Empowering the elderly in Japan: lessons for home care in Canada

It’s a question that’s been weighing on the minds of health care managers in Canada and many countries around the world: how will society meet the home and community care needs of an aging population?

In trying to answer this question, it can be instructive to look at models around the world, and one that’s received much attention is Japan’s Long-Term Care Insurance (LTCI) model.

Japan has the oldest population in the world and has had to respond to the caregiving challenges this poses earlier than most countries. “They’re way ahead of us in the aging curve,” explains Jim Tiessen, an associate professor and director of the School of Health Services Management at Ryerson University. Exacerbating the country’s low birthrate is that Japan has allowed far less immigration to the country than other nations, adds Tiessen, who has studied Japan’s approach to health and long-term care.

In 2000, the Japanese government implemented LTCI in response to calls to help address a skyrocketing caregiving burden on families. Given that women provide most unpaid caregiving support, women’s groups, in particular, were advocating for change, explains Ito Peng, a professor of sociology and public policy at the University of Toronto who is researching the impacts of LTCI on women.

Under the system, all Japanese residents above 40 years old are required to pay into long-term care insurance premiums, which pay for about half of long-term care services. (Corporate and personal taxes cover the rest.) It’s extremely difficult to compare the amount per capita spent on long-term care in Japan with Canada because each country defines long-term care differently. In Canada, the services covered by LTCI in Japan would be divided among numerous different budgets, at the provincial and municipal level.

Leaving cost aside, however, there are many aspects of Japan’s long-term care service delivery that could be adopted here, argues Paul Williams, professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto.

Japan’s long-term care: One-stop access and flexibility in services

Let’s start with comparing how seniors and their caregivers access services. Given that long-term care services are delivered at the provincial level, we’ll look at the differences between Ontario and Japan.

In Japan, the senior, along with his or her caregiver(s), start with an appointment at their community comprehensive care centre, explains Ken Kato, a senior assistant professor at Fujita Health University. There, a case manager, along with a nurse and social worker, assesses the client’s needs through a standardized and lengthy questionnaire. Based on this assessment and a report from the person’s doctor, a committee categorizes a client into one of seven care levels, each with an associated dollar amount, from around $55 to over $4,300 per month. An assessment is repeated every two years or earlier, if care needs rapidly change.

Rather than providing cash, however, as long-term insurance schemes in countries like Germany have done, the funding can only be used for services. The case manager informs the client and caregiver about what services are available in their community. “People can choose where they get their services from,” explains Tiessen. Depending on the care level, and the person’s needs, services can range from “someone coming to just clean up your house and cook for you to nightly nurse visits all the way to full-time 24-hour institutional care,” Peng explains. Those providing the services range from volunteer-driven community organizations to for-profit nursing homes. As a Lancet article described, “the main mechanism for quality control is consumer choice.”

In Ontario, there are some similarities. Like in Japan, people who need long-term care are referred to their local Community Care Access Centre (CCAC), where a care coordinator conducts a standardized assessment. Rather than choosing between a wide variety of services, however, the individual only has access to the services for which he or she meets the eligibility requirements, which can be different from area to area. This issue was identified by Gail Donner, former executive director of the Registered Nurses Association in her report, Bringing Care Home. As Donner explains in an interview, “One CCAC might say you’re entitled to have someone come and help you with a bath. The client says, ‘I don’t need a bath, my daughter gives me a bath, I need physiotherapy services’ but then the CCAC says ‘You’re not eligible for that.’” Donner doesn’t fault the CCACs for this, but the rigid funding rules set by the Ministry. In fact, in a recent report, the Ontario Association of CCACs has raised alarm about the lack of flexibility in what services patients can access. 

Another challenge to creating a one-stop access point in Ontario, and many other provinces, is that many services for the elderly are not provided through contracts to the CCAC. The extent to which CCACs refer people to services outside their organizations is variable, Donner explains, in part because care coordinators aren’t always aware of what services are available. Furthermore, seniors must access these services separately. “Many caregivers in Ontario are burning out because they’re trying to deal with a system that’s fragmented,” says Williams.

Japan’s single access point and flexibility for clients would address many of the shortcomings identified by patients and their caregivers in Ontario. But Donner isn’t sure a “voucher” system makes sense. “We think it should have a limited use,” she says. Allowing people to choose which services they want could mean people overuse services they don’t need, explains Donner. Indeed, Kato points out that one of the problems Japan is facing is that people too often choose to have more help with cleaning and cooking at home, at the expense of nurse visits. As a result, people can miss out on the preventative health care that reduces hospitalization. Donner argues that while Ontario could benefit from adopting Japan’s more flexible approach, the power of seniors to choose services should be balanced by the ability of care coordinators to ensure that a care plan is appropriate for a patient.

Community-driven, rather than health care-system driven

In Canada, oversight of long-term care services falls under the provincial ministries of health; in Japan, long-term care services are controlled much more by municipalities. “It’s quite decentralized, in that the local governments become the main coordinating institution to provide care, and mobilize communities, NGOs, and health care institutions to provide care,” says Peng.

One of the reasons LTIC was established separately from the medical insurance system was to reduce the amount of “social hospitalization,” where people need medical care due to a lack of supports in the community, such as access to adequate nutrition.

To Williams, it makes sense that long-term care is overseen by municipalities, because local governments are best positioned to approve and monitor community services. “A lot of the services involved in long-term care aren’t health care,” he says.

Due to this system, and to Japan’s more communal culture, community-based day programs for seniors and programs people with dementia are more common than they are here. In 2011, for example, community-based services accounted for more than 10% of LTCI services, while home-based and institutional-based services made up the rest.

“The [drop-in centres] have activity rooms and a cafeteria,” says Tiessen. “People can go and engage with others and have a communal meal.” Kato adds that some of the community day centres even have bathing facilities and have a nurse on staff, in addition to support workers. “A van will go around the community and pick up patients,” he says. “They have meal services and some activities like painting.” Studies have found the day care use was associate with lower mortality in frail adults and lowered hospital admission.

In Ontario, meanwhile, such day programs, while available in some communities, are “very difficult to access” says Williams. They’re only available in select, largely urban communities, and the day programs vary in their eligibility requirements – such as a diagnosis of dementia or the presence of a disability.

The community-focussed model is not perfect, however. Home helpers don’t always recognize when a person needs medical care. “A home helper is not trained in medicine, so sometimes they miss the important symptoms,” says Kato. And because long-term care insurance is separate from medical insurance, communication networks between home care and medical care providers suffer, adds Kato. The Japanese government is, however, increasing training, and rolling out technologies in smartphones that prompt home caregivers to send reports of new symptoms to the client’s health care professionals, according to Kato.

Interestingly, now that the senior population in Japan today is older than in 2000, the government has recognized the need for more involvement of medical providers in overseeing long-term care. In 2012, for instance, the government funded 105 home-based medical care programs that are overseen by hospitals or other medical organizations.

While Donner thinks it makes sense for long-term care to be funded and overseen by the health care system in Ontario, she thinks radical changes are necessary to allow for more integrated services. “We’ve got the CCACs and acute care, and a whole range of social services. Some are in health, some are in education, some are in transportation,” says Donner. While community hubs have been proposed as a way to bring medical, education and social services together in Ontario, many legislative and funding barriers stand in their way, according to a recent report.

Challenges facing Japan’s Long-Term Care Insurance system

Japan’s long-term care insurance is “not a panacea” says Peng. Over the years, the amount of services people have been eligible for has been slowly cut back to keep up with the growing demand. In 2000, the year after the program was launched, 2.2 million Japanese people required long-term care services. By 2013, the number accessing long-term care had more than doubled, to 5.6 million, according to statistics from Japan’s Ministry of Health, Labour and Welfare.

“The LTIC has indeed shown to have lightened the burden of the families, particularly women’s caregiving…but women aren’t satisfied with the level of care,” says Peng. Public opinion surveys show that families are still providing the majority of care.

Numerous challenges remain to the system, most prominently the disparities between services in the rural versus urban regions, and a lack of integration among medical and long-term care services. Like in Ontario, waiting times are an issue for some services, such as respite care.

To Tiessen, the fact that Japan has been able to maintain the LTCI for 15 years despite a doubling in demand shows that long-term care insurances is sustainable for countries like Canada. “People here, I think, are afraid to invest in long-term care insurance because we’re thinking before we know it the treasury will be bankrupt or it’s just too complicated and we don’t even know where to start,” says Tiessen. He thinks Canadian provinces should bring in insurance to help people pay for long-term care services not covered by the health system. “With these things, you don’t know how they’re going to work until you bring them in.”