Connecting hospitals and communities for integrated care (Yumi Hirahara)

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[Contribution]

The role of visiting nurses in building a comprehensive community care system in Kita Ward that connects hospitals and communities toward integrated care

Yumi Hirahara (Director, Home-Visit Nursing Station, Japan Visiting Nursing Foundation)

Kita-ku, Tokyo has a population of 340,000 (as of October 2015), and the aging rate is the highest among the 23 wards of Tokyo, estimated at 25.5%. Currently, 86,898 people are 65 years old or older, and the percentage of single-person households 75 years or older is expected to be 53.0%, and lonely death is also a major issue. In this Kita Ward, I have been involved in the community as a visiting nurse for 25 years.

The Japan Home-Visit Nursing Foundation, where I work, currently has 256 users (94 long-term care insurance users and 162 medical insurance users), and has all diseases and disabilities from children to the elderly. We provide home-visit nursing care to the subjects (as of August 2015). He is also actively involved in networks in various regions, and has been focusing on building face-to-face relationships with children with severe physical and mental disabilities for three years. Based on that achievement, last year we were commissioned by the Ministry of Health, Labor and Welfare to carry out a "community life model project for children with severe physical and mental disabilities."

In this paper, we will organize the community-based care efforts of Kita Ward by target and explain how they are involved as visiting nurses.

Roles of visiting nurses in the community-Four activities in Kita Ward

1. 1. Prevention of illnesses and disabilities in the elderly Support that prevents the deterioration of mental and physical functions of the elderly who do not have major illnesses and disabilities and enables them to connect with the community reflects the strength of the community. .. In Kita Ward, there are places where elderly people who tend to withdraw can interact with peace of mind at any time, such as the "Fureai Exchange Salon" and "Otassha Class", and a simple park with a waterfall for health promotion. There is an "old man's house" where you can enjoy your day by exercising and taking a bath. The "Elderly Fureai Meal" has been held at 29 venues so far, and about 700 people have participated.

Home-visit nurses are giving lectures for residents on the theme of "To live and die in a familiar home" together with the Regional Comprehensive Support Center, and talk about the situation of home care in Kita Ward. rice field. To be able to make decisions about your final location, you need to have a good understanding of the social resources that support the community, palliative medicine at home, and end-of-life care in multidisciplinary teams. This also affects the attitude of the elderly to live in the future. Many caregivers also attend the lecture. A caregiver who was upset about caring for his family chose to take care of him at home instead of at the hospital because he heard the story of "the power of living and dying that people originally have". I heard later that there were cases where I did.

2. Early detection and treatment of illness / disability Dementia patients and the elderly living alone have poor lives, and even small changes cause the onset of illness and disability. In Kita Ward, the "Emergency Medical Information Kit" is distributed to elderly people aged 65 and over and those who have a disability certificate to prevent unnecessary emergency medical care and hospitalization by sharing medical information. The "Kita-ku Otagaisama Network" is held twice a month for elderly people aged 75 and over who have hoped by the Regional Comprehensive Support Center, local welfare officers, and cooperators (shopping streets, police stations, fire stations, etc.). We are doing a degree of watching and visiting. At the dementia cafe, dementia supporters consisting of more than 900 inhabitants are also active, providing peace of mind to the community.

In addition, there are four "elderly care center support doctors" entrusted by the government, and in their respective living areas, they can consult with the community, visit the elderly living alone and the elderly with dementia, and the attending physician of long-term care insurance. It creates a written opinion and plays a role in connecting to medical care and long-term care. It is thanks to the cooperation with this elderly relief center support doctor that home-visit nursing can be handled at an early stage. At the "face-to-face cooperation meeting," the staff at the post office's window watches the monthly pension withdrawal situation of the elderly, and if they notice a change in the situation, they contact the Regional Comprehensive Support Center for early detection and early response to dementia. We are working on.

3. 3. In Kita-ku, where 16,483 people who need support / certification for long-term care live, the "Kita-ku Home Care Net" plays a central role in multidisciplinary training including long-term care insurance services. Operates. The government takes the leadership to create a common sheet for long-term care cooperation, a dementia care path, and a bed for home care cooperation support, and organizes social resources so that they are easy to use according to the condition.

A "home care consultation desk" has been set up to support the smooth transition from hospitals to home, and six home-visit nursing certified nurses are in charge of "home care support staff" (hereinafter referred to as "support staff") to cover the area. It is in charge. Visit when necessary, grasp the situation, and coordinate the care team for discharge support. In addition to conducting medical and social resource surveys and public relations activities to various institutions, support staff regularly hold case studies with local doctors to deepen mutual understanding. The support staff is guaranteed the reward per coordination from Kita Ward. Kita Ward divides the area into areas and assigns home doctors and visiting nurses who are familiar with the area to provide detailed support.

Four. The number of super-severe and semi-severe children who are discharged from the pediatric ward and NICU , which creates an area where children with disabilities can live comfortably, is increasing. The families of children with disabilities are complicated and have to visit the vertically divided administrative offices many times, which is a heavy burden. In addition, there is a problem that children themselves have to take a break from school due to insufficient medical cooperation even in the field of education. Therefore, in 2012, we started to create face-to-face cooperation between specialized medical institutions, community-based pediatric emergency hospitals, home-visit nursing stations, special needs schools, home-visit care stations, public health nurses, and counseling support staff. This year, which is the fourth year, visiting nurses have participated in the management council of special needs schools for the first time as members, and are working to reflect the perspective of local living in the educational environment.

From community-based care to integrated care

At present, the center of home medical care is the elderly, but from now on, we should aim for integrated care for all residents. Among them, the home-visit nursing station, which grasps the actual conditions of medical care, welfare, and long-term care for all ages, diseases, and disabilities in the region, plays a particularly important role.

Home-visit nurses not only provide care through daily home-visit nursing care, but also change symptoms, how to deal with family members, and situations where emergency calls should be made so that patients and their families can be treated with peace of mind until the next visit. Give an explanation. In the future, it will be necessary to maximize the power of patients and their families, make maximum use of available services and local networks, and support the continuation of home care. Furthermore, in order to support preventive nursing, home care, and grief care, it may be necessary to have a visiting nurse who can appropriately respond to residents of various health levels in the region.

Expand cooperation between local nurses and provide more generous regional integrated care

At present, home-visit nursing, administration, and medical associations hold the key to comprehensive care for the elderly and children with disabilities in Kita Ward. However, when the aging rate and the single person rate are high as in Kita Ward, many elderly people fall out of the system network. In a survey conducted by Kita Ward in 2011, "hospital doctors / nurses" were the second most common consultants for elderly people living alone after "neighbors / friends" ¹⁾ . By listening to the problems of the elderly, outpatient nurses may be able to prevent early detection of illnesses and disabilities, and eventually lonely death.

Therefore, three years ago, volunteer administrative health nurses, visiting nurses (home nursing specialist nurses), elderly nursing specialist nurses, pediatric nursing specialist nurses, and palliative care certified nurses from regional medical institutions became the secretariat. ， Launched "Kita-ku Nursing Healthcare Net". Hospitals, clinics, special nursing homes for the elderly, pay nursing homes, day services for outpatients, community-based comprehensive support centers, home care support offices, home-visit nursing stations, nursing homes for the elderly, nursery schools, schools, mental health centers, midwives, Public health nurses, nurses, and midwives gather from the Nursing University to continue face-to-face study sessions. This year, we called on a total of 28 specialist nurses and certified nurses belonging to medical institutions in Kita Ward to further expand the range of the network. We believe that the cooperation of nursing by all the institutions in the region will play an important role in building integrated care in the region in the future.

◆ References 1) Kita Ward Health and Welfare Plan for the Elderly (2013-2017). Kita Ward; 2013. http://www.city.kita.tokyo.jp/korefukushi/kenko/koresha/kekaku/documents/attachment.pdf

Mr. Yumi Hirara graduated from the Department of Health Sciences, Shimane Prefectural General Nursing School in 1987. After she worked at Shimane Prefectural Central Hospital for four years, she started visiting nursing at a clinic in Kita-ku, Tokyo from 1991, opened a station, and became the director. She was certified as a home-visit nursing nurse in 2006, and has been the director of Asukayama Home-visit Nursing Station since June of the same year, and she has been in her current position since 2011. She acquired a home nursing specialist nurse in 2012. She has been a director since 2014 and belongs to the doctoral program in Nursing, Tokyo Metropolitan University Graduate School of Human Health Sciences.