Navigating the 24-Hour Home Care Market: Infrastructure as the Key to Social Care in Japan

• Designing LTCI home care services for Japan’s business market 

In Japan, the elderly population was recorded at 36.2 million, making up 29.1% of the total population in 2023 [1]. Long-Term Care Insurance (LTCI) act is a public insurance system managed by local governments. The LTCI system was established in 2000. It is funded equally by public insurance premiums and taxes. The system covers all elderly individuals aged 65 and over, as well as those aged 40-64 who have long-term care needs due to specific diseases [2]. However, local governments in Japan do not directly provide public home care services. Instead, LTCI home care services, such as home help services, visiting nurses, home visit bathing, and day services, are managed in the business market. 

Aging in place can be achieved if 24-hour home help and visiting nurses can provide care at a person’s residence, allowing them to continue living in their community. However, delivering care services at night to people in various housing locations can be challenging. To address this, the Ministry of Health, Labor and Welfare (MHLW) launched a new service to strengthen home help services during nighttime hours. The newly introduced 24-hour routine home-visit services began in 2023 [3]. Then, what is the difference between the existing home help service and the new 24-hour routine home visit service? 

Home Help services are primarily provided during the daytime, as regulated by the care plan. For example, 60 minutes twice a week is a common option. The LTCI service fee for home help is reimbursed on a per-service basis, depending on the service hours and the type of care provided (personal care or practical help). A 24-hour routine home visit can offer home help services, visiting nurse services, and alarm call support 24/7. LTCI service fees for these visits are set on a one-month comprehensive payment based on the citizen’s care level. Regarding visiting nurses, there are two types of providers: integrated type providers, who employ both home helpers and nurses, and cooperative agreement type providers, who outsource nurses (Figures 1-3).

 Figure 1: LTCI services in Japan.

Figure 2: New home help service to strengthen night visits.

Figure 3: 24 hour routine home visit.

Flexible arrangements based on individual needs include short and frequent visits, such as 10 or 20 minutes, five times a day. The 24-hour routine home visit service provides home help and visiting nurse services multiple times a day, 24 hours a day, 365 days a year. Regular round visits support people’s daily lives. Additionally, alarm call setups and on-call visits are available [4]. 

This article focuses on the 24-hour routine home visit service, a crucial service that provides personal care and nursing to help people continue living at home for as long as possible. However, even though 10 years have passed since the service started, it is still not reaching the citizens effectively. Hence, the present research aims to analyze the current situation and gather suggestions for creating a 24-hour care service platform by private operators in Japan.

Purpose 

The present paper aims to achieve the following objectives:

• To investigate the challenges faced by private care providers in delivering 24-hour home care
• To explore different family structures and their approaches to family care
• To develop a 24-hour home care platform in collaboration with private care companies, inspired by Denmark’s model 

Research Method 

Initially, I examined the current number of 24-hour routine home visit service providers by analyzing data from the 2022 Report on the Status of Long-Term Care Insurance Operations (provisional). Next, I analyzed the delivery of 24-hour routine home visit services in a specific area of Tokyo using WAM Net (accessed on 2024-08-13). I plotted the provider offices on a map of Tokyo and identified areas lacking 24-hour routine home visit services. Then, I used the national report, Comprehensive Survey of Living Conditions 2022, to determine the family types of households with members aged 65 years or older and to identify the main carers. Finally, I conducted interviews on March 13, 2024, with officials from municipalities in Aarhus, Denmark, who have contracts with private care providers. The goal was to understand how local governments regulate and support private care service providers. 

Ethical consideration 

The present qualitative research study was approved by the Ethics Committee of the Faculty of Welfare and Social Design at Toyo University (Approval No. F2023-015S). The interviewees were contacted in advance via email, which included a request for research cooperation, the research plan, and ethical considerations, all provided in English. Informal consent for participation was obtained through these emails. Interview dates and times were then scheduled. At the time of the interview, the purpose of the research was explained to each interviewee, formal consent was obtained, and a written informed consent form in English was signed.

• Number of care providers for 24-hour routine home visits in 2022 

Based on my previous studies, in 2017, 804 municipalities (51%) out of 1,572 in Japan had 24-hour routine home visit services (as of October 2017). This means that 49% of the municipalities did not have such services (according to the Ministry of Health, Labour and Welfare, A Survey of Institutions and Establishments for Long-term Care, 2017). When examining the number of users, 481 municipalities had 10 or fewer users (Report on the Status of Long-term Care Insurance Operations (provisional), Table 4-2-1, January 2019) [5]. The delivery area for 24-hour routine home visits was limited. 

In 2022, there were 1,255 providers of 24-hour routine home visit services, even though 10 years had passed since the service was introduced. In contrast, there were 36,420 home-help providers and 14,829 nursing visit providers (as of October 2022) [6]. In contrast, as of October 2022, there were 36,420 home-help providers and 14,829 nursing visit providers [6]. Despite being introduced a decade ago, the 24-hour routine home visit service has not reached many citizens. 

• Blank service area for 24-hour routine home visits in Tokyo 

I examined the list of 24-hour routine home visit providers in Tokyo using WAM Net [7]. As of August 2024, there were 107 providers. I plotted the provider offices on a map, color-coding them to identify areas lacking 24-hour routine home visit services. The map revealed that the service areas are quite limited. Even though there are several providers, each one typically covers a service area with a radius of 4 km or a travel time of 15 minutes. Consequently, the coverage appears to be quite limited and localized (Figure 4).

 Figure 4: Map: Blank service area of 24-hour routine home visits in Tokyo.

• Family types of households with members aged 65 or Over 

Family size and structure are changing in Japan. In 2021, the total number of households was 51,914,000. Families are becoming smaller, with the average household size being 2.37 persons. Regarding the elderly population (65 and over), there were 25.809 million households with at least one person aged 65 or over, accounting for 49.7% of all households [8]. Among these households, aged couples made up the largest proportion at 8.251 million (32.0%), followed by single-living elderly at 7.427 million (28.8%), and aged couples living with an unmarried child at 5.284 million (20.5%) [9]. The number of single-living elderly and aged couples has increased. The number of three-generation households has decreased from 15% in 1986 to 5% in 2021. However, nearly 40% of all families have both children and elderly people living together (including aged couples with an unmarried child, elderly with an unmarried chil and three-generation households) (Figure 5).

 Figure 5: Family types of households with members aged 65 and older in Japan from 1886- to 2021.

Source: Ministry of Health and Welfare Japan, 2022. Comprehensive Survey of Living conditions. (https://www.mhlw.go.jp/toukei/saikin/hw/k-tyosa/k-tyosa21/index.html)

• Who is the main Carer? 

Those who are certified as requiring support or care under the LTCI act and who live at home hereafter referred to as persons requiring care, etc. Households with individuals certified as requiring support or care under the LTCI act (hereinafter referred to as ‘persons requiring care, etc.’) were surveyed to determine who their main caregivers were (n=100,000) (Figure 6). Those who are certified as requiring support or nursing care under the LTCI act and who are at home hereinafter referred to as individuals requiring nursing care, etc. The results of the survey of primary caregivers in households with individuals certified as requiring support or care under the Long-Term Care Insurance Law (hereinafter referred to as ‘persons requiring care, etc.’) are shown in the figure below.

 Figure 6: Who is the main carer?

A total of 57.7% of respondents said that family members were the main caregivers. The breakdown is as follows: Husband or wife 23%, Children living together 16.2%, Children living separately 10.2%, Children-in-law living together 5.4%, Children-in-law living separately 0.9%, Parent 0.1%, and other family members 1.8% [8]. By children-in-law, it means that the son’s wife takes care of the son’s elderly parent. Surprisingly, the situation was that children living separately, and even children-in-law living separately, were the main caregivers. 

• How local governments regulate and support private care service providers in Aarhus, Denmark 

In Denmark, tax-funded “public-public platforms” have been fully implemented in all municipalities, providing free care services through 24/7 helper agencies and home nursing services. Moreover, private providers began entering the home help service sector in 2003 [10,11]. Aarhus Municipality has a total population of 360,846 (as of January 1, 2023), with 54,847 residents aged 65 and over. On the Aarhus municipal website, under the title Sammen om et bedre liv (Better Life Together), the municipality provides its citizens with information on policies, types of services, and the extent and timing of these services. The report offers basic information on healthcare services, including policies, types of services and how and when they are provided to citizens [12]. 

An interview about how local governments regulate and support private care service providers was conducted on March 13 at the Aarhus municipal office in Denmark. The interviewee was a municipal official responsible for managing contracts with private care providers. 

• The interviewee stated 

Small private providers can outsource night services to larger providers in Aarhus. The municipality is divided into three parts, and the offices decide which areas to serve and provide services in a limited area. Private providers can access citizens’ journal information, allowing them to read, write, and share day and night information. Multi-professionals fill in the same journal. Aarhus municipal nurses undertake the nursing visits, so private providers do not need to employ their own nurses (from an interview on March 13, 2024).

Family care remains the norm in japan 

Why is home care for the elderly mainly provided by relatives in Japanese society? To answer this question, we may need to consider the following factors:

• The elderly’s will: They prefer to stay at home as long as possible
• Family’s love, responsibility, history and trusted relationships
• Traditional values and beliefs: Family care is considered the best way
• Norm: It is expected that care for aged parents should be provided by their children
• Pressure from society: Caring for parents is seen as a duty passed down through generations
• Stigma: It is viewed negatively to send parents to a nursing facility
• Financial reasons: Family care is free of charge, whereas social services can be expensive 

Why 24-hour routine home visits are not commonly used and widespread 

The reason 24-hour routine home visits are not widespread can be seen as a chicken-and-egg situation. These services aren’t commonly used due to limited availability. Moreover, providers don’t start offering this service because there aren’t enough users. As a result, people who need care and their families often don’t know about 24-hour home visit services and instead look for care facilities. For providers, there are significant barriers to entering this business. These include financial deficits, a long time to become profitable, and the need for a high level of expertise. It’s not an easy business to enter. 

The business won’t be able to sustain itself until it reaches a profitable level. The proportion of profitable establishments increases when the number of users reaches around 15. There is a mix of loss-making and profitable establishments up to around 30 users, and this mix continues when the number of users exceeds 30 [13]. Takashi Goto estimates that the potential demand for night-time home care will grow if there is a market for it and it is viable as a business. Additionally, the demand will increase if there is a system in place that maintains the quality of care and enables helpers to provide the necessary care [14]. 

There is a shortage of care staff for night shifts. To increase staff numbers, profit is essential. However, it’s challenging to employ staff without profit. This creates an unsolvable loop: providers can’t contract with users if they don’t have enough staff, but they can’t hire more staff without making a profit. In large service areas, driving time reduces the time available for visits. The key is to route visits efficiently and maximize the number of visits in a small area. Users might be seriously ill, requiring care staff with high levels of knowledge and skill. If some users are admitted to the hospital or pass away, rearranging the visiting routes becomes a puzzle-like and time-consuming task. Additionally, the expenditure for employed staff is constant, but income fluctuates widely, easily leading to financial losses. Currently, managing these challenges is very difficult. 

• Building a 24-hour home care platform with a private care company: lessons from Denmark 

In Japan, there are many difficulties in establishing a 24-hour home help and home nursing system in the business market. Both home help providers and visiting nurse providers must compete with each other and make a profit to continue their services. Private providers need to employ staff and maintain their own databases. Information about citizens is kept at the office and not shared with other providers, leading to fragmentation. Small-scale providers cannot deliver services at night. 

In Aarhus, Denmark, small private providers can outsource nighttime services to larger providers. Aarhus Municipality has divided the municipality into three separate areas, with each operator determining its service area and providing services in a limited number of areas. Private operators have access to citizens’ logbook information. Day and night information is read, written and shared. Multiple professions fill out the same logbook. A nurse from the city of Aarhus provides home nursing care. In Denmark, private providers do not need to employ their own nurses. 

Needless to say, it’s a challenge to replicate the Danish way as the systems in Japan and Denmark are designed very differently. However, the Danish system offers valuable insights on how private providers can enter the 24-hour home care market. Local governments play a crucial role. They should create networks to support private providers, strengthen the foundation of 24-hour home care, and gradually build a 24-hour care platform. This approach will help transition from family care to social care. We must move forward.

The newly introduced 24-hour home visit service in Tokyo faces several challenges. These include limited delivery areas, staff shortages at night, and maintaining the quality of care. Currently, family members are still primarily responsible for elderly care. To transition from family care to social care, local governments should develop a platform, build networks, support private providers, and strengthen the foundation of 24-hour home care services.

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