Naoko Muramatsu

Japan's Universal Long-Term Care System Reform of 2005: Containing Costs and Realizing a Vision

Japan implemented a mandatory social long‐term care insurance (LTCI) system in 2000, making long‐term care services a universal entitlement for every senior. Although this system has grown rapidly, reflecting its popularity among seniors and their families, it faces several challenges, including skyrocketing costs. This article describes the recent reform initiated by the Japanese government to simultaneously contain costs and realize a long‐term vision of creating a community‐based, prevention‐oriented long‐term care system. The reform involves introduction of two major elements: “hotel” and meal charges for nursing home residents and new preventive benefits. They were intended to reduce economic incentives for institutionalization, dampen provider‐induced demand, and prevent seniors from being dependent by intervening while their need levels are still low. The ongoing LTCI reform should be critically evaluated against the governments policy intentions as well as its effect on seniors, their families, and society. The story of this reform is instructive for other countries striving to develop coherent, politically acceptable long‐term care policies.

Work Stress, Burnout, and Social and Personal Resources among Direct Care Workers.

Work stress is endemic among direct care workers (DCWs) who serve people with intellectual and developmental disabilities. Social resources, such as work social support, and personal resources, such as an internal locus of control, may help DCWs perceive work overload and other work-related stressors as less threatening and galvanize them to cope more effectively to prevent burnout. However, little is known about what resources are effective for coping with what types of work stress. Thus, we examined how work stress and social and personal resources are associated with burnout for DCWs. We conducted a survey of DCWs (n = 323) from five community-based organizations that provide residential, vocational, and personal care services for adults with intellectual and developmental disabilities. Participants completed a self-administered survey about their perceptions of work stress, work social support, locus of control, and burnout relative to their daily work routine. We conducted multiple regression analysis to test both the main and interaction effects of work stress and resources with respect to burnout. Work stress, specifically work overload, limited participation decision-making, and client disability care, was positively associated with burnout (p < .001). The association between work social support and burnout depended on the levels of work overload (p < .05), and the association between locus of control and burnout depended on the levels of work overload (p < .05) and participation in decision-making (p < .05). Whether work social support and locus of control make a difference depends on the kinds and the levels of work stressors. The findings underscore the importance of strong work-based social support networks and stress management resources for DCWs.

Functional declines, social support, and mental health in the elderly: Does living in a state supportive of home and community-based services make a difference?

This study examines how acute and chronic stresses associated with functional declines in seniors and their spouses are moderated by their informal and formal support contexts. In the United States, states vary greatly in their support for home and community-based services (HCBS) for seniors with disabilities. This state-to-state variation allowed us to examine mental health effects of living in a society supportive of HCBS for the oldest old, who are at high risk for low or declining functions in daily activities and cognitive abilities. Using a ten-year panel study of a nationally representative sample of the oldest old (>or=70 years old) covering the period 1993-2002, we conducted mixed-effects logistic regression analysis to incorporate time-varying characteristics of persons and states. As expected, low and declining functions in daily living and cognition constituted significant stressors among seniors and their spouse. Results demonstrated the important role of informal support available from non-spouse family/friends in lowering depression. Living in a state supportive of HCBS was associated with lower depression among seniors experiencing consistently low levels of function or recent functional declines, especially among those without informal support. Our findings were consistent with moderating or buffering models of formal support, suggesting that state HCBS support is effective mainly under conditions of high levels of stressors. Political will is needed to prepare US society to collectively support community-based long-term needs, given the difficulty of preparing ourselves fully for common, but often unexpected, functional declines in later life.

Work stress and depression among direct support professionals: the role of work support and locus of control

BACKGROUND Although work stress can impede the capacity of direct support professionals and contribute to mental health challenges, external (i.e. work social support) and internal resources (i.e. an internal locus of control) have been shown to help DSPs cope more actively. We examined how work stress was associated with depression, with a particular focus on the role of resources. METHOD Direct support professionals (n = 323) who serve adults with intellectual and developmental disabilities from five community-based organisations completed a cross-sectional, self-administered survey which measured work stress, work support, locus of control, and depression. RESULTS Multiple regression analyses demonstrated that work stress was positively associated with depression, while resources were negatively associated with depression. In particular, work support moderated the effects of client disability stress, supervisory support lessened the effects of role conflict, and locus of control moderated the effects of workload. CONCLUSIONS Such findings suggest the importance of external and internal resources for staff mental health. This research underscores the need for strong work social support systems and interventions to help staff manage work stressors.

What Is the Quality of Quality of Medical Care Measures?: Rashomon -like Relativism and Real-World Applications

Much attention has been directed toward the measurement of health outcomes and the quality of medical care. Some policymakers tout outcomes mea-surement as a promising tool for improving health care, while others question whether current quality of care assessment is valid and of practical importance. Although significant advances have been made in the ability to measure quality of care with validity, several major methodological challenges remain. We analyze the quality of quality of medical care measures, using a conceptual framework that outlines the purpose of the measures; paradigms of the quality of care, including Donabedians structure-process-outcome model and continuous quality improvement; and other key elements, such as scope, time, unit of analysis, and perspectives. Patient preferences and organizational contexts have been underemphasized, and should be incorporated into the framework for conceptualizing quality of care. Quality of care has relativistic and dynamic aspects. Different perspectives lead to different views of what high quality care is, and quality of care is a changing concept since medical science and treatment are constantly evolving. The most appropriate quality measures depend upon whose perspective one takes and the purpose of the measures; if the measures are chosen wisely, the current state of quality of medical care measurement is adequate for both accountability and quality improvement.

Place of death among older Americans: does state spending on home- and community-based services promote home death?

Background:The majority of Americans die in institutions although most prefer to die at home. States vary greatly in their proportion of home deaths. Although individuals’ circumstances largely determine where they die, health policies may affect the range of options available to them. Objective:To examine whether states’ spending on home- and community-based services (HCBS) affects place of death, taking into consideration county health care resources and individuals’ family, sociodemographic, and health factors. Methods:Using exit interview data from respondents in the Health and Retirement Study born in 1923 or earlier who died between 1993 and 2002 (N = 3362), we conducted discrete-time survival analysis of the risk of end-of-life nursing home relocation to examine whether states’ HCBS spending would delay or prevent end-of-life nursing home admission. Then we ran logistic regression analysis to investigate the HCBS effects on place of death separately for those who relocated to a nursing home and those who remained in the community. Results:Living in a state with higher HCBS spending was associated with lower risk of end-of-life nursing home relocation, especially among people who had Medicaid. However, state HCBS support was not directly associated with place of death. Conclusions:States’ generosity for HCBS increases the chance of dying at home via lowering the risk of end-of-life nursing home relocation. State-to-state variation in HCBS spending may partly explain variation in home deaths. Our findings add to the emerging encouraging evidence for continued efforts to enhance support for HCBS.

Changes in Perceived Filial Obligation Norms Among Coresident Family Caregivers in Japan

Purpose of the Study: Japan introduced a nationwide long-term care insurance (LTCI) system in 2000, making long-term care (LTC) a right for older adults regardless of income and family availability. To shed light on its implications for family caregiving, we investigated perceived filial obligation norms among coresident primary family caregivers before and after the policy change. Design and Methods: Descriptive and multiple regression analyses were conducted to examine changes in perceived filial obligation norms and its subdimensions (financial, physical, and emotional support), using 2-wave panel survey data of coresident primary family caregivers (N = 611) in 1 city. The baseline survey was conducted in 1999, and a follow-up survey 2 years later. Results: On average, perceived filial obligation norms declined (p < .05). Daughters-in-law had the most significant declines (global and physical: p < .01, emotional: p < .05) among family caregivers. In particular, physical support, which Japan’s LTC reform targeted, declined significantly among daughters and daughters-in-law (p < .01). Multiple regression analysis indicated that daughters-in-law had significantly lower perceived filial obligation norms after the policy introduction than sons and daughters (p < .01 and p < .05, respectively), controlling for the baseline filial obligation and situational factors. Implications: Our research indicates declining roles of daughters-in-law in elder care during Japan’s LTCI system implementation period. Further international efforts are needed to design and implement longitudinal studies that help promote understanding of the interplay among national LTC policies, social changes, and caregiving norms and behaviors.

When the job has lost its appeal: Intentions to quit among direct care workers

Abstract Background Previous research indicates that work stress contributes to intentions to quit among direct care workers (DCWs) who provide services to people with intellectual and developmental disability (IDD). Though resources can help DCWs cope and remain in a job, little is known about how various dimensions of work stress and resources (social and personal resources) are associated with intentions to quit. Methods A total of 323 DCWs from 5 community-based IDD organisations completed a self-administered survey. We conducted multiple regression analyses to examine main and interaction effects of work stress and resources (work social support and internal locus of control) on intentions to quit. Results Work overload was a significant stressor, and work social support (i.e., supervisory support) was associated with low intentions to quit. The association between locus of control and intention to quit depended on the levels of a stressor: DCWs’ lack of participation in decision-making. Conclusions Supervisory support and an internal locus of control may assist DCWs in managing their stress.

Co-Learning With Home Care Aides and Their Clients: Collaboratively Increasing Individual and Organizational Capacities

Changes in health care provide unprecedented opportunities for collaboration across research, education, and practice for the common goal of enhancing the well-being of older adults and their caregivers. This article describes how a pilot project, Promoting Seniors’ Health with Home Care Aides, has synergistic education, research, and practice effects that enhance individual and organizational capacities. This pilot is an innovative partnership with home care aides to deliver a safe physical activity program appropriate for frail seniors in a real-life public home care program. The intervention and research occur in older adults’ homes and thus provide rare opportunities for the research team and partners to learn from each other about dynamics of home care in older adults’ life contexts. Co-learning is essential for continuous quality improvement in education, research and practice. The authors propose to establish “teaching home care” to ensure ongoing co-learning in gerontology and geriatrics.

Needs for Physician Housecalls–Views from Health and Social Service Providers

ABSTRACT This article examines how the role of a physician housecall program is perceived by health and social service providers that refer their clients to the program in a Midwest suburban community. Focus groups and semi-structured interviews with those providers revealed various housecall service needs of their homebound clients. In particular, the fact that home health agencies were the largest referral source suggests that the housecall program fills the needs that are not met by the current mainstream home health services. Our findings reinforce the argument for the increased physician involvement in home care and physician housecalls.