features of the japanese national dementia strategy in...
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Alzheimer’s & Dementia 10 (2014) 468–476
Features of the Japanese national dementia strategy in comparison withinternational dementia policies: How should a national dementia policy
interact with the public health- and social-care systems?Miharu Nakanishi*, Taeko Nakashima
Institute for Health Economics and Policy, Minato-ku, Tokyo, Japan
Abstract Background: The Ministry of Health, Labour, and Welfare of the Japanese national government
*Corresponding au
E-mail address: m
1552-5260/$ - see fro
http://dx.doi.org/10.10
announced a “Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)” in Sep-tember 2012. This article described features of the Japanese dementia strategy in comparison withinternational dementia policies.Methods: An international comparative study was implemented on national dementia policies toseek suggestions for Japanese national strategy. The study consisted of a bibliographical survey, a fieldsurvey, and an online case vignette survey in several countries.Results: The Japanese health- and social-care system hadmultiple access points in the dementia carepathway, as did Australia, France, South Korea, and the Netherlands. Contrary to Japan, a simplifiedaccess point was observed in Denmark, England, and Sweden. The Orange Plan aimed to establishspecific health-care services, social-care services, and the coordination of agencies for personswith dementia. However, fragmentation remains in the dementia care pathway.Conclusion: The national government should examine fundamental revisions in health, social-careservices, and advocacy in joint initiatives with Alzheimer’s Association Japan to improve the nationaldementia strategy.� 2014 The Alzheimer’s Association. All rights reserved.
Keywords: Australia; Dementia; Denmark; England; France; Japan; Public policy; South Korea; Sweden; The Netherlands
1. Introduction
Japan has experienced an unprecedented increase in theaging of its society, with the proportion of elderly personsreaching 23.3% of the total population in 2011 [1]. The el-derly population rate is estimated to reach 33.4% in 2035and 39.9% in 2060. In 2003, the Ministry of Health, Labour,and Welfare of the national government established a re-search committee and published the report “Long-TermCare for the Elderly in 2015”. The report estimated thatthe total number of persons with dementia was 1.49 millionin 2002 and will reach 2.50 million in 2015 and 3.78 millionin 2045. The revised estimation was released in August 2012as 3.45 million in 2015 and 4.70 million in 2025 [2].
In 2008, the Ministry of Health, Labour, and Welfarelaunched the “Emergency Project for Improvement of Med-
thor. Tel.:181 3 3506 8529; Fax:181 3 3506 8528.
nt matter � 2014 The Alzheimer’s Association. All rights r
16/j.jalz.2013.06.005
ical Care and Quality of Life for People with Dementia” [3].The report of this project, which was published in July 2008,stated that the public Long-Term Care Insurance (LTCI) sys-tem covered most persons with dementia but that a lack ofearly diagnosis and coordination between health-care ser-vices and social-care services caused some unsuccessfulcases. Unsuccessful cases included individuals with earlieronset dementia who did not have access to care servicesand those with severe behavioral and psychological symp-toms of dementia (BPSD) who were admitted to psychiatricbeds because of unavailable community care support. Thereport suggested that an international comparative studywas required to standardize dementia care in Japan. There-fore, the Institute for Health Economics and Policy imple-mented the international comparative study on nationaldementia policies to seek suggestions for Japanese nationalstrategy during the 2-year period from April 2010 to March2012. The study consisted of a bibliographical survey, a field
eserved.
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survey, and an online case vignette survey in several coun-tries. The main concerns addressed in the study were (1)the coordination between health- and social-care services,(2) the coordination in transition from home to residentialcare setting, and (3) specific professionals in dementia care.
After the study report, theMinistry of Health, Labour, andWelfare published a report entitled “Directions of Policies onDementia” in June 2012 and announced a “Five-Year Plan forPromotion of Measures Against Dementia (Orange Plan)” inSeptember 2012 [4]. The article presented here describes fea-tures of Japanese national dementia strategy in comparisonwith international dementia policies in Australia, Denmark,England, France, South Korea, Sweden, and theNetherlands.
2. Method
Aprevious study summarized five dementia strategies [5].In addition to the primary goals of the study, we selectedseven countries that have used a national dementia strategysince at least 2010 and in which public health- and social-care services are available for all elderly individuals. The bib-liographical and field survey collected information on the (1)health-care system, (2) the social-care system for adults, (3)the first access point to care services for individuals with de-mentia and their families, (4) the coordination/care manage-ment/case management of dementia care, and (5) thesecondary care for persons with BPSD in each country.
An online case vignette survey was distributed to socialworkers, public health nurses, or other professionals respon-sible for dementia care in each country. A total of 18 respon-dents were recruited from the participants of the field surveyand from referrals by other respondents. The case vignettewas developed based on unsuccessful cases in Japan andwas reviewed by the professional panel, which consistedof psychiatric nurses, public health nurses, and socialworkers. The case vignette presented a series of three casestories about a hypothetical Mrs. Ivy, as given below. Theparticipants were asked to describe a typical dementia carepathway in his/her community that Mrs. Ivy could utilize.The pathway consisted of (1) the first access point to demen-tia care for Mrs. Ivy, (2) health-care agencies that could per-form a detailed diagnosis of dementia, (3) agencies that cancoordinate health- and social-care services, (4) availablesupport for Mrs. Ivy when she indicates BPSD, and (5) co-ordination of the transition from the home to a residentialcare setting.
Case story 1: Mrs. Ivy is an 85-year-old whose husbandpassed away 10 years ago. She now lives alone in the house.She lives away from her son (60 years old) and daughter(58 years old). It takes 3 hours by car to visit their mother.She has little relationship with her neighborhood. Recently,Mrs. Ivy’s son phoned her, but she did not answer. He triedfor several times, but no one answered, and he became anx-ious that his mother had an accident or became ill. Then, hecalled the city’s town hall and asked a staff member to go andsee his mother. As requested by the son, a staff member vis-
ited her house and rang a doorbell. Mrs. Ivy answered thebell, but she did not open the door.
Case story 2: The following day, the staff member visitedMrs. Ivy’s house again. He told her that he had come becauseMrs. Ivy’s son had asked him to see her to find out if she wasdoing alright. Mrs. Ivy invited the staff member into herhouse. He found plastic containers of preprepared food leftaround; therefore, Mrs. Ivy seemed to be having mealseach day, but she still appeared thin. While they were talk-ing, she repeated the same thing and was getting confusedwith the date and time.
Case story 3: A half of a year later, Mrs. Ivy has a veryshort memory, and she leaves the water running or the stoveon. She often shows difficult behaviors such as wanderingand resistance to help with activities of daily living. She can-not express her preference for home or residential facility(and there is no planning in advance).
3. Results
The international comparative study figured multiple ac-cess points of the dementia care pathway in Japan as well asAustralia, France, South Korea, and the Netherlands. Con-trary to Japan, a simplified access point was described inDenmark, England, and Sweden (Appendix 1).
3.1. Australia
Australia’s health-care system has general practitionersas the entry point for most people. Universal health care isprovided by the federally funded Medicare scheme, whichsubsidizes payments for services provided by physiciansand other health-service providers [6].
The social-care system for adults in Australia includes theHome and Community Care program, packaged communityand residential care services under the Aged Care Act [6],and services under the National Disability Agreement [7].The Home and Community Care program provides commu-nity care services for the aged and the disabled. Under theAged Care Act, community care services include Commu-nity Aged Care Packages, Extended Aged Care at Homepackages, and Extended Aged Care at Home–Dementiapackages. In addition to the Aged Care packages, the Na-tional Respite for Carers program funds direct and indirectrespite care options, offering respite care in a range of ac-commodation settings, including day centers and in-homerespite services. Transitional Care packages provide short-term therapy and support to elderly persons after a hospitalstay to enable them to return home. Residential Aged Careservices provide accommodation and support for elderlypersons who can no longer live at home. Aged Care pack-ages require recipients to undergo assessment and certifica-tion of care needs by the Aged Care Assessment Team.Persons with disabilities or younger onset dementia canuse Aged Care packages if there are no National DisabilityAgreement services available in the community. Because
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there are a wide range of social-care services in Australia,the Commonwealth Respite & Carelink centers are estab-lished to provide information on services that are availablefor elderly persons, persons with disabilities, and familycaregivers [8].
The national dementia policy in Australia began in the1990s with the National Action Plan for Dementia Care1992–1997 [9] and the National Framework for Action onDementia 2006–2010 [10]. Alzheimer’s Australia works inpartnership with the Commonwealth government on the ba-sis of evidence-based policy and delivers the National De-mentia Support program. Under the national initiatives, theDementia Behaviour Management Advisory Service was es-tablished to provide support and consultation services forpersons with BPSD [11]. In August 2011, the productivitycommission reported fragmentation in that case manage-ment is implemented within each care package but notwithin different care systems [8]. The Commonwealth gov-ernment published the response to the productivity commis-sion report in April 2012 [12]. The report stated that thegovernment’s aged care reform will increase the amount ofsupport, home care, and residential care; recognition ofcarers and those from culturally diverse backgrounds; sup-port for those with dementia; and better access to informa-tion [12].
3.2. France
The health-care system in France has universal health in-surance coverage with multiple health insurance programs[13]. General practitioners are the front-line health-care pro-fessionals in terms of their interactions with patients.
The social-care system for adults in France is based onbenefits for community and residential care services. Thesocial-care services for the aged are covered by the Per-sonal Autonomy Benefit (Allocation Personalisee d’Auton-omie) [13]. The National Social and Medico-SocialEvaluation Agency (Agence Nationale de l’�Evaluation So-ciale et M�edico-Sociale) conducts needs assessment anddetermination of the level of care for Personal AutonomyBenefit applicants and manages the care plan of home-care services. The social-care services for the disabledare covered by the Disability Compensation Benefit (Pre-station de Compensation du Handicap) [14]. Several mea-sures have been developed to bridge the lack ofcoordination, including the Local Center for Informationand Coordination (Centre Locaux d’Information et de Co-ordination) and the gerontology networks [13]. For familycaregivers of persons with dementia, voluntary organiza-tions such as France Alzheimer have been established toprovide information and combat their isolation.
The National Alzheimer Disease Plan 2008–2012 waspublished in February 2008 [13]. The plan is divided into6 objects and 44 measures, including the establishmentof several agencies that will provide specific services forpersons with dementia. The Resources and Research Mem-
ory Center (Centre M�emoire de Ressource et de Re-cherch�e) aims to implement research and provide trainingfor professionals in areas such as early diagnosis of demen-tia. The memory consultation (consultations m�emoire) pro-vides consultation of persons with BPSD with otherprofessionals. In addition, the Center for the Autonomyand Integration of Alzheimer’s Patients (Maison pourl’Autonomie et l’Int�egration des Malades d’Alzheimer)and a case manager (coordonnateur) are established asa single access point that coordinates several services forpersons with dementia. The Autonomy and Integration ofAlzheimer’s Patients works in close collaboration withthe Local Center for Information and Coordination andthe Local Social Action Center (Centres Communauxd’Action Sociale).
3.3. South Korea
The health-care system in South Korea has a universalhealth insurance coverage with one health insurance pro-gram (National Health Insurance) [15]. Although health-care providers are divided into three levels of care, there isno registration system of general practitioners.
The social-care system for adults in South Korea con-sists of the public long-term care insurance program forthe aged [15] and tax-funded services for the disabled[16]. The National Health Insurance Corporation is the sin-gle insurer of the long-term care insurance program and isresponsible for needs assessment and management of careplans.
The national dementia policy in South Korea was an-nounced as “Dementia Comprehensive Management Mea-sures ( )” in September 2008 [17]. One of theprimarymeasures in the policywas to provide early diagnosisof dementia through the establishment of public health cen-ters ( ), including dementia counseling centers. Further-more, a comprehensive National Dementia Center( ) was established and replicated in regional hospi-tals (base hospitals for dementia, ) to provide diagnosisof dementia, treatment, and consultation for BPSD. In July2012, the Ministry of Health and Welfare published the sec-ond National Dementia Management Master Plan( ) 2013–2015 [18]. The second plan includesthe following four initiatives: early detection and prevention,tailored treatment, infrastructure for the management ofdementia, and family support and improvement of socialrecognition.
3.4. The Netherlands
The health-care system in the Netherlands has a singlestatutory insurance regime that covers all residents. Thehealth insurance system consists of the following threecomponents: basic medical care aiming to cure (Zorgver-zekeringswet), major medical risks and care in the Excep-tional Medical Expenses Act (Algemene Wet Bijzondere
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Ziektekosten), and supplementary private insurance [19].The Exceptional Medical Expenses Act covers healthcare for chronic disorders, long-term inpatient care, andsome components of social-care services such as homecare, outreach nursing, care for the disabled, and long-term mental health care. The Care Indication Determina-tion Center (Centrum Indicatiestelling Zorg) conductscertification of care needs for the Exceptional MedicalExpenses Act applicants. Insurers of basic medical careand the Exceptional Medical Expenses Act manage thecare plans of the insured persons.
The social-care system in the Netherlands is based on theSocial Support Act (Wet Maatschappelijke Ondersteuning)[19]. The city government (gemeente) is responsible forproviding social supports for persons who have difficultyin daily life. Social home-care services such as householdassistance and guidance have been transferred from the Ex-ceptional Medical Expenses Act to the Social Support Act.The Exceptional Medical Expenses Act has a respite carescheme that pays for informal care by families, friends, orneighbors (mantelzorg). Wmo also provides financial sup-port to informal caregivers.
The National Dementia Program (Lndelijk DementieProgramma) 2004–2008 was implemented to formulate im-provement areas in health-care regions [20]. After this pro-gram, the Integrated Dementia Care (Ketenzorg Dementie)2008–2010 was used to integrate various stakeholders, in-cluding dementia organizations such as Alzheimer Neder-land, insurers, health- and social-care providers, and localgovernments [21]. Although the two national programsachieved coordination in dementia care, large disparities re-mained between regions in the level of accomplishment ofintegrated dementia care. Therefore, the Ministry of Health(Vilans) and Alzheimer Nederland developed the Standardof Dementia Care (Zorgstandaard Dementie) in May 2012[22]. In some regions, the memory clinic (geheugenpolikli-niek) provides diagnosis of dementia and the geriatric team(geriatrische team) provides services for persons withBPSD. Both agencies can be covered by basic medicalcare or the Exceptional Medical Expenses Act. Furthermore,the national policy in the Netherlands is characterized by thedevelopment of dementia case managers who can work ashealth-care providers, social-care workers, public officers,elderly advisers (ouderenadviseur), or elderly consultants(consultatiebureaus ouderen) [23].
3.5. Denmark
The health-care system in Denmark sets the state govern-ment (region) as the principal health-care sector [24]. Thestate governments regulate primary and secondary care.Any person who has the right to public health-care benefitscan choose between coverage in Group 1 or Group 2. Per-sons covered in Group 1 must register with a specific generalpractitioner and have the right to receive free health carefrom the general practitioner. Persons in Group 2 have the
right, but not the duty, to register with a specific generalpractitioner of their choice. They must pay part of the costof health care from a general practitioner. State governmentsand city governments have health agreements on dischargeplanning among elderly, preventive treatment, and rehabili-tation [25].
The social-care system in Denmark is based on thetax-funded services for persons who require social care[26]. The city government (kommune) is responsible forthe assessment of care needs and service provision. Alldwellings for elderly are housings with service exceptthe sheltered dwellings (beskyttede lobig) and nursingdwellings (plejehjem) that existed before the reform ofdwellings for elderly (ældreboligreformen) in 1987. Since2007, the Free Care Housing Act (friplejeboligloven) en-ables people to choose private housing with service incompetition with the public sector. The private entities ac-counted for 0.5% of all residents in housings with servicein 2011 [27]. Social workers in city governments typicallycoordinate health- and social-care services for clients. TheServices Act (Serviceloven) also regulates use of force andinterventions for persons with impairment in mental capac-ity. Interventions for persons with dementia include the useof a personal alarm system or special door opener, restraintto prevent injury, restraint during personal hygiene situa-tions, forced isolation in the home, the provision of fabricstraps to prevent falls, and involuntary admission to hous-ing with service.
The national dementia policy in Denmark was publishedas “National Dementia Action Plan (National Handlingsplanfor Demensindsatsen) 2010–2014” in December 2010 [28].The national plan consists of seven measures, including di-agnosis of dementia and social interventions. Along withthe national plan, the Ministry of Social Affairs and Integra-tion and the Danish Health and Medicines Authority re-ported “Mapping of Dementia in Denmark (Kortlægningaf Demensomr�adet i Danmark) 2010” [26]. The mappingof dementia care revealed that some health-care agencies es-tablished multidisciplinary teams among geriatrics, neurol-ogy, and psychiatry that provided diagnosis of dementiaand support for persons with BPSD. The name of the multi-disciplinary team varies from area to area, such as “memoryclinic” (hukommelsesklinik) and “dementia clinic” (de-mensklinik). In addition, most city governments had a de-mentia coordinator (demenskoordinator) or dementiaconsultant (demenskonsulent) to coordinate care for personswith dementia. Voluntary organizations such as Alzheimer-foreningen and Ældre Sagen play a central role in providingadvocacy and a respite for family caregivers.
3.6. England
The health-care system in England is characterized by theNational Health Service, which provides free health-careservices for all residents [29]. General practitioners and pri-mary care trusts are responsible for managing local health-
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care services. Intermediate-care services have been devel-oped to help persons avoid unnecessary hospital admissionand to speed recovery and rehabilitation.
The social-care system for adults in England provides thetax-funded services for the aged and disabled [29]. The citygovernment (local authority) is responsible for the assess-ment and certification of applicants’ care needs. Service pro-vision is typically commissioned to private entities. In 2010,the private entities accounted for 93% of all residence in carehomes [30]. The social workers in city governments typi-cally coordinate health- and social-care services for clients.The social-care services from local authorities are typicallymeans-tested, with National Health Service continuing careand National Health Service-funded nursing care schemes inwhich the National Health Service pays a contribution to-ward care services [31]. National Health Service and localauthorities are responsible for discharge planning for pa-tients in line with the single assessment process [32]. Thesocial-care system in England is also characterized by theCarers Strategy, which offers family caregivers services inconsidering their options and making informed choicesabout their lives.
The national dementia policy in England, “The NationalDementia Strategy 2009–2014”, was published in February2009 [33] independently from the strategy in Wales [34],Scotland [35], and Northern Ireland [36] in the United King-dom. The development of the national strategy involvedclose cooperation between the Department of Health andthe Alzheimer’s Society. The national policy in England de-scribes 17 objectives and the dementia care pathway, whichsummarizes the themes of the National Dementia Strategyand the commissioning challenges. The memory clinic pro-vides diagnosis of dementia to patients who are referredfrom the general practitioner, and the Community MentalHealth team provides services for persons with BPSD [33].The national dementia policy also addresses the dementiaadviser, who facilitates easy access to appropriate care, sup-port, and advice for persons with dementia and their care-givers. The national strategy has an implementation planto evaluate and monitor the progress of implementationwithin areas. The outcome of the implementation plan waspublished in September 2010 [37].
3.7. Sweden
The health-care system in Sweden sets the state govern-ment (landsting) as the principal health-care sector [38].Since January 2010, patients can choose any primary-careagency in the state governments [39]. The health center(v�ardcentral) provides information on the primary-care re-sources that are available in the area.
The social-care system in Sweden is based on the tax-funded services for persons who require social care [38].The city government (kommun) is responsible for the assess-ment of care needs and service provision. Since January2009, the Act on System of Choice (Lagen omValfrihetssys-
tem) enables people to choose private social-care services incompetition with the public sector. The private entities ac-counted for 20.4% of all permanent residence in specialhousings in October 2011 [40]. The elderly reform(€Adelreforme) in 1992 established the Medical ResponsibleNurse (Medicinskt Ansvariga Sjuksk€oterska), who is respon-sible for health care among residents of special housings ineach municipal government. Municipal governments mustalso pay for prolonged hospitalization because of a lack ofsocial-care services (payment of completed medical treat-ment; betalningsansvar av medicinskt f€ardigbehandlade)[41].
The National Guideline for Care in Cases of Dementia(Nationella Riktlinjer f€or V�ard och Omsorg vid Demenss-jukdom) was published in May 2010 [38]. The guideline in-dicates recommendations and priorities in health- andsocial-care services for persons with dementia to reducethe cost of dementia care. During the development processof the guideline, the National Board of Health and Welfareconducted a survey to investigate the variations in the health-and social-care system across local governments [42]. Theresults of the survey indicated that three quarters of respon-dent cities had a dementia nurse (demenssjuksk€oterska) whocoordinated care for persons with dementia. Some state gov-ernments and city governments had a BPSD team (BPSD-teamet) that provided support for persons with BPSD.Nonetheless, inspections of the social-care services in2010 revealed that approximately 60% of special housingsfor dementia had insufficient staffing for residents duringthe night. Therefore, new regulations were established underthe Social Services Act (Socialtj€anstlagen) to clarify the re-sponsibility of city governments for persons with dementiain July 2012 [43].
3.8. Japan
The health-care system in Japan includes universal healthinsurance coverage with multiple health insurance programs[44]. There is no registration system of general practitioners;thus, insured persons can access any health-care provider(called “free access”). The Medical Center for Dementiawas established in the Emergency Project to provide demen-tia diagnosis and support for persons with BPSD at home-care settings [3].
The social-care system for adults in Japan consists ofthe public LTCI program for the aged and tax-funded ser-vices for the disabled [44]. Although municipal govern-ments manage the LTCI program as insurers, theprovision of services is open to the private sector andhealth-care services. A care manager is assigned to a clientto coordinate home- and community-based care servicesunder the LTCI program. Care management is terminatedwhen the client is admitted to a residential-care facilityor health-care institution. Elderly persons who receive pre-ventive services are covered by the Community GeneralSupport centers that provide comprehensive support for
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community residents under the LTCI program [45]. LTCIservices are available for persons with younger onset de-mentia; however, employment services are not covered.Thus, the disabled must access tax-funded services forthe disabled on the basis of the Services and Supports forPersons with Disabilities Act [3].
The Ministry of Health, Labour, and Welfare publishedthe Orange Plan, which planned to establish health care, so-cial care, and advocacy services for persons with dementiaduring the 5-year period from 2013 to 2017 (Appendix 2).The Orange Plan is characterized by the establishment ofthe Initial-Phase Intensive Support Team in the CommunityGeneral Support Center and by the presence of a dementiacoordinator in local governments. The model of the Initial-Phase Intensive Support Team was derived by the CroydonMemory Service model in England [46]. The Initial-PhaseIntensive Support Team conducts home visits and assess-ments and provides information and advice. In addition,the national policy plans to establish the definition of “per-sons with dementia who require psychiatric inpatient care”to prevent individuals with dementia who may not need psy-chiatric care from prolonged hospitalization in psychiatricbeds. BPSD increases the difficulty of providing continuinghome care and residential-care services, and some facilitiesreject admission because they are unable to care for personswith BPSD. Hence, psychiatric beds result in accommoda-tions for persons with BPSD [47]. Japan has the highestnumber of psychiatric beds among Organisation for Eco-nomic Co-operation and Development countries, with2.7 per 1000 population in 2010 [48], and most psychiatricbeds are managed by private entities (92.4% in October2011) [49].
4. Discussion
The dementia care pathways of several countries weresummarized into a “referral” system from general practi-tioners or other primary-care providers to secondary-careservices that provide diagnosis of dementia. In Japan, thefirst access point of the dementia care pathway is undeter-mined in primary health-care services because of the ab-sence of general practitioners.
Some countries, such as Denmark, England, and Sweden,have local government personnel who coordinate health-and social-care services for dementia. The social-care sys-tem in these countries is managed by city governments,which sustain care coordination from home to residential-care settings. By contrast, the care system in Australia hasbeen fragmented. The complicated social-care system re-quires a new care coordination agency such as the Autonomyand Integration of Alzheimer’s Patients in France and the de-mentia case manager in the Netherlands. The coordination ofdementia care in Japan is still fragmented among the Initial-Phase Intensive Support Team, the dementia coordinator,and care managers. Community General Support centersare based on the LTCI program; thus, the Initial-Phase Inten-
sive Support Team may have little capacity to provide infor-mation on the resources available for persons with youngeronset dementia. Even if the Initial-Phase Intensive SupportTeam works well in the early stage of dementia, fragmenta-tion can occur as the person is transferred from preventivecare to home care, residential care, and inpatient care.Furthermore, Community General Support centers and citygovernments are not involved in discharge planning aslocal authorities are in Denmark [25], England [32], andSweden [41].
Secondary services in several countries (except the mul-tidisciplinary team in Denmark and the Medical Centers forDementia in Japan) are typically divided into those that di-agnose dementia and those that provide community supportfor persons with BPSD. The number of Medical Centers forDementia will be increased to 500; however, this number isinsufficient to cover all community residents with BPSD.Thus, the Japanese national initiative should explore a modelthat helps psychiatric service providers transfer patientsfrom inpatient care to Community Mental Health services(with a functionality similar to the community mental healthteams in England).
Finally, several countries have developed national de-mentia policies to support family members as well as indi-viduals with dementia in joint initiatives with theirAlzheimer’s associations. A Japanese strategy for familysupport and advocacy remains to be explored. There is nolegislation on advanced directive/care planning in Japan. Al-though adult guardians have authority to contract the use ofhealth-care services and LTCI services, they are not involvedin the decision-making process for the arrangement of ser-vices. In dementia care, the final decision-making processtypically relies on family members. Nonetheless, thesocial-care system in Japan does not have a support programfor family caregivers, such as the respite care program inAustralia, funding for mantelzorg in the Netherlands, andthe Carer Strategy in England. The national governmentshould examine fundamental revisions in health- andsocial-care services as well as advocacy in joint initiativeswith Alzheimer’s Association Japan to improve the nationaldementia strategy.
It is important to note that the study presented here did notinclude the National Alzheimer’s Plan (as seen in the UnitedStates) or other recent national dementia policies. Futurestudies should more extensively investigate internationalmodels to improve national dementia policies around theworld.
5. Conclusions
The Ministry of Health, Labour, and Welfare of the Jap-anese national government announced a “Five-Year Planfor Promotion of Measures Against Dementia (OrangePlan)” in September 2012. The article presented here de-scribed features of the Japanese dementia strategy in com-parison with international dementia policies. The Japanese
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health- and social-care system had multiple access points inthe dementia care pathway, as did Australia, France, SouthKorea, and the Netherlands. Contrary to Japan, a simplifiedaccess point was observed in Denmark, England, and Swe-den. The Orange Plan aimed to establish specific health-care services, social-care services, and the coordination ofagencies for persons with dementia. However, fragmentationremains in the dementia health-care pathway. The nationalgovernment should examine fundamental revisions inhealth- and social-care services as well as advocacy in jointinitiatives with Alzheimer’s Association Japan to improvethe national dementia strategy.
Acknowledgments
The study presented here was part of a research project in theInstitute for Health Economics and Policy. The Ministry ofHealth, Labour, andWelfare provided funding for the projectwithout any involvement in the study design, methods, datacollection, analysis, interpretation, or preparation of themanuscript. The paper represents the personal views of theauthors and is not the official view of the Ministry of Health,Labour, and Welfare; the Institute for Health Economics andPolicy; or other organizations below.We thank all participants who responded to the online casevignette survey from each country. We are especially grate-ful to the following individuals for their support in devel-oping the dementia care pathways: Christie Atkinson,Community Mental Health Team in Newcastle upon Tyne;George Bannister, Alzheimer’s Society County Durham Lo-cality; Emma Black, Department of Health of Victoria StateGovernment; Mette Brynskov, Caritas; Charlotte Clarke,University of Edinburgh; Lissie la Cour, �Arhus Kommune;Colleen Doyle, National Ageing Research Institute;Margaret Eccleston, Royal Freemasons; Pernille QvistEngstrøm, VIA University College; Conny Flensborg, Alz-heimer F€oreningen Østjylland, Afd; Hanna Frustuck, De-mens Caf�een I �Arhus; Takeshi Gotoh, Japan EuroPromotions; Angie Grey, Byker Lodge Resource Centre;Noreen Henderson, Cheviot Homes; Koichi Hiraoka, Ocha-nomizu University; Barry Hodgson, Newcastle University;Kirsten James, Dementia Behaviour Management AdvisoryServices; Sumiyo Kinoshita; Yasuhito Kinoshita, RikkyoUniversity; Dorte Lausten, �Arhus Kommune; Yoko Mat-suoka, Tokyo Kasei University; Bronwyn McPherson, Com-monwealth Respite & Carelink Centre Southern RegionVictoria; Tony Metcalf, Newcastle City Council; AkitoshiNishishita, Tokyo Keizai University; Makiko Okamoto, Ja-pan Research Institute; Masahiro Omori, Ochanomizu Uni-versity; Sanjeet Pakrasi, Connect for Care; Line F. Peterse,Caritas; Margaret Roe, Gainford Nursing Home; StephenScott, Connie Lewcock Resource Centre; David Sykes, Alz-heimer’s Australia Victoria; Masumi Takeuchi, VIAUniver-sity College; Sue Tiplady, National Health Service NorthTyneside Primary Care Trust; Atsuhiro Yamada, Japan
Research Institute; Naomi Whymant; and Birthe Ørndrup,�Arhus Universitet Hospital Risskov.
RESEARCH IN CONTEXT
1. Systematic review: An international comparativestudy was implemented on national dementiapolicies to seek suggestions for a Japanese nationaldementia strategy. The study consisted of a biblio-graphical survey, a field survey, and an online casevignette survey in several countries.
2. Interpretation: The Japanese health- and social-caresystem had multiple access points in the dementiacare pathway, as did Australia, France, South Korea,and the Netherlands. Contrary to Japan, a simplifiedaccess point was observed in Denmark, England, andSweden. After the study report, the Japanese nationalgovernment announced a “Five-Year Plan for Pro-motion of Measures Against Dementia (OrangePlan)” in September 2012. However, fragmentationremains in the dementia care pathway.
3. Future directions: The national government shouldexamine fundamental revisions in health- andsocial-care services as well as advocacy in joint ini-tiatives with Alzheimer’s Association Japan to im-prove the national dementia strategy.
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Appendix
Appendix 1 illustrates the care pathway and multidisciplinary team for a person with dementia in each country. A left squareshows a dementia care pathway in which a person with dementia (blue circle) is transferred to health care (blue box), social care(red and green), and other agencies (purple) according to arrows. A right square shows a multidisciplinary team following a per-son with dementia from home (upper left) to residential-care settings (bottom right).
Appendix 1. Care pathway and multidisciplinary team for a person with dementia in Japan and seven other countries. LTCI, Long-Term Care Insurance; GP,
general practitioner; HACC, Home and Community Care; CACP, Community Aged Care Package; EACH, Extended Aged Care at Home; EACH-D, Extended
Aged Care at Home–Dementia; DBMAS, Dementia Behaviour Management Advisory Service; RAC, Residential Aged Care; PCH, Disability Compensation
Benefit (Prestation de Compensation du Handicap); APA, Personal Autonomy Benefit (Allocation Personalisee d’ Autonomie); NHIC, National Health Insur-
ance Cooperation; ZVW, basic medical care aiming to cure (Zorgverzekeringswet); AWBZ, Exceptional Medical Expenses Act (Algemene Wet Bijzondere
Ziektekosten); Wmo, Social Support Act (Wet maatschappelijke ondersteuning); CMH, Community Mental Health.
M. Nakanishi and T. Nakashima / Alzheimer’s & Dementia 10 (2014) 468–476 476.e1
Appendix 1. (Continued)
M. Nakanishi and T. Nakashima / Alzheimer’s & Dementia 10 (2014) 468–476476.e2
Appendix 1. (Continued)
Appendix 2
Summary of the “Five-Year Plan for Promotion of Measures Against Dementia (Orange Plan)” in Japan
Measure Objective
Standardized dementia care pathway Establish a dementia care pathway at each municipality
Implement the pathway in the municipal Long-Term Care Insurance plan from 2015 to 2018
Early diagnosis and intervention Increase the number of physicians who serve as a family doctor of persons with dementia from 35,000 to 50,000
Increase the number of dementia support doctors who provide support and advice to family doctors from 2500 to 4000
Establish 500 memory clinics (including Medical Centers for Dementia)
Develop a model of Initial-Phase Intensive Support Team in community general support centers under the Long-Term
Care Insurance program
Implement a Community Care Conference in all municipalities
Health-care services Establish a guideline for pharmaceutical therapy for dementia
Develop a definition of “persons with dementia who require psychiatric inpatient care”
Establish a critical pathway for discharge planning
Long-term care services Enhance workforce of community-based services under the LTCI program
Family support, peer support Increase the number of dementia coordinators to support persons with dementia in the community from 175 to 700
Increase the number of dementia supporters from 3,000,000 to 6,000,000
Establish a system to train and support citizen guardians for adults in all municipal governments
Increase the number of dementia cafes and other community resources available for families
Younger onset dementia Develop a handbook of younger dementia resources
Assess care needs for younger onset dementia in state governments
Health and long-term care workforce Develop a model of “Dementia Life Support (Dementia Care)”
Increase the number of Dementia Care Practice Leaders (direct care workers under the LTCI) from 26,000 to 40,000
Increase the number of Dementia Care Advisers (directors of direct care workers under the LTCI) from 1600 to 2200
Provide training for 87,000 health-care workers in general (acute) hospitals
Appendix 2 shows the seven measures and 21 objectives of the “Five-Year Plan for Promotion of Measures Against Demen-tia (Orange Plan)” in Japan.
M. Nakanishi and T. Nakashima / Alzheimer’s & Dementia 10 (2014) 468–476 476.e3