13 November 2018 Chief Adviser : Akio KOIDe -Project on Seamless Health and Social Services provision for Elderly Persons (S-TOP) - Nov.2017～ 13 November 2018 Chief Adviser : Akio KOIDe

CTOP, LTOP and NEXT CTOP 2007 -2011 Trial for Integration of Health and Social services LTOP 2013-2017 Introduction of “ care management” and training of “care giver” New Seamless Care Project 2017- Development of Intermediate care and Rehabilitation from hospital to home ②プロジェクトの背景として、先ほどK Patcharaから説明がありましたように、JICAは今までタイ政府とともにCTOP, LTOPという２つのプロジェクトを実施してきました。この２つのプロジェクトは主に社会サービス・介護に焦点をあてておりました。新しいプロジェクトでは、病院から自宅へのギャップをなくすため、特に中間ケア（IC）とリハビリテーションに焦点を当てることになります。 Medical/Health Care 　　　 Social service / Long-Term Care

Project on Seamless Health and Social Services provision for Elderly Persons (S-TOP) Nov.2017- 5years　 ■Back ground: Aging rate of Thailand is 16.5% in 2016, this will increase by ap.30% in the next 20years. Length of stay at acute hospitals is limited, averaging at 5-7days, in Thailand. Bed Occupancy Rate(BOR) of acute hospitals is over 100% and most people go back home after discharged from acute hospitals. Contrary, BORs of some community hospitals are relatively less than acute hospitals. Thus, community hospital based Intermediate Care (IC) is expected to improve the quality of rehabilitation and efficiency for providing services, which consequently improves ADL and QOL of the elderly population as well as reducing the burden of family care givers. ■Project purpose: Toward the nationwide expansion, community-based models are developed for the seamless provision of medical, rehabilitative, social and life-support services for elderly persons. ■4 Targets: 1.) “Service Provision Model” 2.) Training system and method of Human Resource 3.) Feasible Financing system 4.) Effective and Efficient Use of Information Technology ⑤ではプロジェクトの概要を説明します。プロジェクトは2017年11月に開始、実施期間は5年間の予定です。プロジェクト目標は、全国展開に向けて、高齢者のためのシームレスな医療、リハビリテーション、社会そして生活支援サービスのためのコミュニティベースドモデルが開発されるという事です。 この目標を達成するために４つのターゲットを設定しました。 ➀サービス提供モデル ②人材育成のシステムと体系だった手法 ③実現可能な財政システム ④効果的かつ効率的なITの活用

Definition of IMC (referred from “KPI for evaluating the policy toward long term care” issued by MOPH) “Intermediate care means a transitional care between the period after acute conditions and care at home or in community with connectivity and continuity. It is the care for patient with stable medical* conditions but not sufficiently stable for being taken care by the capability of family or community in general. The patient who needs intermediate care is still in need of medical, nursing, multidisciplinary care in medical facilities (intermediate bed or intermediate ward). Major care during this period does not require specialized doctor or complicated medical procedure and equipment; it can be safely operated at M and F level hospitals. It is the care during a period of time (not more than 6 weeks or 45 days**”). “Since the definition of intermediate care is various, to provide its definition, the problem context and health system of Thailand are considered. This is to avoid the overlap to existing service system, especially in terms of community-related matter, the increase in resource and bed management efficiency, academic evidence, foreign experience, in-country best practice, patient safety, acceptability, convenient access to service. It focuses on filling the gab and linking to the existing system, e.g. community-based rehabilitation, elderly long-term care system or family medicine team. “ * Follow the standard and medical principle or doctor’s opinion. ** Consider the appropriate period of time which is based on intensive rehabilitation principle, in-country lesson learn and best practice at Bangklum, Hatyai, Saraburi. <Purpose of Intermediate Care> 1) To reduce congestion in hospitals. 2) To restore capability and reduce complication, e.g. intensive rehabilitation. 3) To reduce readmission because of the same disease or complication occurred from such disease. 4) To increase efficiency of bed utilization at provincial or regional level. 5) To increase skill on self-care in patient and care giver. 6) To link care plan and care to the care provided in community and home. <Target group> 　1) Patient with stroke after acute phase 　2) Patient with trauma brain injury and spinal cord injury 　3) Patient who have some problems depending on the site context and in need of intermediate care, e.g. patient with BOR and is in high risk of readmission, patient who needs intensive rehabilitation, patient who needs comprehensive assessment and rehabilitation, elderly people, etc. ⑪念のため、こちらが保健省が発行したICの政策文書からの抜粋です。一つめの黄色ライン、ICとは急性期の状態から自宅もしくはコミュニティでのケアの間のトランジショナルなケアとされています。また、2つ目の黄色ラインで、レベルM とレベルFの病院で行われ、6週間もしくは45日以内の期間に行われるケアとされています。最後に3つ目のライン、中間ケアは現存するシステムにリンクさせながら、急性期と慢性期の間にあるべきはずの医療（ギャップ）を補うこと、とされています。 特に右のページ、ターゲットグループとして、脳卒中・脊髄損傷・脳外傷があり、プロジェクトでもまずこの対象疾患に限って実施していく想定です。

S-TOP project, Japanese advisors 10/9/2018

S-TOP project, Japanese advisors Conceptualization of “IMC” and “Seamless care” in Thailand S-TOP project, Japanese advisors 10/9/2018

What S-TOP has done so far… November 2017: Project began December 2017-June 2018: Pre-research to select pilot sites (visited 11 areas) and information gathering at MOPH, MSDHS and NHSO April 2018: 1st Working Team meeting May 2018: 2nd Working Team meeting June 2018: 1st Joint Coordination Committee (JCC); Pilot sites had been approved and confirmed July 2018: 1st National seminar, kick-off meeting of S-TOP August – September 2018: Visited 7 sites and 1 potential setting for the local kick-off meetings 10/9/2018 S-TOP project, Japanese advisors

Findings in Community Hospitals(1) Hospitals providing acute care services. They are energetic in delivering services, often overloaded. - DEVELOPING stage in IMC Hospitals with many vacant beds, which can be utilized as IMC beds accepting more patients. - INITIAL stage in IMC *It was often observed that the beds prepared for IMC were not used. Hospital-based intensive IC; 2 different stages in IMC Home visit rehabilitation and care as IMC services. Community-based IMC ⑯さて、それではコミュニティホスピタルでのfindingsを説明します。 まず、ICに２つのタイプを確認しました。１つ目がホスピタルベースの集中的IC、2つ目がコミュニティベースのICです。 1つ目のホスピタルベースの集中的ICを実施している病院では、２つのタイプの病院を確認。前者はICの開発にすでにとりかかっている病院、とくにこれらの病院の特徴は急性期医療も多く提供しており、病床にもほぼ空きがなく、エネルギッシュに医療サービスを提供しているという事です。反面後者はICに関してはまだまだ最初のステージで、空いているベッドが多くこれらがもっと多くの患者をICとして受け入れ、使用するためのベッドとして使用可能な病院です。またこれら後者の病院ではICが用意はされているがほぼ使われていないところもありました。 下のコミュニティベースのICの提供としては、訪問リハや訪問ケアがICサービスとして実施されている事を確認した。

Findings in Community Hospitals(2) Rehabilitation services PT services are common. Most hospitals intend to link PT services closely to acute care services. OT and ST services are less, compared with PT services. Nurses and PTs are trying to develop their capabilities of OT and ST in some regions. Link to social services Some hospitals have clear intentions to refer the patients to social services of local authorities. CTOP/LTOP legacy has been utilized. IT Each area has its own IT system with unique characteristics, which sometimes makes the situation complicated. Link to social services, Workforce and IT ⑰ リハビリテーションサービス関して、PTは一般的に全ての病院で確認。ほとんどの病院は急性期医療サービスとPTが密な関係をとろうとしていました。反面OT,STサービスはPTと比べると一般的ではなく少なかった。これを補うため、看護師やPTがOT,STの一部役割を担うべく、OT,STの一部治療内容を訓練し実施している地域もあった。 社会サービスへのリンクについて、いくつかの病院は患者退院後、地域の社会サービスにつなごうとしている積極的な努力・試みが見られた。CTOP/LTOPサイトではその資源が発展・活用されていた。 ITに関して、それぞれの地域で患者紹介のための独自のITシステムがあった。しかし独自のシステムが複数ある等、医療関係者・介護関係者等のユーザーにとって使い勝手が悪く、状況が複雑化している地域もあった。

IMC, Challenges Acceptability of patients and families for medical treatment at community hospitals Limited accessibility to places providing IMC services Existing work forces at community hospitals have been pressed by existing work Recognition of rehabilitation among all fields of medical staff Current financing scheme seems not to respond to IMC ⑱これらのFindingsからおおきく５つのチャレンジがあると考えました。まずは、患者や家族のコミュニティホスピタルでの医療・治療に対するアクセプタビリティについて。これがホスピタルベースのIC実施の壁になっている可能性があるという点。患者・家族のリハビリテーションへの理解、入院への理解、また入院中も家族介護がベースとなっている事がアクセプタビリティの低下に寄与していると考えています。２つめはアクセシビリティ。入院中の家族介護は家族への大きな負担になりうる、特に病院から遠いところに住む家族にとっては、です。これが患者・家族から十分なアクセプタビリティが得られない理由の一つにもなっているかもしれません。いずれにせよ、OPDでも利用者側のアクセスが限られ,訪問リハではサービス提供者の負担が増えます。3つ目、今のコミュニティホスピタルにおける人材について、いくつかの病院では入院患者対応に追われ、またほとんどの病院では外来治療とコミュニティベースドリハですでに手一杯な状況ですICを実施するためには、人材が不足すると考えます。最後に、現行のファイナンススキームがICサービス提供に対応していない、という点です。

MAIN SITE Structure of pilot sites PRACTICAL SUPPORTER Chiang Mai Khon Kaen Nakhon Ratchasima Nonthaburi BMA Chonburi Surat Thani Chiang Mai PRACTICAL SUPPORTER Songkhla Saraburi POTENTIAL SETTING Vachira Phuket hospital Mettapracharak hospital Khun Tan hospital ACADEMIC SUPPORTER Any related universities etc... Sirindhorn National Medical Rehabilitation Institute

Result on kick-off meetings in S-TOP pilot sites ✔Local kick off Meetings were held in every 7 sites during the period of 15th Aug – 5th Sep ✔Invited the persons from acute Hos., community Hos., THPH., municipalities and local Health office, HSO, SDHS office. ✔Gathered app. 70-120 persons in each sites. ✔Further understanding of and sharing information to stakeholders about project objectives, how to proceed the operation, such as analysis and goal setting and, how to setup future activities ✔“Key persons” in each sites became clearer ✔Different circumstances, relationship among stakeholders (esp. with LTC/social services) and initiatives became clearer S-TOP project, Japanese advisors

example

Planning the Activities (S-TOP) Revising and submitting “Forms” to S-TOP by referring to discussions in each meeting and S-TOP will give them feedback and the good examples to the other sites Sharing the general information for the Study trip in Japan (*Jan and Feb 2019) and consulting about the participants with Thai side The sites need to draft activity plan (Form 4) and progress management sheet (Form 5) Holding the National Seminar to prepare Study trip in Japan and discuss the drafted activity plan by each site Study trip in Japan *Jan: “Introduction of seamless care training”, app.14persons in 14days Feb: “Policy for seamless care training”, app.10persons in 7days Joint Coordination Committee to complete the activity plan of each site S-TOP project, Japanese advisors

Ratio of age 65 +over to total population 2/5/2019

What we would like to introduce to Thailand from Japan’s experiences ✔ Experience of development and dissemination of elderly rehabilitation (Eg. “Campaign to ‘reduce the bedridden elderly to ZERO’”～) ✔Featured and utilizable Japan’s medical and LTC services, facilities etc for Thailand. ✔Quantity and quality of actual activities of rehabilitation practitioners, successful examples of early rehabilitation intervention and team rehabilitation ✔Successful examples of rehabilitation that are close to each person's life ✔Key concept and elements of evaluating and financing rehabilitation services ✔Collaboration in community (Japan’s “community-based integrated care systems”) *Need to continue the discussion for matching with problem recognition on “seamless care“ with Thai side　　　 各パイロットサイト（10か所）にてモデルサービス作りに向け、現状分析・活動内容等協議 日本人短期専門家によるパイロットサイト等における会議、研修の開催 パイロットサイト等の中間管理層を対象とした日本での短期研修の実施 保健省、病院幹部等の日本での短期政策研修の実施 あわせて日本人短期専門家によるＬＴＯＰサイトのフォローアップを実施

Development of Medical Rehabilitation Services in Japan 1980s and 90s - plenty trials (&errors) by voluntary initiatives of pioneers - public awareness to effectiveness of MRS and its best practices - Service flow model (acute →　restorative(recovery) → chronic (long-term care) ) is recognized by leaders in medical fields and MHW(government) Year 2000 (Y2K) -Health care insurance started to cover restorative(recovery) rehabilitation facilities -New long-term care insurance system is introduced 2000s and 2010s - Increase of rehabilitation facilities, related human resources and financing budget Recognition of the elderly’s hospitalization for non-medical reasons and bed-ridden elderly as social problems 10/9/2018 S-TOP project, Japanese advisors

References - Japanese social security systems Health care insurance Est 1922 ext to all nationals 1961 (BD2504) Long-term care insurance Est 2000 (BD2543) Public pension scheme Est 1942 ext to all nationals 1961 (BD2504) -all participants are compulsory covered = have to pay contributions -government subsidizes to weaker insurer Work injury insurance Est 1947 (BD2490) Employment insurance Est 1947 (BD2490) 2/5/2019

Outline of health insurance system Individuals /patients (3) co-payment (1)Premiums /every month Health Insures Hospitals, clinics, Pharmacies etc (2)Medical service Health insurance associations and others (no 1491) for employee Municipalities(no 1879) for self-employed Hospital; 8565 Clinic; 100152 (5) Sending examined bills (7) Payment of medical services fees (6) Payment of billed amount (4) Billing for medical service fees MHLW(government) -decide the price lists every 2 years consulting with relating stakeholders MHLW and Local governments -subsidize to weaker health insures -audit to hospitals, clinics etc Examination and payment agency Social insurance medical fee payment agency ; no 47 Federation of national health insurance association ; no 47

Structure of Long-term care insurance system in JAPAN Premium 50% of total cost ①Consultation/Advice for cases Community general support center Category 1 insured 65 over(29mil pop) Patients/ Family Insurer (municipality) Finance Category 2 insured 40-64(43mil pop) ② Apply/certify of needed LTC App 1600 baht / month Certification committee Tax50% of total cost Care manager State 25% Prefecture 12.5% Municipality 12.5% pay 90% of each cost ③Provide care plan Service provider (in home care) ④provide services Service provider (in facility care) Regulate/audit 10% co-payment (in principle) etc 2/5/2019

Varieties of Long-term Care Insurance Services Home-visit Services Home-visit Care, Home-visit Nursing, Home-Visit Bathing Long-Term Care, In-Home Long-Term Care Support, etc.　 Private Home Day Services Outpatient Day Long-Term Care, Outpatient Rehabilitation, etc. Short-stay Services Short-Term Admission for Daily Life Long-Term Care, etc. Residential Services Daily Life Long-Term Care Admitted to a Specified Facility and People with Dementia etc. In-facility Services Facility Covered by Public Aid Providing Long-Term Care to the Elderly, Long-Term Care Health Facility, etc. Long-term Care Facility 2/5/2019 21

suggestion to thai society from Japanese experience① Personal Opinion suggestion to thai society from Japanese experience① Increase Burden of family care giver changed public opinion for Ltc ---from only family member to society( assisted by paid care giver) Traditionally Eldery cared only by family member* Increase burden for family care-giver Change of public opinion towards socialization of LTC (cared by paid care-giver) 1980s and 90s *wife, daughter, daughter in law Change of Family structure Labour participation of women Prolonged LTC period 2/5/2019

Prevention/Health promotion Personal Opinion suggestion to thai society from Japanese experience② Balancing 3 components is important and challenging tasks for LTC Japan Prevention/Health promotion In-facility care Community care prevention In-facility community prevention community ? ? ? Thailand 2/5/2019

suggestion to thai society from Japanese experience③ Personal Opinion suggestion to thai society from Japanese experience③ Social Insurance system Easy to cope with increase of benefits than tax system though difficult to control them In Japan, contribution is main revenue and tax is used to support financially weak insurer LTC lincage with health insurance Technically, LTC insurance is on the basis of health insurance in Japan - contribution collecting, administration, reimbursement system to service provider etc Very tough tasks to include Informal sector* to social insurance system suggestion Tax system on the current UC scheme may be realistic to finance LTC in Thailand ?? Estimation and planning for both workforce and costs are extremely important *Japan 30% Thai 75% to total workforce 2/5/2019

suggestion to thai society from Japanese experience④ Personal Opinion suggestion to thai society from Japanese experience④ In aging society, health & ltc are primary industry - 10% of GDP , 14% of total employment in japan 2/5/2019 source : JILPT Source : WHO

Khob khun krab ! Arigatou ! Thank you ! 2/5/2019