Interprofessional Work Model for Dementia Care in Hospitals for Community-Based Care

In this manuscript the authors have studied interprofessional work model for dementia care in hospitals for community-based care. As present situations and problems of dementia patients in hospitals for community-based care, 8 core categories (19 categories) were extracted and as actual situations of interprofessional work for dementia care, 8 core categories (13 categories) were obtained. The authors examined a function of interprofessional work model and practice contents using these categories. The results revealed that better interprofessional work can be expected by six specialists of nurses rehabilitation specialists, MSW, pharmacists, dietitians and care workers developing dementia care based on “Family handling function” “ADL maintenance and improved function” “Staff member education and empowerment function”.

Health medical provision systems, and the number of required hospital beds is examined by classifying medical functions into highly acute phase, acute phase, recovery phase and chronic phase. Local Medicine Plan Adjustment Meeting [3] was launched in 2017, and the committees consisting of medical group representatives from the local communities, medical institution managers, local government and insurer have discussed the above issue so far. Furthermore, hospitals for community-based care have been founded in accordance with the revision of medical service fees in 2014, and Hospital Fee and Hospital Treatment Management Fee (hereinafter called Hospital Fee/Management Fee) I and II were established. The increase in elderly to whom conventional acute phase medical service is not adapted and the presence of elderly who require discharge support through rehabilitation influence it in its background [4]. Roles in acceptance of patients after acute phase, support at the time of sudden change of home care patients and support for patients who return home are required for hospitals for community-based care. In particular, the support for patients who return home has come to be performed through two phases of in-hospital and local multi-job-title collaboration [5]. The in-hospital multi-job-title collaboration assumes rehabilitation, eating function therapy, mouth care, nutrient instruction, dementia care, drug reduction adjusting, patient compliance instruction, discharge support and adjustment. In the local multi-job-title collaboration, medical social workers (hereinafter called MSW) and care managers arrange home care service that enables patients to return home and resume daily life. In this way, multi-professional collaboration is essential for hospitals for community-based care, and its role in support for patients who wish to return home is important. Medical service fees were also revised in 2018, and the hospital fee and management fee of the hospitals for community-based care were classified into four phases. In this revision, the home return rate was not changed from 70% while the home return support was confined to Hospitalization Management Fee I and II at the present. A final report on the present situation of the hospitals for community-based care has been submitted from Japanese Association of Hospitals for Community-based Care [6]. According to their inpatients survey, their average age was 76.6 years old, and their main diseases were various such as musculoskeletal system, respiratory system, injury, burn injury, poisoning, digestive system disease, kidney and urinary system diseases and so on. The hospitals for community-based care aim to achieve patients' discharge within 60 days, though there is a concern that addition for dementia care and nursing staff night assignment might make it difficult to treat their main diseases. In particular, when acquiring the addition, dementia patients needing care accounts for a half or more for Dementia Care Addition I, and the ratio of dementia patient is to be more than 30% to acquire the addition for nursing staff night assignment. In this way, since the hospitals for community-based care were launched in 2014, actual scenes of discharge support for dementia patients and their families presumably have become complicated. Further, Horinouchi et al. [7] reviewed literature from 2016 through 2019 for the trend of studies on hospitals for community-based care. The study purposes of the literature they had examined focused on discharge support, outcomes, readmissions, stress and growth of the nursing professions, usability of the hospitals for community-based care and pharmacists and so on. Therefore, this study analyzed the present situations and problems of the dementia elderly hospitalized in wards for community-based care and the qualitative data collected from reality of collaboration and cooperation for dementia elderly care, aiming at clarifying interprofessional work model for dementia care.

Term Definition
Interprofessional work model: A team for dementia care, consisting of all sorts of specialists including nurses, full-time rehabilitation specialists who are to be assigned to the wards and staff members in charge of supporting home return (MSW).

Subject and Data Collection Method
For hospitals that the subject patients belong to, the authors selected hospitals having 200 beds or less that acquired Hospital Fee/Management Fee I for the hospitals for community-based care and Dementia Care Addition II. The reason why the above hospitals were selected was that it would probably be possible to reveal the real conditions of dementia patients who returned home in hospitals that acquired Hospital Fee/Management Fee I. Furthermore, it was supposed that the hospitals that acquired Dementia Care Addition II worked on dementia care actively aiming at the acquisition of Dementia Care Addition I. For these reasons, the present situation and problems of dementia care and multi-job-title collaboration are visualized by discussion by plural different professionals working in the hospitals for community-based care, which enables us to explore interprofessional work model, we presume. Focus group interviews (hereinafter called FGI) were performed for plural professionals in three hospitals in which permission was obtained from their hospital presidents, senior nursing officers and general chief nurses. Conditions for selecting subjects were arranged so that nursing professions, rehabilitation specialists and MSW who were determined to be assigned to wards for community-based care would participate in the study.
Decision for participation of specialists other than the above was entrusted to the hospitals. The participants were 7 workers from 6 job titles in Hospital A, 5 workers from 4 job titles in Hospital B and 7 workers from 6 job titles in Hospital C. The participants discussed on the interview items "The present situation and problems of dementia elderly hospitalized in hospitals for community-based care" and "Reality of collaboration and cooperation of dementia elderly care" for 60 -80 minutes. We asked the hospitals to set the place for discussion and quiet private rooms were selected. The data collection period was from December 4, Health 2018 to March 15, 2019. The subjects' basic attributes collected were job title, gender, age, years of experience in the job title, years of experience in hospitals for community-based care.

Data Analysis Method
The contents obtained in FGI were recorded verbatim, and the contents that corresponded to the interview items "The present situation and problems of dementia elderly hospitalized in hospitals for community-based care" and "Reality of collaboration and cooperation of dementia elderly care" were extracted. First, meaning of the data extracted from the three hospitals was read for each of the hospitals and the contents were coded. Furthermore, similar codes were summarized and categories were extracted. Moreover, core categories were extracted by integrating the categories and codes extracted from the three hospitals. For the analysis, we asked two study participants to check analysis results to secure stringency and certainty. Further, it was necessary to examine the analysis process for reaching core categories and therefore our study was supervised by nursing researchers familiar with qualitative studies so as to raise the validity.

Ethical Consideration
The participants were explained about the study contents including the study purpose, and were informed that participation in the study was based on free will and they had a right to reject the participation both orally and in document form before the interviews. Further, they were informed that the data would not be used for the purposes other than those of this study, handled carefully and the study results would be presented at conferences and published in magazines with their personal information protected. Based on the above, consents were obtained in document from the participants. Further, conversation in FGI was recorded with an IC recorder upon agreement made beforehand. At the interviews, number cards were put on a table or a desk, and they call each other by the numbers during the conversation to secured anonymity. This study was approved by the Ethics Committee of Kobe University Graduate School of Health Sciences (approval number 418-1).

Outline of the Hospitals
As shown in Table 1, for all of the three hospitals, four years passed since the establishment of words for community-based care, they acquired "Hospital Fee/Management Fee I" and "Dementia Care Addition II".

Contents of "The Present Situation and Problems of Dementia Elderly Hospitalized in Hospitals for Community-Based Care"
The extracted core categories, categories, codes and law data are indicated with  Details of the categories and code are as shown in Table 4. For [Dangerous behavior responded by multi-job-titles], the narrations "There is a team that separate the patients by their arousal state to see drug effects", "Like... this patient moves actively during this time so this drug will be effective in that time rage... <<Usage of nutritional supplementary food mainly centered on diet is impor-tant>> was obtained as seen in the narrations "Some patients cannot finish all so they are given oral supplement to fix the calorie they take. The pharmacist prescribes high calorie stuff like Ensure" and "The goal is, the patients take medicine while they enjoy eating". The code <<Discuss eating ability, tableware and diet arrangement with multi-job-titles>> was captured as seen in the narrations "We consult the dietitian for the form of the diet after a patient is hospitalized, but we can probably do it at an earlier stage" and "We currently confirm the pa-  you're doing good!', you know" and "I feel many people talk to me and it really encourages me", <<Empowerment by multi-job-titles>> was captured. For [Home support by multi-job-titles], as seen in the comments "They all say that the interprofessional work is a discharge adjustment conference but there are no others in which care managers join observation tour for rehabilitation work.
Unique aspect in our hospital" and "It's highly rated that care managers can directly talk with other specialists. You know they can directly learn like, 'this is dangerous' or 'this risk is bra bra...' all kinds of possible behaviors", << Observation tour for rehabilitation by local specialists and visit before the discharge>> was obtained. Furthermore, one subject commented "Once a patient goes home, there are many things they can get back. If they are in a completely new environment, they wouldn't be able to pile up their energy but you know, going back to their own home where they originally had their life, they could start their life with some advantage. I believe such a power".

The Present Situation and Problems of Dementia Elderly Hospitalized in Hospitals for Community-Based Care
This study was conducted in three hospitals that had had wards for community-based care for four years. . These categories correspond to "Rehabilitation, NST, dementia care and polypharmacy" described in "Present situation and problems of the wards for community-based care [8]". First, for [Wards for community-based care becoming complicated], it was supposed that the actual sites were confused from the following three points. First, specialists are pressed by care of the patients' main disease and dementia during the hospitalization of up to 60 days. From the interview conducted in this study revealed the opinion that 60 days are too short because the number of days for rehabilitation after orthopedics is insufficient. Secondly, unexpectedly hard dementia care is performed because of acquisition of dementia care addition and addition for nursing staff night assignment, the authors presume. Thirdly, the problem is not only that the patient's dementia turns worse and they cannot leave the hospital but the symptom of the dementia patient who cannot leave the hospital turns worse, which makes the dementia re even more difficult. Next, for [Difficulty of dementia care], dementia patients feel difficulty in accepting that they are losing themselves. In particular, those in an early period of dementia generally think that they cannot forget things. Such a symptom continues for a while, while the patients show anger or denial repeatedly. The results obtained in this study have shown that such situations overlap and the specialists working in the actually sites could not afford to respond them, we presume. Moreover, what is the most difficult is that the patients' family who are originally wished to be on the supporting side cannot function. As symbolized by the words "elderly care by elderly" and "dementia care by dementia", it is difficult to obtain support from the patients' family, and in some cases their families need to be hospitalized socially. In this study, all three hospitals reported that the patients' family cannot understand dementia. Furthermore, this complicates words for community-based care, we infer. In this way, if a dementia patient and their family cannot understand dementia correctly, explanation by specialists is really difficult for them. Furthermore, it is difficult for a dementia patient who lives alone to return home, and they cannot enter facilities and therefore cannot leave the hospital. Moreover, if the dementia symptom turned worse in the hospital, it would be a vicious circle, which makes it even more difficult to be discharged. are not yet in place to provide dementia care. In addition, it was found that there was a problem of not being able to secure a discharge site in the community, and professionals were not able to develop case management to connect the hospital and the community. Therefore, it was thought that appropriate staffing and system development of professionals, securing a discharge site in the community, and case management would have a significant impact on dementia care.

Actual Situation of Collaboration and Cooperation for Dementia Elderly Care
The  [10] developed Point Of Care (POC) rehabilitation and reported that occupational therapists resided in a ward for community-based care, and provided service at the time when a dementia patient was unrest. Similarly in this study, not only nursing profession but also rehabilitation specialists and pharmacists corresponded to dangerous behaviors. Further, in this study, it has been found that there is a hospital that performed drug effects measurement using colors.
It is a method to support dementia patients while observing drug effects on their dangerous behaviors, and it can be a clue for dementia care based on interprofessional work in each hospital. Moreover, for [Diet support by multi-job-titles], [Drug assessment and usage of medicine examined by multi-job-titles] and [Approach to increased activity by multi-job-title collaboration in the daytime], dietitians, pharmacists and rehabilitation specialists need to play a key role in urging specialists. Furthermore, for [Collective approach by multi-job-title]. In this study, one hospital already has started tracking support, and it has been narrated that being able to secure time to talk led made the dementia patients feel security. This indicates that it is important to have somebody who is always near the dementia patient and snuggles up to them. One of the collective approaches includes an in-hospital daycare. Yoshida [11] expected that it would improve the relation with patients and ability to support them, leading to the pa-Health tient' and their family's confidence on their life after discharge. It is desired to consider in-hospital daycare in accordance with characteristics of each hospital. For [Dementia and its care in the local community and at home learned from multi-job-titles] and [Home support by multi-job-titles], it is needed to newly continue learning of dementia. In addition, it is necessary to learn more about characteristics of the actual site of home medical care and place to which the patient is discharged. Pre-discharge visit is a good chance for the specialists to see local community and home and therefore it is needed for them to participate in it positively. Further, for [Empowerment by multi-job-titles], Amagi et al. [12] describe that nursing to draw the patient's strength is effective in any treatment place and is an important factor for dementia nursing. Similarly in this study, the codes <<It is important to notice what the dementia patient can do>>, <<Find what the dementia patient can do>> and <<Encourage the dementia patient cooperating with multi-job-titles>> were obtained. Those who provide support and are supported can look at good points of each other and therefore it is expected to be a good method. Furthermore, it is transmitted by encouraging a dementia patient with multi-job-titles that many people need the dementia patient. As we have seen so far, the actual situations of the multi-job-title collaboration are diverse, and it might support dementia patients and their family. Table 5 shows a tentative plan of a model of interprofessional work for dementia acquired by organizing problems of dementia patients and actual situations of interprofessional work obtained in this study. Nursing professions, rehabilitation specialists and discharge support specialists (MSW) are the arrangement standard for the wards for community-based care. In this study, actual situations of cooperation among pharmacists, dietitian and care workers have been clarified. Therefore, the authors propose dementia cares by 6 specialists, to which these 3 job titles are added. The reason why we propose the first "Family handling function" is because there were not many cases of the approach to family by multi-job-titles in this study. This is because there is a concern that when a family has a dementia patient, they tend not to come to see the patient in the hospital. Above all, such a family does not admit that the patient is dementia as a background. Therefore, it has been shown by the categories that even if the patients' family talks with each job title, approaches are not made by multi-job-titles. Therefore, it is necessary to build up a familiar-face relationship with the family who are confused with the situation, and to respond to them by multi-job-titles spending sufficient time. Secondly, we propose "ADL maintenance and improved function". Here, as practice contents of the dementia care, categories related to medicine, diet, rehabilitation and physical restriction were given. It has also been revealed that they work on these problems based on interprofessional work. Much of the content of the practice is taking place, suggesting the need to continue to do so in the future. At the same time, it would be difficult to discharge The authors propose a dementia care special team consisting of six specialists below (nurse, rehabilitation specialist, MSW, pharmacist, dietitian, care worker). Reason for choosing the six job: The arrangement standard of nursing professions, rehabilitation specialists and MSWs includes "full-time work". Moreover, pharmacists and dietitians showed their wish to participate in wards for community-based care. Care workers are not only is adjacent to ADL but also capable of collecting information including the family and the patient's back ground.

Model of Interprofessional Work for Dementia Care
Functions and practice contents of the multi-job title cooperation Base: The present situation and problems (19 categories) Base: Actual situation of collaboration and cooperation by the multi-job titles (13 categories) 1. Family handling function (family) *Provide the family with an opportunity to learn dementia correctly *Explain that the patient is dementia spending time after description is given by the physician, *Have the family see the situation of ADL and treatment during the hospitalization *Confirm wishes about the medication management and explain changes one by one *Talk about the life after the discharge including the place where the patient is discharged to *Support the life of the family and the patient comprehensively Treatment of both the main illness and dementia is needed Difficulty that the family has The family believes that the patient will be recovered The patient's family cannot understand dementia without an opportunity Respect for the patient's ability and self-determination at home 2. ADL maintenance and improved function (dementia patient) *Grasp diet habit or internal use situation at the time of hospitalization and provide the ward with it. *Perform periodical assessment of ADL and share it among specialists *Reduce recumbency in the daytime and perform investigation not to have the patient be confined to bed *Regularly assess the influence of psychotropic drugs on diet and rehabilitation *For effect measurement of psychotropic drugs, examine dangerous behaviors by separating them by colors Control such as suppression, medicine and diet is not performed well The patient's food intake decreases under the influence of cognitive function degradation and medicine It is necessary to watch calorie intake The patient is re-hospitalized for being unable to do self-management Psychotropic drugs used from hospitalization exerts an influence on the patient's life Worried for prescription Dilemma occurs for setting a limit to the patient's behaviors I feel worried with the situation that the patient's sleep hours in the daytime are long while results are demanded Cannot provide the cares that I want because of restriction in the duties time The dependence on specialist prevents cooperation Investigation of the diet forms and the use oft food and medicine Investigation of place for diet, sitting position maintenance and tableware sizes Being able to arrange medicines at the time of hospitalization and information exchange with the specialists in the local community Investigation of medicine effects and medicine usage for the hospitalized patients Raise the patient's activity by collaboration of rehabilitation specialists and nurses Consideration of specific support including transfer and portable restrooms Practice of observation of dangerous behaviors and care by the prediction Predischarge visit and observation rehabilitation of the local specialists 3. Staff member education and empowerment function (specialist) *Provide places where staff can learn new knowledge about dementia *Provide information on cares in the local community and at home particularly on characteristics of the place where the patient is discharged to *Respond to dangerous behaviors by tracking support *Examine time zones and places which dementia patients can be involved with each other safely *Examine in-hospital daycare and increase activity in the daytime *Tell the meaning of the empowerment to the dementia patient, their family and staff members *Invite the local specialists to an observation tour of rehabilitation and cooperate with them for discharge support Dementia patient case harder than expected Dementia patients who are confused Stress by being unable to have place where the patient is discharged to The patient does not have money living alone, and there is not a network to support them in the local community Difficulty in returning home Empowerment by multi-job titles Review of the patient's livelihood time and investigation of their relation with others Need of tracking support and in-hospital daycare as staff member education Promotion of learning and workshop of dementia