-scale reform regarding the "health care provider system" and the "long-term care service delivery system" is being carried out to address the rapid changes in population and disease structure. 　In 2014, to promote overall health care and long-term care insurance through the establishment of efficient and high-quality health care provision systems and "community-based integrated care systems," a structure known as the "regional health care comprehensive insurance policy" was established. 　In addition, within the health care system, the "community healthcare initiative" and "hospital beds function report" was institutionalized. Also within the long-term care insurance system, enhancement and restructuring of community support business, ensuring fairness of the cost burden, and prioritization of the benefits were conducted. 　Legislation of a "community-based integrated care system" is a breakthrough as this progressed the system towards holistic support of home life for elderly people from the user's point of view.

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In the era of rapid aging and the following changes in the social structure in Japan, health and social services professionals need to develop networks that flexibly reflect particular situations of each locality including the number of elderly people and the health care delivery arrangements. In other words, this is the system that is currently encouraged at the national level, enabling various services including health, social, and welfare to be provided appropriately in order to support the daily life of elderly individuals in their home/community settings (community-based care system). In this report, I will illustrate the actual process of the network building towards integration of health and social care at the local level by explaining the experiences from my initiatives in the city of Matsudo, where I belong to the medical association. Regarding the network building, I emphasized the importance of health and social care in todayʼs clinical practices, especially in the form of horizontal integration. Furthermore, sharing and uniting norms among various professionals and residents in the locality is essential for the integration ("normative integration"). Based on the experiences and findings from the initiatives, including that mentioned above, it is expected that communities will be built using multi-actor cooperation networks to support individuals, their families, and the locality on the basis of a local government, health professionals, and the residents.

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In Japan, we have problems with delivery systems for local health and social care because of the inequality of available care resources and collaboration arrangements. Therefore, in order to establish a care delivery system in local communities, it is necessary to clarify the obstacles and find solutions to ensure the health and social care resources that meet the needs of a local community and arrange interventions to minimize the difficulties of coordination between health and social care systems. 　In this report, I will introduce the initiatives in Shizuoka prefecture in Japan by focusing on two approaches facilitating coordination between health and social care: 1) training doctors for primary health care and home care and 2) establishing a hub for primary health care and home care. Through examining these two approaches, I will discuss the direction for the future. 　Regarding the training of doctors for primary health care and home care, we first analyzed the current situation of the home doctor training project in Chu-Toh-En Area in Shizuoka and found that those home doctors are trained as general practitioners. Therefore, I emphasize the importance of continuing to train home doctors with specialized educational programs in order to establish a community-based care system in a municipality. 　Regarding the establishment of a hub for primary health care and home care, I examined the example of a primary health care and home care center, In Japan, we have problems with delivery systems for local health and social care because of the inequality of available care resources and collaboration arrangements. Therefore, in order to establish a care delivery system in local communities, it is necessary to clarify the obstacles and find solutions to ensure the health and social care resources that meet the needs of a local community and arrange interventions to minimize the difficulties of coordination between health and social care systems. 　In this report, I will introduce the initiatives in Shizuoka prefecture in Japan by focusing on two approaches facilitating coordination between health and social care: 1) training doctors for primary health care and home care and 2) establishing a hub for primary health care and home care. Through examining these two approaches, I will discuss the direction for the future. 　Regarding the training of doctors for primary health care and home care, we first analyzed the current situation of the home doctor training project in Chu-Toh-En Area in Shizuoka and found that those home doctors are trained as general practitioners. Therefore, I emphasize the importance of continuing to train home doctors with specialized educational programs in order to establish a community-based care system in a municipality. 　Regarding the establishment of a hub for primary health care and home care, I examined the example of a primary health care and home care center, "Fukushia," in Kakegawa city in Shizuoka. This care center offers a unified access point to the administration, a community-based integrated care center, a social welfare council, and home-visit nursing stations, which enables individuals to connect promptly and efficiently with both formal and informal services across different care sectors including medical, health, social, and welfare. Having a system that allows different professionals in a local community to have organic collaboration aids coordination between health and social care for elderly individuals as well as solving obstacles for elderly individuals to continue living independently in their local communities.

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The establishment of the Japanese community-based care system was (first) presented in the report of the National Council on Social Security System Reform in August of 2013. Since then, each function aims at supporting the lives of the elderly people in their homes and local communities where they feel attached by dividing and/or sharing (various) care tasks. 　This system includes the concept of community-based care in addition to that of integrated care, which is designed to support elderly individuals with chronic health conditions and ensure their independent lives after discharge from hospitals by delivering services tailored to those individual's conditions. 　This integrated care is considered to contribute to the sustainability of the health system by moderating the demands of unnecessary hospitalizations and expensive emergency services and to support maintaining the quality of life of individuals to reach a high level of independence and satisfaction in their lives. 　In this article, I will explain the position of the Japanese community-based care system in the context of health services integration. Meanwhile, I intend to clarify the international problems with health services integration and to give insights into their solutions by reviewing previous worldwide studies. 　From international reviews of previous studies, integration and coordination of health services are found to be considered problematic on the international level as well. In order to facilitate integration of health services, we suggest establishment of an integrative service delivery model through systematic organization of integration frameworks (horizontal/vertical and linkage/coordination/full integration). 　From the domestic trends in Japan, with the prospect of further division of roles in each function in the service delivery system, it is necessary to clarify the care management process including patient admission and discharge from hospitals in order to achieve seamless care management for people with care needs. Moreover, in order to strengthen this management function, it is necessary to develop a practical tool to support better information sharing across different health care sectors. At the same time, municipal governments are expected to support this type of initiative from multiple aspects.

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Pension and medical insurance schemes were operated in Japan since before World War II, but some people in the informal sector were not covered. Amid rapid economic growth after the war, the government sought to solve this problem, and universal insurance coverage was introduced in 1961. Japan's history after the introduction of universal insurance coverage overlaps with the history of aging countermeasures. 　The government has been continuing its efforts to integrate care to meet the needs of a super-aged society and to strengthen primary care and community medicine, enacting the Re-arrangement of Relevant Acts for Promoting the Comprehensive Provision of Medical and Nursing Care in Communities in 2014. This act promotes the building of community-level comprehensive support and service setups (which is to say community-level comprehensive care systems) so that, as far as possible, people can continue to live in their own way and in familiar surroundings until the end of their lives. 　On the other hand, the concept of frailty has become more important in gerontology and geriatric medicine. Frailty is a common clinical syndrome in older adults that carries an increased risk for poor health outcomes including falls, incident disability, hospitalization, and mortality. There are many elderly people becoming the need of nursing care via frailty. The frailty measures are new important issues in the integrated community-based care system. Ministry of Health, Labour and Welfare will work on frailty measures of the elderly from fiscal 2016. 　In order to structure the integrated community-based care system and to improve the quality of comprehensive care in the regions, it is critical to strategically use the regional activities that presently exist in each local region as well as new regional resources that might be created out of changes in the social environment in the future. 　At the same time, it is likewise necessary to strengthen the coordinating functional capability to link information-based support to the specific care services. Social and community prescription is a strategic management tool that links the non-specialized service to the specialized service of the integrated community-based care system. We can strengthen the coordinating function by building up the system of social and community prescription.

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Integration of health care and long-term care has come to be promoted by Japanʼs national governmentas a part of policy measures to build an integrated care system at a local government or municipality level. To evaluate the policy, it is important to monitor how the local governments or the municipalities utilize the statutory survey data and other administrative data on medical, health, and long-term care, incorporating them to develop the measure for the integrated care system. In this paper, we, the research team of the Department of Health and Welfare Services, National Institute of Public Health, report the results of our nationwide survey on data utilization by the local government for building a community based integrated care system, which was conducted in January of 2015 as part of the research project supported by the Health Labour Sciences Research Grant. The results suggest that empirical datautilization for an evidence-based program design and evaluation has not yet spread in the municipalities. The results also showed that few administrative data, accumulated in preventive care and medical care sections, have been utilized in the long-term care sections in municipalities. Currently, the integration of health care and long-term care at the level of data utilization is far from realization. Our survey results are to be the baseline for monitoring and evaluating the development of heath care and long-term care integration in local governments.

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This paper describes the present condition of the role of public health centers in health care and longterm care integration and discusses the future prospects of such centers. 　Currently, the Ministry of Health, Labour and Welfare encourages municipalities to focus on the home medical care cooperation promotion business in collaboration with district medical associations. The business was founded in 2015 to implement a long-term care insurance business plan, and all cities, towns, and villages are expected to participate by 2018. However, few networks have been established and very little relevant knowledge about setting up a promotion business has been accumulated at the municipality level. In addition, a discharge adjustment for a person requiring long-term care often necessitates the coordination of resources that extend beyond the geographical boundary of a municipality, making it difficult for a municipality to manage a discharge adjustment rule within its administrative range. 　Prefectural public health centers, on the other hand, have promoted construction of home medical care systems at secondary medical care areas and have indicated positive results of such a system, which covers a larger geographical area than a municipality, as part of health care planning in cooperation with district medical associations, home care support medical offices or hospitals in the city, and district public health centers. Prefectural public health centers are expected to play a role in helping municipalities promote home medical care and long-term care integration from broad and complimentary perspectives. 　We show the present condition of the role of public health centers in health care and long-term care integration, which was gleaned from a questionnaire survey and a field hearing investigation carried out by us. We then discuss the future prospects of the role of such centers by referring to these survey results as well as the outcomes of activities carried out by the Japanese Association of Public Health Center Directors and the Ministry of Health, Labour and Welfare community health synthesis promotion business.

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To build a medical system for nuclear facilities, I explained what kinds of actions were performed with the TEPCO Fukushima Daiichi Nuclear Power Plant Accident and what kinds of actions are going to be performed in the future. We examined the health and medical care of the emergency workers in nuclearfacilities including TEPCO Fukushima Daiichi Nuclear Power Plant from 2014 to 2015 in the Ministry of Health, Labour and Welfare (MHLW). We carried out a detailed hearing from stakeholders of electric companies and medical institutions about the medical system in nuclear facilities carrying out urgent activities. 　It has been said that the electric company is responsible to maintain the medical system for affected workers in nuclear facilities. However, TEPCO could not find the medical staff, such as doctors, by their own effort at the TEPCO Fukushima Daiichi Nuclear Power Plant Accident. The network of doctors familiar with emergency medical care support dispatched the medical staff after July of 2011. 　The stakeholders indicated that the following six tasks must be resolved: (1) the fact that no electric company performs the action of bringing up medical staff who can be dispatched into nuclear facilities in emergencies in 2015; (2) bringing up personnel in charge of radiation management and logistics other than the medical staff, such as doctors; (3) cooperation with the community medicine system given the light and shade by nuclear facilities; (4) performing training for the many concurrent wounded based on the scenario of a severe accident; (5) indicating both the condition of the contract and the guarantee of status that is appropriate for dispatched medical staffs; and (6) clarifying the organization of the network of stakeholders. 　The stakeholders showed the future directionality as follows: (1) To recruit the medical staff expected to be dispatched into nuclear facilities, (2) to carry out the discussion and conveyance training to strengthen cooperation with the conveyance and acceptance of the suffering workers, and (3) to establish the organization that can pursue medical staffs confidently. 　The MHLW received these proposals and started the following two actions to support workers affected by nuclear facility emergencies in the 2015 fiscal year: (1) bring up medical staff and (2) constructing the network of stakeholders.

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Background: The symptoms of Parkinsonʼs disease (PD) can lead to problems in maintaining oral health and an inability to swallow which can then negatively affect the patientʼs quality of life. The purpose of the present study was to investigate oral health conditions, oral health behavior and swallowing among patients with PD in Japan. Methods: We investigated 200 Parkinsonism patients in the east Iburi area of Hokkaido, Japan by mail. From 108 respondents, we used 100 PD patients over 60 years of age as cases. Dental examinations for Parkinsonism patients were not conducted. One thousand and thirty-four persons over 20 years of age underwent dental examinations conducted by the municipalities in the Tokachi area of Hokkaido. We selected 708 persons over 60 years of age as control. A structured questionnaire was employed for both cases and controls. We compared oral health conditions and related factors between 100 PD patients and 708 controls. The logistic regression model was used for adjusting for sex and age. We also conducted stratified analysis by sex while adjusting for age using this model. Results: (1) Compared with the controls, PD patients had more complaints of chewing difficulties, toothache, gingival bleeding, bad breath, sliminess of the mouth, annoying teeth alignment, food impaction, swollen gums or mucosa and denture discomfort. (2) Fewer PD patients had their own teeth regardless of sex. (3) More PD patients used a fluoride toothpaste than controls, regardless of sex. (4) PD patients performed daily tooth-brushing or denture cleaning more frequently than the controls. (5) Among PD patients, 55.6% had problems with swallowing. Conclusion: We found that PD patients had more complaints about oral health and troubles with swallowing. It would be important for public health center to conduct dental checkups and professional oral care through home visits for PD patients.

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Objectives: The risk of health impairment or disorder originating from intrauterine growth restriction has been discussed (hypothesis of Developmental Origins of Health and Disease: DOHaD hypothesis). However, the correlations between factors related to delivery and risks of health impairment or disorder are unclear. Methods: The authors investigated the rate of receiving public health and medical care (PHMC) in local health and medical service areas in Gunma Prefecture in groups divided by maternal age or birth order as well as its correlations with factors related to delivery (maternal age, birth order, birth weight, birth week, Caesarean section, delivery of twins or more) and health impairments or disorders (low birth weight, early delivery, respiratory disturbance, jaundice, hypoglycemia, small or large weight for delivery date [SFD], etc.) in babies (n = 232) who received PHMC during the years 2008-2012. The correlations were evaluated by multiple regression analysis. Results: (1) Babies born to mothers of older maternal age (≥35 years) and third-born babies or higher had a high rate of receiving PHMC. (2) The relation factors for early delivery were older maternal age and Caesarean section, and those for low birth weight were early delivery, Caesarean section, delivery of twins or more, second-born or more babies, and others. (3) The relation factors for SFD or absolute value of SFD were low birth weight, delivery date, and others. (4) The relation factors for respiratory failure were early delivery, birth order, and others; that for jaundice was birth weight under 1,200 g; and those for hypoglycemia were low birth weight, SFD, and others. Some factors of the symptoms were interrelated. (5) There were reversed relations between birth weight under 2,000 g and birth weight under 1.200 g, among others. (6) The relation factors for older maternal age were early delivery and high birth order, and that for younger maternal age was first-born babies. (7) The relation factor for birth order was maternal age. (8) The relation factors for Caesarean section were older maternal age and second-born or more babies, and those for delivery of twins or more were Caesarean section. Conclusions: Early delivery and low birth weight were related to the risks of health impairment or disorder included in SFD, respiratory failure, and others. Older maternal age and third-born babies or higher were related to early delivery and low birth weight. Therefore, babies born to mothers of older maternal age (≥35 years) and third-born babies or higher must have risks of health impairment or disorder mediated by early delivery and low birth weight. Health management, especially nutritional support based on the DOHaD hypothesis, should be provided according to the above risks of health impairment or disorder.

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