[Feature: Thinking about "Home Care"] Home-Visit Nursing as a Business

2019/12/05

There are currently about 10,000 home-visit nursing offices, which calculates to one office for every 12,000 people. As shown in the figure on the next page, market growth can be divided into three periods: the creation period starting in FY1993, the stagnation period starting in FY2000, and the growth period starting in FY2011. While many industries are seeing market shrinkage in an era of population decline, the home-visit nursing business is growing. Furthermore, the Japanese Nursing Association aims to have twice as many home-visit nurses working by 2015.

Management entities for home-visit nursing businesses include large corporations, medical corporations, and corporations established by individual nurses; some companies have even gone public through their home-visit nursing business. While joint-stock companies cannot directly manage hospitals, they can manage home-visit nursing. While services like home-visit care can only use long-term care insurance, home-visit nursing can also use medical insurance because it serves children requiring medical care, young patients with mental illnesses, and cancer patients. The government is utilizing market forces to the extent that it allows joint-stock companies to operate services that can use medical insurance. The number of elderly people will peak between 2042 and 2060, and the market will mature over the next 20 to 30 years, so investing now with a medium- to long-term strategy is required.

There are 600,000 monthly users of home-visit nursing. Roughly speaking, the basic structure involves five visits per month, one hour per visit, at a cost of 10,000 yen (with the individual paying 1,000 to 3,000 yen), and the market size is approximately 360 billion yen. The number of nursing staff per home-visit nursing office is six full-time equivalents, and sales per person are approximately 6 million yen. Depending on the operator, sales per person can exceed 10 million yen. While a nurse in a rural area might make three visits a day with a one-hour one-way drive, a nurse in the city center might make six visits a day with a 10-minute one-way trip by bicycle.

Every business has a pioneer. Regarding home-visit nursing, that person is Ms. Shizuko Muramatsu. I heard Ms. Muramatsu's lecture in a class during my first year at the Faculty of Nursing and Medical Care. Ms. Muramatsu began providing home-visit nursing as a volunteer for patients being discharged from hospitals, and later, people began paying out of their own pockets. When Ms. Muramatsu started home-visit nursing for a fee, she was criticized by the nursing community for "turning nursing into a business." Nevertheless, Ms. Muramatsu proceeded with the commercialization of home-visit nursing based on her conviction that nursing needs to respond to the needs of patients.

The government also took notice of this, investigated the service content provided by Ms. Muramatsu and others, and the system was developed so that public insurance could be used. Today, few people know who created home-visit nursing, but in any business, we must not forget to respect the person who first dug the well.

Recently, the market environment has changed, and demand for children requiring medical care, patients with mental illnesses, and terminal cancer patients is increasing. In particular, amid constraints on social security financial resources, the number of people being discharged from hospitals is increasing, and a need for home-based care is emerging. Because of the high medical costs of end-of-life care in hospitals and the fact that citizens wish to spend their final moments in their familiar homes, "home-based end-of-life care" in private homes or nursing homes is being promoted. For these reasons, we need to spend the next 10 to 20 years creating the next generation of home-visit nursing businesses.

Public funding for home-visit nursing is derived from taxes and social insurance premiums, so unnecessary services cannot be provided. Therefore, it is necessary to identify and provide service content and quantities that are necessary and sufficient for the user. And, if possible, it is desirable for the user to become independent to the point where home-visit nursing is no longer necessary and to end the use of the service. Under the current medical and long-term care fee systems, there is no clear performance-based compensation system, but providing high-quality services leads to gaining the trust of users, families, collaborating medical institutions, and care managers. Furthermore, it becomes a source of professional pride for the working staff.

I graduated from the Faculty of Nursing and Medical Care in March 2005, and after working at a management consulting firm and a university hospital, I founded "CarePro" in December 2007. Initially, we expanded from a preventive medical service called "One-Coin Health Checkups."

Then, through volunteering after the Great East Japan Earthquake on March 11, 2011, I faced the problem of "end-of-life refugees" dying in isolation, and I thought this might be a microcosm of Japan in an aging society with many deaths. If home medical care does not become widespread, isolated deaths will increase. It was estimated that there would be 300,000 end-of-life refugees in 2020, and if each home-visit nurse cared for 10 people a year at the end of their lives, we needed to increase the number of nurses by 30,000. Therefore, I entered the home-visit nursing business with the ambition of increasing the number of home-visit nurses and preventing isolated deaths.

When analyzing the home-visit nursing industry, it was characterized by an average nurse age of 47, which was more than 10 years higher than in hospitals. Because nurses visit patients with various diseases and disabilities—such as pediatric, psychiatric, or cancer patients—alone, experience and skills are required, and the common wisdom was that it was difficult for anyone other than a veteran.

On the other hand, while 55,000 new nurses graduate every year, it also became clear that 19.6% are interested in community medicine, such as home-visit nursing, at some point. As the nursing education curriculum at universities and nursing schools evolved, home-visit nursing practicums became widespread, and many students became interested. However, home-visit nursing providers, who would be the recipients, do not have education programs or budgets, so they do not accept new graduate nurses. In other words, the structure was one of "procuring" nurses who had been trained at hospitals.

However, in any industry, to become independent as an industry, it is required to procure human resources—the most important management resource—internally. Therefore, our company worked on training new graduate home-visit nurses, thinking that if the number of new graduate or rookie home-visit nurses increased by three at each of the 10,000 home-visit nursing offices nationwide, the number of home-visit nurses would increase by 30,000 nationwide, leading to the prevention of end-of-life refugees.

I have heard that when Toyota first made four-wheeled vehicles, they were laughed at by Western countries, but with the support of the Japanese government, the Japanese automobile industry grew significantly and began to earn foreign currency. Regarding the development of human resources for home-visit nursing, it was necessary to create know-how that could train people from scratch.

Therefore, CarePro began hiring new graduates in 2013 and has trained 12 people so far. We invest 3 million yen per person to train them into full-fledged professionals. They accompany seniors on about three visits a day and gradually become able to make solo visits. When they start doing night shifts, there is a possibility of receiving calls from over 100 patients, so they need the ability to handle patients with various diseases and conditions. Together with nurses who specialized in education at graduate school, we compiled our internal know-how and even published it as a textbook.

Until then, hiring and training new graduate home-visit nurses was considered a taboo, but together with St. Luke's International University and the National Association for Home-visit Nursing Care, we created training guidelines for new graduate home-visit nurses and held seminars for home-visit nursing providers nationwide.

As a result, while only about 20 new graduate home-visit nurses were hired annually nationwide in 2013, more than 300 were hired in 2019. By becoming able to hire new graduate home-visit nurses, the hiring of experienced nurses with fewer years of experience is also progressing. The Ministry of Health, Labour and Welfare and local governments have also begun to provide education subsidies to offices that hire nurses performing home-visit nursing for the first time.

Home-visit nursing is a public insurance service, and the price is fixed. In a normal business, one can take a price strategy of "low quality but low price, high quality but high price," but because of the official prices, variations in quality tend to occur despite the same price.

What recent home-visit nursing users want is things like "responding 24 hours a day when something happens" and "responding even if symptoms become severe." Our company has 50 staff members in the home-visit nursing business, which is a large scale, and because we can respond to the diverse needs of users, we have reached the point where we have to turn people away. In the future, the visualization of provider quality will progress, and we will enter an era where providers are chosen.

Also, currently, many offices have about five nurses, and 10 is considered large-scale. Large-scale offices find it easier to provide 24-hour support, and having staff with diverse expertise makes it easier to guarantee quality, leading to many profitable operations. However, the success factor for scaling up is having multiple management positions, and there is a limit for sole proprietors who manage with a single administrator or owner. Therefore, there is a need to corporatize. Our company also receives consultations regarding expansion and M&A, and in a crowded field, a strategy for survival is necessary.

Home-visit nursing under public insurance can provide services to the home, but it does not respond to needs such as wanting someone to accompany them on trips, shopping, hospital visits, commuting, or ceremonial occasions. Therefore, those who wish for a nurse to accompany them for travel or shopping must pay the full cost themselves. At our company, we have received requests for outing support from people like Akiyuki Nosaka, and I learned that there are many people who want to go out freely despite having illnesses or disabilities.

On the other hand, there are many people who cannot easily pay 10,000 yen per hour, and there is a situation where a new business related to outing support that is affordable and guarantees quality is required.

Our company is developing a reservation system that directly matches people who need mobility assistance with nurses and others. Immediately after launching the service, a Japanese person living in New York requested outing support for their mother living alone in Japan. Amid a shortage of healthcare personnel, I believe it would be good if nurses and helpers across Japan could perform mobility support as a side job during their spare time, based on the concept of the sharing economy. By taking on work as individuals, the price can be kept down to about 3,000 yen per hour.

Keio does not perform home-visit nursing, but some school corporations have entered the home-visit nursing business. Also, within the Keio Gijuku Shachu, there are likely expectations for home-visit nursing services provided by Keio or Keio graduates. Many patients at Keio Hospital also use home-visit nursing, and the effect of Mita-hyoron (official monthly journal published by Keio University Press) will likely increase demand further. As the author, I personally wish to contribute, even in a small way, to Keio leading society in home-visit nursing as well.