[Feature: Thinking about "Home Care"] Roundtable: The Era of "Home Care" Supporting an Aging Society

Currently, as the aging society progresses and the structure of society changes in various ways, what is called "home care" or "community-based integrated care" is being promoted at the national level in medical and nursing care. I believe some readers of the Mita-hyoron are users of home care. Today, various practices such as medical care, nursing, rehabilitation, and caregiving are being carried out in "home care" outside of hospitals, but there are parts that are not well known, and it is also a field that will continue to change due to technological progress and institutional reforms.

Today, I would like to ask those in each specialized field who support and practice home care about current initiatives, their challenges, and future prospects and possibilities. First, I would like you to talk about what you are doing at your respective sites.

My specialty is geriatric medicine, and I have been involved in home medical care since around 1990, which means for nearly 30 years. I see patients, especially elderly people, in the Chiyoda City area through outpatient and home visit consultations.

To tell an old story, around 1990, home medical care was in a state where there was still nothing, despite it being necessary. However, the Long-Term Care Insurance System was established in 2000, and other systems have gradually been put in place, and it is now becoming active. I am very happy that young people like you are entering this field.

Initially, home medical care started with a pair consisting of a doctor making house calls and a nurse providing home-visit nursing. Now, people from rehabilitation and caregiving, pharmacists, and those in the dental field have also joined.

This is very deeply moving. When I started, home medical care was a complete outsider's job done by eccentrics (laughs). Now, while I won't say it's the mainstream, it has reached a position where it has a bit of a voice, it has become mainstream as a national policy, and it has become familiar to the citizens receiving medical care. I am very pleased about this.

I am a physical therapist at Shonan Fujisawa Tokushukai Hospital. I also head the management of the rehabilitation departments for all Tokushukai hospitals across the country, and I occasionally visit sites not only in urban areas but also in rural regions.

Tokushukai hospitals are acute care hospitals, and our basic stance is not to turn away ambulances. With an average hospital stay of 9 to 10 days, it is a hospital that sees all emergency patients, improves their condition to some extent, and sends them home.

Even before long-term care insurance began, our hospital was providing home-visit rehabilitation. This was rare. The reason we started home-visit rehabilitation was that people with disabilities we worked with in the hospital do not have their disabilities cured even if they are discharged and go home.

In the past, there was no system to look after patients after they were sent home. Therefore, out of necessity, we started by saying, "Let's go and do the rehabilitation ourselves."

You mentioned being an outsider earlier, and home rehabilitation within an acute care hospital was also initially met with a feeling of, "You've started a strange business. Is that our role?" However, from our perspective, it was a matter of, "Doctor, are you going to send them home only half-cured?"

It originally started from a hospital called Chigasaki Tokushukai, but the hospital became old and moved to the neighboring town of Fujisawa. We have a market share of over 95% in Chigasaki City for home-visit rehabilitation. In other words, there are very few places doing home-visit rehabilitation. It has increased slightly in the last few years, but it's not keeping up at all. We have a staff of about 10 people in total, and our immediate goal is to increase the number of people who can do home rehabilitation.

What kind of users are most common?

The most common are elderly people, especially those at home after a stroke or fracture. For home-visit rehabilitation, the only patterns are to go out from a hospital-affiliated department or to belong to a home-visit nursing station and go as a type of home-visit nursing.

Under the current system, it is not possible to set up a standalone "home-visit rehabilitation station." A major problem stands in the way here.

I am a certified care worker working at a small-scale multifunctional in-home care facility in Bunkyo City.

Before the Long-Term Care Insurance System began, during the "administrative measure era" when all care and medical services were provided by taxes, care practices like physical restraint, which are now strictly forbidden, were commonly performed. At that time, volunteers created "Takuro-sho" (community-based care homes) because they wanted to provide normal care to the elderly. The government institutionalized these, and small-scale multifunctional facilities are a one-stop business format that combines home visits, day service, and overnight stays with care management according to the user's needs.

I am from the last generation of the "employment ice age," and I started caregiving work with the aim of becoming a welfare professional. I have been doing home-visit care, home-visit bathing, day services, and small-scale multifunctional support for a long time.

Until now, I have often seen people in so-called difficult cases, such as those in poverty or living alone. My current workplace is in Bunkyo City, so there are few people in obvious poverty, and I mainly see people with dementia. About half live alone, and I support such people in living their lives in the community.

I started my own company and provide home-visit nursing. I established the first one in Edogawa City, the second one in the neighboring Koto City last year, and there are other offices in Okinawa, Fukuoka, and Ichinoseki in Iwate Prefecture. There are about 60 nurses in total.

I've been a nurse for about 10 years, but I was only at the Emergency and Trauma Center of Kitasato University Hospital for the first two years, and I've been doing home-visit nursing ever since.

In emergency nursing, elderly people in their 90s are brought in with cardiopulmonary arrest. Then, while the family is in a panic, we ask, "Do you want to intubate?" and get consent to "do everything," and perform life-prolonging treatment. Even with intubation or cardiotonic injections, saving them is difficult, and they meet their end in a treatment room full of machines, leaving the family in shock. I wonder if this was a good way to end a life, and we nurses also wonder if it's necessary to go this far. Moreover, a huge amount of money is being poured into this. When I thought about that, I felt that even though everyone is working hard, no one is happy.

There should be opportunities to think together beforehand so that people don't have to receive medical care they don't want. Thinking that way, I thought, "Isn't that the job of a nurse, whose role is to protect rights in home care?" and I started home-visit nursing.

The characteristic of our home-visit nursing is not only 24-hour support but also being open 365 days a year, including weekends and holidays. And we value the philosophy of "providing the option to return home for everyone." "Everyone" means "all illnesses." This includes people with mental disabilities, children, people with intractable diseases, and the elderly—everyone.

That is amazing.

Sometimes people cannot return home because home-visit nursing services refuse them, saying, "We don't specialize in children or mental disabilities, so we can't look after them." That's frustrating, so I decided I would do everything, especially focusing on areas where there are few places to accept them.

Another thing is that our expansion into regional areas is in the form of a franchise chain. There are nurses who want to look after the people living in their local areas forever. In the form of local production for local consumption of nurses, the Okinawa team now has about 15 people, and everyone, including the nurses, is from Okinawa. Also, a characteristic of all our stations is that the average age is in the early 30s, with many mid-career nurses in the prime of their working lives.

We've heard from each of your perspectives, but Dr. Tsuji, what kind of patients do you have many of?

Since my specialty is geriatric medicine, many are elderly and have dementia. As expected, the number of people with dementia and other illnesses is increasing. Another thing I'm realizing is that many people live alone. I don't know about rural areas, but in Tokyo, it's normal for family members not to live together.

I am facing the question of how to provide care for such people.

For those living alone, I think people around them might sometimes think it's difficult for them to stay at home.

If I think living alone is impossible, I will say so, but the individuals themselves often say they want to stay at home. Many family members also take the stance that if the person says so, they want to respect that. Then, we just have to do it.

Thirty years ago, it felt like we were supporting caregiving by teaching family members, along with nurses, how to treat pressure sores or handle bladder catheters. However, now that there are no family members, we do it, but we can't be there 24 hours a day. Yet, the person says they want to stay at home. There's a difficulty there.

Recently, I sometimes think it's harder to spend time at home when there is a family. The person says they want to stay at home. But there are many cases where the family gets exhausted by various events. I feel that for those living alone, they are free and easy, and it's often easier to spend time without family.

Ah, that might be true.

When there is a family, interests might be complicated. Recently, at a community care meeting, a case like this was presented.

An old man living alone with dementia disappeared in the morning. Helpers and neighbors couldn't find him. Then he just wandered back around evening. The sister living far away wants to put him in a facility, so the question was what to do.

Everyone was scratching their heads. But I said, "If he comes back, isn't it fine?" I wonder why people don't think that even if he's wandering, it's okay because he comes back at night.

There's a person who has been taken into protective custody more than 20 times since the beginning of this year. He went from Bunkyo City all the way to Meiji Jingu, was found, and was sent back in a patrol car. When I asked the police officer, "Are there many people like this?" he said, "They're here every day."

Police officers are used to it, aren't they?

In other words, even though such people who wander are sufficiently supported by the community, I think the trend of saying "that's not allowed" is very strange.

We get quite friendly with the local police officers. They'll say, "He's here having tea right now" (laughs).

It's not just the police, but also local shops, right?

There's a wealthy old lady with mild dementia. Her symptoms are such that she can ride the train alone, and she's at Care Level 1.

That lady suddenly started putting on makeup. She got a boyfriend. He's an older man, but one day when I visited, a call came and she went out. It violates her rights, but I followed her and sat next to them at a cafe to listen. It turned out that boyfriend was a scammer.

I knew it. I thought so.

So, what to do? We set up a dragnet everywhere with the police, the welfare commissioner, the neighborhood association president, and the family. The police officer initially said, "You have to put a person like this in a facility quickly," but when I suppressed my anger and persuaded him, he said, "These people will increase, so we have to protect them in the community," and told me to definitely contact him if anything happened.

In that way, there are many people who manage to live supported by the community.

I'd like to ask the medical professionals: if infrastructure challenges can be cleared in Japan today, can people in any condition live at home?

The things that can be done at home are increasing significantly. It depends on the clinic, but recently we sometimes do blood transfusions. For chemotherapy, patients often come home with a bag while attending outpatient visits normally. Except for intensive care and surgery, I think it can be done to some extent if there is consent from the individual and the family.

However, it is still often difficult to send people with blood-related diseases such as leukemia home, and there are very few places on the home care side to accept pediatric cancer.

Regarding the elderly, hospitals sometimes don't know about home resources, and care managers and we also have a sectionalism where once someone is hospitalized, we leave it to the hospital and our interest decreases until there's a prospect of discharge. I think this is one obstacle to restarting home life. It's like a feeling of "I don't know about that side of things."

Hospital doctors and nurses tend to worry unless things are in a proper state like in a hospital, thinking, "Is it okay to go home in this state?" or "Is it no good unless care and medical treatment similar to a hospital can be provided?" I think if they gradually understand that "it's actually okay," the threshold will become a little lower.

I sometimes hear home-visit nurses complaining to each other, "Hospital nurses really don't understand, do they? Why can't they send them home sooner?" But I think, "If you've never worked in home care, there's no way you could understand."

This is a dream, but I'd like to try doing rounds where we go to the wards, say "hello," and regularly provide consultations on "this person can go home, this person cannot."

I think some hospitals are starting to do that.

It's a question of to what extent the hospital should prepare things before sending them home. Conversely, the hospital side thinks they've prepared everything and sends them home, but sometimes it's not ready at all. They say they went home because a handrail was attached to the house, but when I went to see it, it was a suction-cup one for hanging bath towels (laughs).

But I think there are cases where you send them home for the time being and adjust things a bit.

From a rehabilitation perspective, we visit in advance to check the house before they go home, but in most places, it ends there.

Sometimes I wonder why they put the bed in such a place. Like, "What are you doing putting the paralyzed side against the wall?" Therefore, we basically send them home on the condition that home-visit rehabilitation will definitely be included.

Firmly supporting the transition period immediately after discharge from the hospital. Does that mean things will work out after that?

In terms of rehab, things will work out. After that, we can leave it to others, so how we visit in the first week, the week they return, is important.

We place great importance on "graduating from home-visit nursing." Of course, there are people who cannot physically graduate, but because it's long-term care, I feel people have an image that they must be nursed for a lifetime.

There are many home-visit nurses who think so.

But care fees and medical fees are received from social security costs, right? If we move them to the next supporter or connect them to people in the community, home-visit nursing might not be necessary.

If we keep going to people who can be independent just because "it's reassuring," it's a waste of taxes and insurance premiums, and it could even hinder the person's health. Therefore, let's have those who can graduate, graduate. Provide intensive care immediately after discharge, and if it can be reduced, reduce it. I think we should increase the things they can do for themselves while successfully connecting them to welfare, community members and resources, and enhancing the person's self-care.

In reality, there are few personnel for rehab alone. There are 150,000 physical therapists (PT) like me. There are 70,000 occupational therapists (OT). But what is most needed in home care now is speech-language-hearing therapists (ST).

Many elderly people at home suffer from aspiration. That's why ST intervention is necessary, but there are only 30,000 STs. Moreover, 3,000 of them are not working. Therefore, except for those with intractable diseases such as ALS (Amyotrophic Lateral Sclerosis), we basically have to set a time limit and say, "Please order again when there is a change," or we won't be able to keep up. Naturally, the situation is even more serious in rural areas.

I think the idea of using human resources wisely is very important. However, some home-visit nursing stations consider long-term relationships to be good, and I feel that's a difficult point in the field.

The evaluation is hard to understand. When intervening in care, how do you look at the points of that evaluation? Since nursing sometimes enters a case due to social requests, it's difficult to show "specifically where things got better." That's why I think it's desirable to have discussions in a multidisciplinary team and change the plan as appropriate.

With the elderly, there is aging, and it's quite difficult to improve physical functions, but in a social sense, their options can increase, or their social and psychological health can change surprisingly well, so it would be good if we could "withdraw" care accordingly. I suppose it's a feeling of doing it together while consulting with the individual and family about goals, care content, and things they've become able to do.

I feel like you are providing very ideal care. I think the care manager is at the core of that, but do you feel that care managers have the perspective of trying to subtract care if possible for the person's independence?

I think people who mainly do care management for those with mental disabilities are very good at it. They skillfully and intentionally change plans according to changes in independence.

From the start of the long-term care insurance system until around 2007, I feel that care emphasized quality, but since around the Lehman shock, the emphasis has shifted toward quantity. Currently, in order to increase the headcount for budgetary reasons, new recruits are being brought in one after another.

While that is necessary in its own right, new people with different educational backgrounds and ages—even foreign nationals—are coming in at a time when middle managers have not been developed, making it extremely difficult to manage them. And when people capable of management leave an office, it creates a situation where new recruits who don't understand care well are the ones providing it.

Since the 'Zero Caregiver Resignation' policy was announced, I strongly feel that the trend has shifted toward reducing the family's caregiving burden rather than focusing on the individual. The clearest example of this trend is the huge increase in the use of day services. Families feel more secure leaving someone at a day service for the whole day rather than using home-visit care or home-visit nursing.

It allows them to have their own time as well.

Exactly. Care managers are in that state too. When cases are introduced, there are instances of day services seven days a week.

That's incredible.

If they live alone, it might be understandable, but it's becoming like that based on the family's needs. If you look online, long-term care insurance is being treated like a financial technique, with advice on "how to use it like this."

On the caregiving side, incentives work to include as many services as possible to increase the volume of business for the office, so while services can be increased, they are rarely decreased.

Due to these circumstances, I feel it is becoming harder to provide care for the sake of the individual or as a professional.

Originally, long-term care insurance was supposed to be about supporting independence, but now there is a demand to meet needs, and it may be that more of those needs are unclear as to whether they are the user's true needs.

Certainly, since many people use day services, the days available for home-visit consultations are limited. In the old days, if you looked at a calendar, it only said "the day the doctor comes" (laughs).

As you say, services are often packed in according to the family's wishes, and the idea of providing care based on proper goals like rehabilitation is often absent among nurses or those from traditional welfare backgrounds. Actually, doctors don't have much of it either; they don't say, "You've gotten better, so I don't need to come as often."

I personally think that doctors don't need to visit that much. It's better to have nurses or rehabilitation staff go instead.

But conversely, there are cases where I think, "You don't need this much rehabilitation." For example, someone who is walking around the house just fine but has rehabilitation scheduled three days a week.

It has become something like a protective charm in some ways, hasn't it?

Just like medicine, problems arise if you assume that more is always better. Services, medicine, and treatment will all increase if you just provide them as requested. I believe one role of researchers and organizations like the Academy of Home Care is to conduct strict evaluations.

There is a sort of "doctor myth" among the public. Bunkyo Ward has many university hospitals, so people go to a university hospital for every little thing. But a clinic would be fine.

The 20th century was the era of the hospital. Medical care was something done in a hospital, education was something done in a hospital, and we were raised there. That was the mainstream, and house calls were thought of as food delivery. Eating at the restaurant is the real thing, while delivery gets cold and loses its flavor.

However, I believe home-visit consultations are absolutely not delivery, but a different type of cuisine altogether. But doctors within hospitals, especially the older ones, haven't learned to what extent sick people can be treated at home. The younger generation in their 30s can understand if you talk to them, because home care is finally being taught even in the School of Medicine. But doctors from before that don't have the concepts of coordination or team medicine in their heads. I think it's all a problem of medical education.

There are about 2 million nurses in Japan, and about 1.5 to 1.6 million are employed, but only 50,000, or about 3.4%, are doing home-visit nursing. To begin with, only 5% of all nurses are men. If you multiply that...

It's very few (laughs).

I strongly feel that a career in home-visit nursing is not the mainstream. What's strange is that senior nurses in hospitals say, "You shouldn't do home-visit nursing until you're a veteran with over 10 years of experience," but in the same breath they say, "Home-visit nursing is just drinking tea and chatting" (laughs).

So, it's a matter of ignorance and position-taking; in reality, there is no superiority or inferiority at all. With the demands of society, the number of people returning home will continue to increase, so there is no doubt that we will need people to look after them.

When teaching home nursing, if I ask students to write down what they want to learn before they go to a home-visit nursing station for practical training, some students write things like, "I want to ask why they want to go home," or "I don't understand why they want to stay home when they are in a state that requires recuperation and treatment."

It's like, "Don't you feel the same way?" (laughs). There's a disconnect. They think there is a category of people called "patients," and that "patients are supposed to be in hospitals."

They think as if they were born and raised in a hospital. That's why they think in terms of "returning." It's not really returning; they just happened to enter the hospital.

But until I started home care, I also thought that patients were people who came to the hospital. When I was a resident, I thought everyone walking outside the hospital was healthy. But when I did geriatric medicine, I realized there are many people who cannot come to the hospital. Also, there are people who return home from the hospital only partially cured.

When I first took charge of someone with a difficult neurological disease, my presentation was just giving a difficult diagnosis and saying, "That is all, they will be discharged." After a while, I wondered what happened to that person.

Also, during a night shift, I went on rounds and found an old man who seemed energetic. He said, "Doctor, I want to go home, but they won't let me." When I went back to the staff room and asked the attending physician, he said, "That man is in the terminal stage of cancer."

Since it was 30 years ago, the individual hadn't been informed. When I said, "He says he wants to go home," I was told the family said not to let him go home. It was an era of disregard for human rights by both the medical side and the family side. I thought the hospital was like a prison.

I entered the field of home care in my 30s, around the same age as all of you. At that time, I was also told, "It's too early to go into home care." In the case of doctors, one standard course was to build a career in a hospital until 40 or 50, and then open a practice or take over a family business.

But I thought if I waited until 40, I might not be able to do home visits, so I jumped in while I was young. It's important to start early. Medical students with straightforward hearts will freshly say, "That's great." But then they gradually become jaded, so to speak.

For nurses too, once they go to a hospital, it happens before they know it.

I think it's good to take them to home care sites before their ward training. To show them that this is normal life.

I think it's the same for nursing, but since children come, elderly people come, those with intractable diseases come, spinal cord injuries come, and cancer patients come, there is no specialization in rehab. Therefore, when going into home rehab, it's more useful technically to be an almighty generalist.

If someone can see a stroke patient but doesn't understand someone with a heart condition, that person isn't useful. In our case, we send people out for home visits who have spent at least five years rotating through various teams. It would be unfair to the users to say, "Go learn that on-site in a one-on-one home visit."

The situation in long-term care is completely different. Basically, people who have received proper professional education at a training school for certified care workers often enter facilities. Then, those who have not received sufficient care education enter home care with a helper qualification. In other words, in terms of expertise, people with lower levels are the ones running home care.

I also think it's better for almighty generalists to go into home care, but lately I feel it's a bit different.

This is because we have many severe cases such as mental illness and intractable neurological diseases, and almost all the children have severe motor and intellectual disabilities. We also see 40 to 50 terminal cancer patients a year. But you won't find a nurse who has sufficient experience in every single field.

What I'm saying is a generalist who can see many fields, not a specialist. If there are 10 fields, I'm not saying become a specialist in all of them, but someone who has only seen the elderly won't even know what to do if they suddenly go to a child's home.

My idea is that as someone who can provide benefits without causing harm to the person paying, they should at least reach a minimum level where they can work independently. It's a bit different from being a specialist in pediatrics, geriatrics, and intractable diseases all at once.

I have the same idea. Since many of the nurses who join are young, their background is in one or two fields. In that case, they may lack experience, but we cover that as a nursing team. We support each other's strengths and weaknesses and respond generally as a team.

Conversely, are there cases where someone goes for home-visit nursing even without experience, depending on the patient's case?

In our case, the system is now reasonably well-established, and we have experts in each field in the background. Therefore, we have a learning system such as OJT so that they can gain experience while preparing.

There were cases when we first started where we wondered what to do. At that time, when I asked the user's family, "I haven't seen a child of this age before, but I think I can do it if I have support. What would you like to do?", there were many times when they said they didn't mind at all, they just wanted me to come, and that they could teach me.

With children, sometimes the mothers are more knowledgeable, aren't they?

From the perspective of receiving money, there is a dilemma, and I often discuss this with other nurses. I don't have a background in psychiatry, but when I said I was doing quite a few visits to psychiatric patients, a home-visit nurse who only handles psychiatry said to me, "Isn't it strange for a nurse who has never experienced palliative care to receive money for terminal cancer care? Isn't it the same? Shouldn't you not be seeing them?"

I think that perspective certainly exists, but when I reply, "What will happen to the many people who are rejected because there is no place to take them and cannot return home? Will you see all of them? Are you trying to create a system in society that can see them?", they say, "I can't do that."

If so, I think it is more sincere to disclose that "we are really okay with us?", and then start care while learning, and try to accept as many people returning home as possible within that. In terms of quantity and quality, I suppose it becomes a story of quantity. But it does make my heart sting a little.

Resources are still insufficient, but the fact that talk of specialists is gradually emerging even in home care is, in a sense, something that can be said because resources have increased slightly.

But I've rarely been asked for highly specialized medical care in a home setting.

Since about four or five years ago, clinics in Tokyo that specialize in certain areas have been increasing, probably as a sales pitch. If you ask a care manager, they will introduce home doctors by field. I don't know if that's a good thing.

Specialization is popular in cities now, isn't it? Even among clinics specializing in home visits, those specializing in cancer, pediatrics, or heart disease are in the spotlight.

I feel like it's better to have someone who can see everything.

We are often referred people whose lives are being hindered by dementia. It's not that we specialize in dementia, though.

A specialist system for general practitioners has started, for now. The Japan Medical Association, which is an organization of practitioners, also conducts various training under the name of family doctors, and you can't get credits unless you do everything from pediatrics to psychiatry to dementia to home medical care. I think we've entered an era where generalists and organ-specific specialists exist side-by-side.

But I think what is required in home care is, after all, a generalist. And it would be good to have a coordination network where you can be guided by conventional specialists or specialist nurses. Large clinics have doctors who are good at cancer or good at heart disease, so you can just think of it as training there.

Our clinic also has a network called the Ochanomizu Doctors Network, consisting of five home-care support clinics and one hospital. One is a clinic specializing in neurology, and one does palliative care for cancer. Since we have conferences with each other every month, there are cases where we say, "Doctor, please see them after all," or we see them while receiving guidance. I think it would be good to have relationships and networks where we can ask each other for help in nursing and rehabilitation as well.

If there is someone with a terrible pressure ulcer, do you ever ask a specialist nurse from a hospital outpatient department to go out into the community?

I ask, but they don't come. So I often unilaterally send photos by email, call them, and ask, "What do you think?"

I think they're just too busy to go out. It would take half a day to come, and they would end up leaving a hole in the ward.

I think just sending a photo and getting a comment is a good relationship. Specialists are still in hospitals and can't come out to home care immediately. The same goes for doctors. If you have the minimum training, you can get by as long as you have a network. Since ICT is developed now, I think people in inconvenient rural areas could consult with Tokyo.

There's the question of what happens with medical fees, but in any field, if you send videos or photos and get advice, I think residents or nurses can go and do it. If we do that, I think we might not need to solve the doctor shortage in rural areas entirely.

If human resources will never be completely sufficient no matter what, we have no choice but to utilize ICT, and I think that can also improve quality. How is that in home-visit nursing?

We are all connected via an internal business SNS, and if there's something in a rural area like, "What should I do about this?", they can take a photo at the visit site and consult with an internal expert. There are issues of personal information and responsibility when crossing corporate boundaries, but within the group, it's actually possible even now.

There are far more nursing resources in the community than doctors. Therefore, we basically have an arrangement with our partners where the nurses act as the front line, so doctors can sleep at night; we'll contact them for death confirmation or when we want instructions, and we'll handle the rest. We have all first calls come to us, and we want the doctors to be seeing many patients.

The number of people a nurse can take charge of is 20 or 30 at most. Doctors basically see people in units of 100, and on top of that, they have emergency responses, so overall it's very inefficient. I think it's definitely better for nurses to handle the front line and have doctors come only where necessary.

But occasionally there's a very passionate doctor who says they'll go on a house call for every emergency response or minor trouble. When I say, "Doctor, social security costs are higher for doctors, so it's a waste," they say, "Do you guys want work that badly?" (laughs).

In the community, everything moves according to medical fees, so clinics are on a 24-hour system and are supposed to do things themselves, and since they have to have someone on duty, there's a sense that it's a loss if they don't go once they're there.

I hardly ever do house calls outside of hours. I only go out at night for end-of-life care. Also, for emergencies that are completely curable, I call an ambulance. I mean, what's the point of a house call for a myocardial infarction or stroke? There's no CT, and you can't perform procedures. But there are occasionally clinics that boast about the number of house calls they make. A house call for a fever of 37.2 degrees—what do they think the medical costs are? (laughs). This is a waste of resources.

In long-term care services, there is something called "Regular Visiting and As-needed Response Service for Home-based Long-term Care." This involves care helpers and welfare services coming in according to daily life, and there is very close communication.

It's long-term care and nursing based on the premise of coordination.

That's right. There are doctors, nurses, and a generous number of helpers, so we only have to go when it's truly necessary. Furthermore, when needed, patients are screened and a doctor goes. It is very rational.

Things won't keep running unless we move in the direction of allocating and utilizing resources skillfully like that, will they?

I find myself envious that everyone is focusing on the topic of quality. The reality of long-term care is that there is a shortage of human resources, and new recruits who haven't been sufficiently trained are being sent to the field. Even so, we can't keep things running unless we have those people come in.

I wonder if it is truly necessary to keep increasing the number of care workers. Facilities use the fact that their "staffing levels are higher and more generous than national standards" as a selling point, but that means productivity is poor, doesn't it? The common sense in care is still that "the number of people equals quality," and there is a sort of myth about the power of human hands.

Education appeals to emotional things like dignity or being close to the person, but textbooks don't say anything at all about how to use technology. People only see care equipment for the first time when they get to the field, and you find situations where bath towels are just draped over lifts.

The number of people in the very early stages of dementia—whose bodies are healthy but whose daily lives are hindered—will continue to increase rapidly. However, the home care workers who support them are not keeping up. The current situation is a trend where volunteers, who are not professionals, are expected to look after them in the community without any consensus on the matter.

Is it okay for volunteers to not have professional expertise in long-term care?

To be honest, I think it's less a matter of whether they can or can't, and more that they have no choice but to do it. If we are to use care workers who can properly observe hindrances to daily life through their expertise and coordinate appropriately with medical care, I think we have to filter them to some extent.

We are creating more and more lower-level qualifications to broaden the base, but the more we do that, the more expertise is diluted. In that case, we should provide proper compensation and then filter them. It would be good if those people could use technology to provide high-productivity care, but that requires funding.

Without a debate on whether to increase the public burden for welfare, the burden is falling on well-intentioned care workers, and only the call to create community volunteers is moving forward. I think this distortion will become very apparent in the future.

I also think it might be better if medical professionals took the initiative in home care.

But I think that might lead to starting to think about the control of life itself in a managerial way. I believe welfare professionals are the experts when it comes to daily life. I do wonder about a medical-centric approach if things like the family being prioritized over the individual occur.

By initiative, I mean human resources who can think together with the individual and their family about what the ideal state of home care should be.

To conclude, I would like you to talk about the future potential of home care and your vision for what could be achieved by taking a step forward in your respective fields.

There are two things I want to do. First, regarding care and case studies, discussions are basically only held by the people providing the care. I believe the people receiving it—the parties involved—should always be present in those discussions.

So, I invited a person and their family to our study group, asking if they would like to do a case study of their own case, and it was wonderful. We did it with everyone—the family, the individual, and the team currently intervening—and the individual understood what they felt at the time, and what the family was actually thinking. I find it strange that the parties themselves don't participate in discussions about their own care, and I want to make that a normal occurrence.

Second, the results of home care are very difficult to see, so it's hard to know what to attach compensation to. Since multiple professions are involved, I think there are various factors in the effects, but quantitative data is absolutely necessary.

This is because there are many instances in the knowledge base where great interventions and great teamwork produced results. However, since only the people who experienced it know about it, it doesn't reach the people who truly need that service. That is very unfortunate. I am currently working on measuring those quantitative results.

Regarding the knowledge base, there are various things the university must do as well.

I think care is very broad, and while it's a prerequisite for professionals to collaborate with each other, the question is how to connect beyond that. The people who make first contact might be shopkeepers or postal workers, and I wonder if we can connect more with people like that.

A friend of mine who does local consulting once asked me if there is any meaning in using tax money to support elderly or disabled people who have no productive value. This is my starting point. I always think about what our job is. I felt as if the very existence of the people I meet in the field was being denied, and I am always searching for something we can do together. I want to go out into more and more diverse fields.

Also, as an ongoing initiative, I want to create a foundation for accumulating research in the field of care and welfare. This is because I believe that research into on-site care is important—just as medical sciences has progressed—so that support for an individual's independent living and dignity is not just a matter of craftsmanship, but something practiced nationwide.

As I mentioned earlier, many elderly people at home suffer from aspiration, so I believe training speech-language-hearing therapists (STs) is an urgent task. Home rehabilitation has been done by physical therapists until now. The image was moving a hand that doesn't move or making legs that can't walk somehow able to walk, but from now on, no matter how you think about it, STs should be going into the home.

Tokushukai is currently working on an initiative to send STs into home care. However, because resources are scarce to begin with, it is particularly tough in rural areas. It doesn't match the needs at all.

The national examination for STs only started 40 years after PTs and OTs. The history of STs is the same as the history of long-term care insurance, so their numbers are small to begin with. And actually, even among doctors, many are not familiar with the concept of the work STs do. Bringing STs into the public eye is my current task.

Inside a hospital, a doctor only needs to do a doctor's job. However, when you go into the home, you can learn for the first time what everyone else—nurses, rehab staff, etc.—is doing and what they are capable of. I think you must have that knowledge first.

Independent home medicine courses do not yet exist in the School of Medicine, and they only appear slightly on national exams. Nursing is the most advanced in this field. Both the public and doctors have been brainwashed into thinking that hospitals are what medical care is, so they thought people working in hospitals were superior, and home care was seen as doing something anyone could do.

However, we are in an era where we must change that way of thinking. Hospital medicine must continue to exist, but I think the public and professionals as a whole must change to the idea that hospitals should specialize in acute care, intensive care, and advanced medicine, while primary care is something done outside the hospital.

To that end, for one thing, I would definitely like to present the accumulation of evidence at the Japan Society for Home Care.

Another thing is new technology. Actually, the number of specialized clinics called Home Care Support Clinics has plateaued. Also, I don't think the number of care personnel will increase that much. As expected, I would like to see more utilization of fields Japan is good at, such as care robots, ICT, and AI. I think this won't expand unless people completely outside the medical profession—people in engineering and business—get involved.

Recently, Japanese home care has been attracting a lot of attention from countries that will face a super-aging society following Japan's lead, and people from China, Taiwan, and South Korea often come to visit. Therefore, we should take advantage of the aging population to share and market it to the world. I want to work with all of you to create a "Made in Japan model" of home care for that purpose. That is my dream.

I have been doing this for 30 years, and I have high expectations for the emergence of young people like yourselves.

We have heard some visionary talk with a global perspective. To that end, it will become important to accumulate evidence and for not only providers but also service users and the entire population to think about home care as something close to them.

I thought it was very important to discuss home care on equal terms, from the perspective that you might be the user next.

I truly hope that all the participants here today will continue to be even more active. Thank you very much for today.