Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People

Background: Long-term care facilities for older people play an important role as alternatives to family care in an aging society. This study aimed to assess staffing problems linked to emergency healthcare for residents of these facilities, and to investigate the relationship between these problems and the characteristics of the facilities. Methods: The study surveyed managers of long-term care facilities for older people in a Japanese urban area between September and December 2014. The type of care facility, the number of staff and any problems providing or accessing emergency healthcare for the residents were evaluated. Multiple logistic regression analysis was used to explore the factors common to facilities reporting staffing problems linked to emergency healthcare of residents. Results: In total, 321 long-term care facilities were eligible for this study and 226 (70%) returned the questionnaire. We compared the characteristics of facilities reporting and not reporting staffing problems in emergency healthcare of residents. The type of care facility was significantly associated with staffing problems in emergency healthcare of residents both during the day (p < 0.01) and at night (p = 0.04). The facilities most likely to report problems were group homes for older people with dementia, because of staffing shortages. Conclusions: Problems in emergency healthcare systems in Japanese long-term care facilities for older people varied by type of care facility. Our data underscore the need for telemedicine and consideration of mergers between smaller facilities such as group homes for older people with dementia. How to cite this paper: Sato, N., Akazawa, K., Mitadera, Y., Suzuki, T., Ibe, N. and Hirose, Y. (2017) Clarifying Problems with Emergency Healthcare Systems in Japanese Long-Term Care Facilities for Older People. Health, 9, 1159-1175. https://doi.org/10.4236/health.2017.98084 Received: July 22, 2017 Accepted: August 20, 2017 Published: August 23, 2017 Copyright © 2017 by authors and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution-NonCommercial International License (CC BY-NC 4.0). http://creativecommons.org/licenses/by-nc/4.0/ Open Access


Introduction
Population aging is a major concern in many industrialized countries, and Japan is the most rapidly aging country in the world [1] [2].In most developed countries, almost one third of the population will be older than 60 years by 2050 and increased long-term care (LTC) services are needed [3].Although the definitions of nursing home vary internationally, LTC facilities for older people are often used in place of family care in an aging society [4] [5].The Japanese government has reported that the number of people using public LTC facilities has dramatically increased, from 520,000 in 2000 to 890,000 in 2014, an increase of 71% [6].
The government has addressed this issue by providing different types of LTC facilities, including public and private.Table 1 shows the types of LTC facilities available in Japan.A public long-term care insurance (LTCI) system was introduced in April 2000 [7].Care services under the LTCI program cover home services and residential services.Residential services include sanatorium-type medical facilities for older people needing LTC, intensive care homes for older people, and LTC health facilities.The national government added group homes for older people with dementia to the LTCI program in 2006.To receive LTCI services, insured older people must be certified as needing LTC.The requirement for LTC is classified into seven care-needs levels [2].
LTC residents have been found to make frequent visits to the emergency department and be more likely to be admitted to hospital [8] [9].Studies have demonstrated that several interventions including palliative care service delivery or geriatric specialist services reduce hospital admissions from nursing homes in the United States and European countries [10].However, hospital admission and use of emergency departments for LTC residents are likely to increase in Japan, because there are problems with emergency healthcare systems in LTC facilities for older people.First, the Japanese government does not require full-time attendance of medical staff (nurses or physicians) in most types of care facility (see Table 2).Care workers in Japan must therefore usually take residents to a clinic or hospital if they need emergency healthcare.Care workers cannot provide medical care, although nurses can provide a range of treatments such as oxygenation or withdrawal of urine.Second, although care facilities often have a formal collaboration arrangement with a particular hospital or clinic, hospitals are not obliged to accept admissions of residents and most clinics are closed at night and during holiday periods.Third, the concept of living wills and advance directives by the patient are generally less accepted in Japan than the United States or European countries [11].The purpose of this study was to assess problems encountered in LTC facilities when residents need emergency healthcare.We also aimed to investigate environmental factors associated with staffing problems in LTC facilities linked to emergency healthcare of residents (e.g. the type of care facility, number of the residents and number of the staff).The survey location was a typical urban city in Japan, so the study may help other countries to avoid problems in LTC Health facilities in the future.

Study Design and Participants
The study took place in Niigata City, on the northwest coast of Japan, which has a population of 800,000 people.The percentage of residents aged 65 years or older was 22.9% in 2012, which is similar to the rest of Japan

Measures
The questions included type of care facility, number of residents, care workers, nurses, and physicians.The number of residents was classified into three groups: 1 to 10, 11 to 50, and over 51.The term "care worker" did not include nurses.
Problems linked to medical emergencies among residents were recorded by time of day or night.They included perceived staffing shortages among care workers and nurses, lack of cooperation with the collaborating hospital's acute care services, absence of living wills or "do not resuscitate" orders and difficulties with decisions about referrals to acute medical care.
We compared characteristics between facilities reporting problems with emergency healthcare of residents, both during the day and at night, and those that did not do so.

Ethical Considerations
This study was approved by the institutional ethics review board of Niigata City General Hospital and conducted in accordance with the Declaration of Helsinki.
Informed consent was obtained from all participants with the administration of the survey.Participation in this survey was voluntary, and confidentiality was maintained throughout the study.

Statistical Analysis
Descriptive statistics were used to summarize the data.Continuous data with skewed distributions were shown as median and interquartile range (IQR), and categorical data as proportions.The proportions among several categories of discrete variables were compared using Pearson's chi-squared test or Fisher's exact test.
Given the dichotomous outcome, multiple logistic regression analysis with stepwise regression was used to explore the factors significantly associated with problems linked to emergency healthcare of residents.Candidate independent variables included the type of care facility, the proportion of residents per care worker, the proportion of residents per nurse, and number of physicians.All statistical tests were two-sided.We considered a p value of less than 0.05 to be statistically significant.Data analysis was performed using SPSS, version 23.0 (IBM Corporation, Armonk, NY, USA).

Characteristics of Facilities
A response rate of 70.4% was obtained, with 226 facilities returning the questionnaire.A further 95 facilities did not respond.Twelve facilities were excluded because of problems with information on the number of residents, nurses or physicians.Table 3 shows the characteristics of the remaining 214 facilities.LTC health facilities and intensive care homes for older people had more residents than other care facilities.Full-time physicians were present in 56 facilities (26.2%).
Only one group home for older people with dementia and two fee-based homes for older people had full-time physicians, compared with all LTC health facilities.The median number of residents per care worker was 4.5 (IQR 3.0 -6.4) during the day and 15.2 (IQR 9.0 -21.4) at night.Only 18.2% of LTC facilities had no nurses during the day, but 82.7% of them had none at night.In particular, 28 group homes for older people with dementia (68.3%) had no nurses during the day and 39 (95.1%) had none at night.

Risk Factors Associated with Problems for the Staff in LTC Facilities in Emergency Healthcare of Residents
Univariate analysis with a chi-squared test or Fisher's exact test was used to identify the significant factors associated with any problems with emergency healthcare during the day or at night.This showed that type of care facility was significantly associated with problems linked to emergency healthcare of residents both during the day and at night (Table 5 and Table 6).The results of the stepwise multiple logistic regression analysis are shown in Table 7.The type of care facility was associated with staffing problems linked to emergency healthcare of residents during the day (p < 0.01) and at night (p = 0.04).Group homes for older people with dementia were significantly associated with the occurrence of problems with emergency healthcare of residents during the day (p < 0.01).

Discussion
Our analysis showed that problems with emergency healthcare systems in Japanese LTC facilities for older people varied greatly by type of care facility.In particular, group homes for older people with dementia reported problems needing rapid resolution.
Group homes for older people with dementia are small-scale facilities for older people with mild to moderate dementia.Originally, they were developed in the belief that small-scale living facilities could both have benefits for residents and improve the working environment for staff (e.g.fewer physical restraints,   fewer psychotropic drugs and less work pressure for staff) [14] [15].However, our study demonstrated that more than half of these facilities had staffing shortages that affected emergency healthcare systems.Potential reasons for the observed association include residents with dementia and absence of medical staff.
People with dementia have higher rates of hospitalizations for medical illness including bacterial pneumonia, urinary tract infections and chronic heart failure [16].Dementia can increase the risk of falling by impairing judgment, gait, visual-spatial perception, and the ability to recognize and avoid hazards.One study found that nursing home residents with dementia were nearly twice as likely to fall as those without [17].When there are few staff on duty in group homes for older people with dementia, advice and assistance cannot easily be obtained, and this is likely to be more stressful for the staff concerned with provision of emergency healthcare.The absence of medical staff in group homes for older people with dementia is likely to become a more acute problem.Overall, LTC facilities in Japan had lower levels of medical staffing than in the United States or Europe.An international survey found that physicians regularly visited nursing home residents in 37% of the countries surveyed [18].In the United States, advanced practice nurses are directly supervised by physicians [19].Most countries rely on advanced practice nurses for much of the healthcare within LTC facilities.By contrast, our data showed that just 26.2% of LTC facilities in Japan had physicians attending regularly.In particular, only 2.4% of group homes for older people with dementia had full-time physicians and 68.3% of these homes had no nurses, even during the day.Care workers in these facilities must therefore manage the residents without medical or nursing support on site.
In Japan, 4.6 million people live with dementia [20].That figure is projected to rise to 7 million by 2025, and is likely to lead to an increase in demand for group homes for older people with dementia.Japan has the most rapidly aging population in the world.Action is therefore needed now to deal with this situation, and other countries are likely to see similar problems in the future.Our findings have important implications for government policy.Group homes for older people with dementia need urgent support because of staffing shortages and increasing numbers of older people with dementia.We suggest two strategies and measures to improve the staffing issues in these facilities.
The first measure is merging small-scale facilities.This could increase the number of staff in each care facility.In larger facilities, staff may have more flexibility to be able to help each other.These mergers would need careful consideration of location, number of older people in each facility and the scale of the facility.
The second measure is use of telemedicine.There is a limited number of nurses in Japan, although LTC facilities should also be encouraged to employ medical staff as in other developed countries [18] [21].We therefore suggest that telemedicine, which makes real-time medical consultation available via two-way videoconferencing, may be a good alternative to face-to-face consultations in LTC facilities [22].This could improve access to medical care by allowing medical staff to evaluate a resident with an acute change of condition and recommend a course of treatment without being on-site.Telemedicine has been found to reduce emergency department transfer and potentially avoidable hospitalization rate from LTC facilities [22] [23].Investment would be needed in the technology to establish the system, but telemedicine has been shown to be a cost-effective way to reduce inpatient spending in United States [22].
Our study has several limitations.First, passive surveillance introduces the potential of reporting bias.LTC facilities with problems may have been more likely to respond.However, we had a high response rate for the questionnaire.
Second, we used a modified version of the original questionnaire tool.This may prevent us from comparing our findings to those resulting from the use of the original version, or other tools.Despite these limitations, our findings should help health policymakers and the managers of LTC facilities set priorities for improving staffing and work environment, and therefore support better emergency healthcare of residents of these facilities.

Conclusion
Problems with emergency healthcare systems in Japanese LTC facilities for older people varied widely by type of care facility.In particular, group homes for older people with dementia reported staffing shortages needing immediate resolution.
Our study demonstrates the need to support group homes to enable them to use telemedicine.We also consider that the government should encourage mergers of small-scale care facilities where this will not have an adverse effect on residents.
[12].The operational sample (n = 321) consisted of all LTC facilities in Niigata City except sanatorium-type medical facilities for older people requiring LTC.These were excluded because they are effectively hospital-type facilities with physicians on site.Figure1shows the location of LTC facilities and the density of the population of older people in Niigata City.Facilities included 74 intensive care homes for older people, 36 LTC health facilities, 45 fee-based homes for older people, 48 group homes for older people with dementia, and 118 facilities offering short-term admission facilities.An original questionnaire was developed using information from previous surveys in Japan (a copy of the questionnaire is in the Appendix)[13].It was pilot-tested on two LTC facility managers in Niigata to clarify the wording of the questions and to provide appropriate answer categories.The final version of the questionnaire was mailed to LTC facility managers, and returned by post after self-completion between September and December 2014.

Figure 1 .
Figure 1.Geographic information system maps showing the capacity of 321 long-term care facilities for older people and the population of older people in Niigata City in 2010.

Table 1 .
Types of long-term care facilities in Japan.

Table 2 .
Details of staffing and residents in long-term care facilities in Japan.

Table 3 .
Characteristics of study facilities.
*Percentages may not sum because of rounding; † The term 'care worker' does not include nurses.

Table 4
shows problems with emergency healthcare systems in Japanese LTC N. Sato et al.DOI: 10.4236/health.2017.980841165 Health

Table 4 .
Problems with emergency healthcare systems in Japanese long-term care facilities for older people by type of care facility.
facilities for older people, by type of care facility.In total, 81 facilities (37.9%) had problems with emergency healthcare systems during the day, and 186 (86.9%) at night.Major problems with emergency healthcare systems included shortage of nurses, lack of cooperation from the collaborating hospital, and shortage of care workers.Shortage of nurses was the biggest problem both during the day and at night.Group homes for older people with dementia often had staff shortages.LTC health facilities were more likely than other facilities to have problems with medical cooperation rather than staffing shortages.

Table 5 .
Unadjusted models comparing long-term care facilities with and without staffing problems linked to emergency healthcare of residents during the day.
†The term "care worker" does not include nurses.

Table 6 .
Unadjusted models comparing long-term care facilities with and without staffing problems linked to emergency healthcare of residents at night.

Table 7 .
Multiple logistic regression models comparing long-term care facilities with and without problems linked to emergency healthcare of residents.