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Aim: When elderly people return to their daily lives after inpatient treatment, they may be offered a chance to change the residence to which they are accustomed. The present study clarified the changes in the residence of elderly patients through an Integrated Community Care Ward (ICCW)., Subjects and Methods: Patients were admitted to and discharged from the ICCW (53 beds) of Hospital A, located in a city with a population of 30,000 and an aging rate of 37%, for 2 years from April 1, 2018, to March 31, 2020. Patients ≥65 years old were included in the study. We conducted a retrospective survey of information recorded in the electronic medical record system and collected information on activities of daily living, medical procedures at the time of discharge, residence before and after hospitalization, and intentions regarding discharge destination within seven days of hospitalization., Results: Of the 735 patients ≥65 years old who were admitted to the ICCW, 608 were included, excluding 127 patients admitted for scheduled surgeries. The average age was 82.9 years old, with 52% being over 85 years and 26% being over 90 years old. Of the 465 people hospitalized from home, 64% were discharged, 23% changed to a facility or hospital, and the remaining 13% died. More than 80% of the 143 discharged from facilities or hospitals returned to facilities, but 36 (25%) were discharged to a different facility from before admission. Of the 404 patients who were admitted from home and discharged alive, independence in eating, independence in movement, and having family members living with them were independently related factors for achieving discharge home. Regarding the intended discharge destination within 7 days after hospitalization, of the 246 hospitalized patients who wished to be discharged home, 56 said they wanted to be discharged to a facility or hospital, showing a discrepancy of 23%., Conclusions: Many elderly people changed their residences after admission to the ICCW. While coordinating disagreements within families as well as navigating medical and nursing care constraints, dialogue across multiple professions should be continued to help elderly patients live their own lives.

For terminal-phase cancer patients, being discharged from a palliative care unit(PCU)is often challenging. To explore this reason, we compared patients who went home alive from the PCU with patients who died in the same unit. Among the survival cases, the average duration from their diagnosis to admission into the PCU was longer. Their slow progressions might allow them to leave the PCU. Patients with head and neck cancer were more often among those who died in the PCU, and the ratio of patient with endometrial cancer was higher in the survival cases. These ratios were relevant to the duration before their admission and variety of their symptoms.

In addition to electroencephalogram (EEG), arterial spin labeling (ASL) perfusion images with the dual postlabeling delay (PLD) method are useful for evaluating the hemodynamic state of status epilepticus (SE). A 72-year-old man suffered from an acute infarction in the right occipital lobe, resulting in SE with general periodic discharges on EEG with a higher amplitude on the right side. On ASL, blood flow was increased at a wide area of the right hemisphere centered on this infarct. With improvement of SE, sequential ASL with dual PLD method clearly demonstrated not only the reduction of the signal both in intensity and area but also the decrease of the blood flow velocity.

Objective　Tuberculosis (TB) patients are discharged after confirming their non-infective status. However, elder-care facilities often refuse to admit discharged TB patients. As no study has investigated anxiety among elder-care facility employees, we aimed to identify anxiety-associated factors among elder-care facility employees regarding the post-discharge admission of TB patients who have completed inpatient treatment.Methods　Among the 74 elder-care facilities under the jurisdiction of the Ibaraki Public Health Center in Osaka, Japan, (we excludes facilities that provided only daycare services), and invited all 3,213 employees of the remaining 70 facilities to participate in this questionnaire-based survey. Copies of an anonymous, self-administered questionnaire were mailed to the manager of each facility and were further distributed among employees. Responses were initially collected individually and subsequently directly collected from each facility by a public health nurse at the center. The questionnaire items included: the presence/absence of anxiety, resistance, and/or a feeling of difficulty about admitting TB patients who had completed inpatient treatment ("anxiety"), age, sex, occupation, years of work, total experience caring for TB patients, and knowledge of TB. The correlation between the presence/absence of anxiety and each item was analyzed using the chi-square test.Results　Completed questionnaires were obtained from 1,950 employees (response rate, 60.7%), of which 1,290 without missing data for relevant items were analyzed. Anxiety was present in 987 (76.5%) respondents. A significantly higher proportion of anxiety was observed in relation to the occupation (care workers and helpers), experience of caring for TB patients (respondents without such experience), and among employees who incorrectly answered questions on knowledge of TB, such as the infectiveness of TB patients after discharge, their management, and the risk of developing TB following infection.Conclusion　The study identified anxiety-associated factors among employees of elder-care facilities about admitting TB patients who had completed inpatient treatment for TB. Therefore, anxiety-mitigating environments may need to be established for such employees to facilitate the admission of discharged TB patients and their smooth return of patients to their pre-TB lives.

A 71-year-old man had persistent cervical pain secondary to thunderclap headache during sleep. MRI conducted the next morning revealed subdural hematoma and convexity subdural hemorrhage on the right occipital region, and the patient was hospitalized. MRA showed vascular narrowing in the bilateral PCA. Follow-up MRA on day 8 of admission showed aggravated vascular narrowing of PCA, indicative of reversible cerebral vasoconstriction syndrome (RCVS). The patient was treated with a calcium-channel antagonist. Post-discharge MRA showed improvement of PCA narrowing, and the diagnosis of RCVS was confirmed.

A 75-year-old man with a history of temporal lobe epilepsy (treated with levetiracetam) was transferred to our hospital because of loss of consciousness. At admission, he was drowsy and exhibited myoclonus on the left side of face. We established a diagnosis of status epilepticus and started treatment with levetiracetam, fosphenytoin, and midazolam. FLAIR and DWI showed hyperintensity in the right cerebral cortex. Electroencephalography (EEG) showed lateralized periodic discharges (LPDs) at the right hemisphere, indicative of non-convulsive status epilepticus (NCSE). He regained consciousness after treatment with anti-epileptic drugs but showed persistent LPDs in EEG. MRI arterial spin labeling (ASL) showed normal perfusion in the right hemisphere; therefore, he was deemed to have recovered from status epilepticus and transferred to the rehabilitation hospital. MRI ASL is useful for diagnosing recovery from NCSE irrespective of sustained periodic discharges on EEG.

Aim: To clarify changes in location before hospital admission and discharge destination over the 10-year period of 2010 to 2020 and to identify prognostic factors associated with the survival in hospitals with chronic-phase inpatients., Methods: The subjects were patients newly admitted to 12 hospitals in 2010 and 2020. The age, sex, location before hospital admission, outcomes at 90 days after admission, discharge destination, and results of 6 biochemical tests at admission were evaluated. A survival analysis was performed for the age, sex, and biochemical tests at admission., Results: We analyzed 8007 newly hospitalized patients. Compared with 2010, there were more hospital admissions from acute-care hospitals and fewer admissions from long-term-care facilities in 2020. In addition, relative to 2010, regarding the outcomes at 90 days after admission, there were more discharges to home and residential facilities in 2020, fewer discharges to long-term-care facilities, and lower mortality rates. In the survival analysis, a multivariate analysis revealed that an elderly age, male sex, low albumin, high total cholesterol, high urea nitrogen, and low serum sodium were poor prognostic factors. These five variables were consistently poor prognostic factors in both 2010 and 2020, and Kaplan-Meier curves showed that the scores were dose-dependent prognostic factors for a poor survival., Conclusions: The present analysis of pre-admission location and discharge destination in hospitals with chronic-phase patients revealed an elderly age, male sex, high urea nitrogen, low serum sodium, and low albumin at the time of admission to be strong predictors of poor outcomes in these patients.

The coronavirus disease 2019 (COVID-19) infection has spread worldwide, with no sign of its control in Japan yet. Eight elderly COVID-19 patients over 90 years of age were treated at our hospital. We herein report three cases with characteristic progression. Case 1 was a 91-year-old female patient diagnosed with bacterial pneumonia previously who did not show improvement with medication; thus, she was transferred to our hospital 16 days after the onset. She was diagnosed with COVID-19 using the SARS-CoV-2 polymerase chain reaction (PCR) test. Favipiravir, methylprednisolone, and unfractionated heparin were administered, but she only tested negative 68 days after the onset, at which point she was discharged. However, she was transferred back to our hospital 80 days after the onset since she tested positive again. She was transferred to another hospital 110 days after the onset without testing negative. Case 2 was a 102-year-old female. Despite being a mild case, it took 32 days to obtain negative PCR findings, leading to a decline in the activities of daily living. Case 3 was a 90-year-old male patient treated with favipiravir, dexamethasone, and unfractionated heparin, but his condition deteriorated. He never tested negative for PCR and ultimately died 20 days after the onset. Reports suggest that PCR positivity does not necessarily indicate infectivity, but there are no clear criteria for lifting a quarantine. Therefore, PCR negativity is often sought for "peace of mind." In the current situation where hospitals are fully occupied, clear criteria for lifting the quarantine should be promptly determined. After the completion of treatment, it is more important to monitor symptoms and take standard precautions, such as daily health monitoring, wearing a mask, and keeping an appropriate distance from others, than to obtain a negative PCR result.

Aim: The controlling nutrition status (CONUT) score assesses the nutritional status of subjects by considering the serum albumin level, total lymphocyte count, and total cholesterol level. We estimated the efficacy of total parenteral nutrition for improving the nutritional status and zinc deficiency., Methods: In total, 493 elderly inpatients who were admitted to the internal medicine department of an emergency hospital over 7 years were divided into 2 groups: patients who were discharged (320 patients) and those who died in the hospital (173 patients). The discharged patients were further divided to four groups according time of discharge from the hospital; oral nutrition, enteral nutrition, peripheral parenteral nutrition, and total parenteral nutrition. Using analysis of variance (ANOVA), we compared the albumin and zinc levels and the CONUT score within 10 days post-admission and before discharge from the hospital., Results: Japanese society is rapidly aging. In patients who were leaving the hospital, the CONUT score improved with oral and enteral nutrition. The zinc level improved with oral, enteral, peripheral parenteral, and total parenteral nutrition. While the nutritional status of patients at the time of discharge improved with oral and enteral nutrition, total parenteral nutrition without oral or enteral nutrition did not improve the status., Conclusion: To discharge patients alive, efforts must be made to continue oral and enteral nutrition for as long as possible.

Introduction: Chronic subdural hematoma(CSDH)is a common condition encountered by neurosurgeons. Owing to increasing life expectancy and rapid population aging, the age at disease onset is delayed, which negatively affects hospital discharge arrangements. This retrospective study investigated patients aged ≥90 years who underwent surgery for CSDH., Subjects and Method: The study included 53 patients diagnosed with CSDH(63 sides)for the first time, who underwent surgery at our hospital between April 2018 and March 2019. The mean age was 78.7 years, and the study included 40 men. A subdural drain was placed after burr hole surgery performed for hematoma evacuation and lavage. The basic protocol included 8-day hospitalization comprising surgery on the day of admission, rehabilitation initiated the day after surgery, and suture removal 7 days after surgery, followed by hospital discharge. The 'elderly' group(Group E)included patients aged ≥90 years, and the 'others' group(Group O)included patients aged <90 years. This study focused on hospital discharge arrangements., Results: The mean length of hospitalization was 7.6 days in 10 patients(19%)in Group E. The rate of intervention by a discharge support nurse or medical social worker(Medical Consultation Team)was 100% in Group E and 65% in Group O. All patients were discharged to planned living arrangements with the assistance of the Medical Consultation Team and rehabilitation intervention., Conclusion: Among elderly patients, difficulties with hospital discharge arrangements could be attributed to exacerbation of dementia symptoms after hospitalization and manifestations of disuse syndrome and complications. Surgical treatment can be offered to patients with CSDH regardless of age(even to those aged >90 years)and facilitates smooth discharge with multidisciplinary intervention.

A 74-year-old man with aspiration pneumonia was admitted in the internal medicine department. CT revealed progressive carcinoma of RS-Ra, which became the focus of intervention after the pneumonia was treated. After having been allowed temporary discharge, the patient was rehospitalized for surgical operation and rehabilitation. During the perioperative period of cancer patients, we use body distribution data for teaching and environment setting, which is a useful tool in rehabilitation. Rectal cancer was observed after hospitalization for pneumonia, presenting an interesting case. Therefore, care needs to be taken as body pressure distribution may be modified by comorbidity.

Recently, palliative care units are required to provide home-care support. In our palliative care unit, we support withh ospital discharge according to patient's wishes. In 2 years since April 2016, 104 of 536 hospitalized patients were discharged home (home discharge rate 19.4%). Among these patients, 30 died at home. Using the cases of the 30 patients, we investigated proper discharge and home-care support. As a background factor, the existence of"care by a woman"and"opioid unused" was likely to facilitate death at home. The patient was widely introduced to 18 clinics in the local area, not a specific medical institution. As reasons for home discharge,"Advanced understanding of medical condition" and"Recognition of the goodness of home"was cited. The median time from discharge to death at home is as short as 14 days, and so cooperation between the hospital and the home medical team is indispensable. To that end, the hospital guarantees emergency hospitalization, and the home medical team needs to accept discharge of the patient who is approaching death.

In this study, we considered the role of home care support clinics for patients who wanted to go back to their homes from a hospice, duringa pre-discharge conference. The subjects of our study were 8 patients, of which 7 of them had cancer. Two patients died after the conference. These patients were discharged from the hospice three days after the conference and caregivers from the home care support clinics visited their homes 24 hours after their discharge. The clinic has a role to fulfill in terms of medical treatment and support, based on their life style and power of caregiving. We considered an advancedmeetingwith family or caregiver benefits in the conference. Further, the clinic has a role of establishinga relationship with each multi-disciplinary care unit and cooperate with them as soon as possible when needed.

Palliative care for cancer patients requires information sharing, including prognoses, to fulfill the wishes of the patient and patient's family as well as to avoid wasting time. It is necessary to recognize the importance of the pre-discharge conference and home medical care to realize the wishes of the patient and the patient's family.

Due to promotion of home medical care, the number of patients who highly depend on medical care is increasing. Therefore, the role of pre-discharge conferences where a care manager is involved starting from pre-discharge support has become more important. In addition, in a usual relationship, cooperation between the hospital staff and the home care support team is crucial. Among home care workers, the word "coordination" has generally been used for a long time to prepare for the transfer of patients from a hospital to home. However, there is a considerable gap between healthcare and caregiving; consequently, it is difficult to actually create coordination between them because the terms to be used and the contents mastered by personnel in each field are different. In this paper, we report a case of successful coordination for smooth transfer of a patient with ALS from a hospital to home, by creating a homecare team in which all members work together based on the information obtained from a hospital social worker.

Shortened hospitalization periods result in an increase in discharged patients with a lack ofself -care agency and families with lower caring ability. The role ofoutpatient nurses becomes more important in such situations. In this study, to clarify the role played by outpatient nurses, we surveyed them about their actual situation ofhome care support and awareness of regional cooperation. Subjects included outpatient nursing managers ofgeneral hospitals with inpatient facilities publicized in Osaka Prefecture; for the survey, questionnaires were sent to them via mail. The questionnaire collection rate was 16.5%. Regarding issues related to outpatient nursing, insufficient manpower was the most frequent response. Although efforts to provide nursing care have been made, such as the use ofmedical professionals and the arrangement ofcertif ied nurses and specialized nurses, the actual situation was clarified with difficulty to ensure nursing quality such as working shifts of the staffs and arrangement standard. Reasons why nursing quality cannot be ensured included the following: readiness of the patient cannot be understood, time cannot be ensured because ofthe large non-nursing workload, and nursing volume cannot be determined. Although efforts such as arrangement of certified nurses and establishment of outpatient sections for nursing were found to ensure nursing quality, insufficient regional cooperation was clarified with issue of nursing cooperation inside hospitals. This situation was considered to be influenced by large nursing-related workload, such as shortened waiting time, concentrated treatments, and smooth functioning.

Due to the rising number of patients at the terminal stage or with high dependence on medical care, the cooperation of 2 teams, the hospital discharge support team and the home support team, has become very important. The recent spread of the Internet has enabled both patients and their families who have chosen home care to obtain a wide range of information about home services, as well as diseases, and form a picture of what will happen. However, there are actually many cases in which patients and families find that things are not as they imagined, and they are uneasy and unsure of what to do. Here, we report a case in which the mismatch between the patient's and family's expectations created an unsatisfactory care situation.

We conducted questionnaire surveys focusing on the"actual situation of cooperation between discharge nurses and homevisiting nurses etc. from transition to home-care through the terminal phase in terminal cancer patients."As a result,discharge nurses were employed at acute-stage hospitals to practice discharge adjustment. Medical staff in home care and home care workers continuously supported the patients and their families in managing difficulties such as changes in pathological conditions and care-related anxiety after the patient was discharged. Amidst these efforts,over 80% of home-visiting nurses thought that there was some disagreement about the understanding of pathological conditions between the hospital medical staffs and the patients/their families while shifting to home care(immediately after shifting to home care). It was also clarified that the informed consent for and instructions regarding discharge according to individual patients and families were insufficient.

An 88-year-old man, 155 cm in height and 45 kg in weight, was scheduled for total stomach extirpation. Partial cerebral infarction and cerebral arterial stenosis were diagnosed 20 days before the operation. The patient's mean arterial pressure was 80 mmHg. Regional brain 0₂ saturation (rSO₂) obtained via non- invasive monitoring using the INVOS™ system was above 65% on both sides, and these were used as con- trol values before anesthesia induction. Anesthesia was induced with propofol 50 mg and rocuronium 40 mg intravenously after thoracic epidural catheter placement. Throughout the operation, mean blood pressure was over 70% of the control value. Stroke volume variation (SVV) was tracked during the operation by arterial pressure-based continuous cardiac output monitoring (FloTrac™); SVV values under 13 were maintained using vasopressors and fluid loading. The rS0₂ levels were consistently above control values on both sides. The operation was completed as a gas- tric-bypass surgery and the patient was discharged from the hospital without complications. Using the INVOS™ and FloTraTM systems to maintain mean pressure over 70% of the control value may have prevented a new cerebral ischemic event This potentially useful application of the INVOS™ and FloTrac™ systems should be validated in future stud- ies.

Objective　The aim of this study was to investigate the association between economic status and discharge destination of elderly patients from acute care hospitals.Method　We conducted a case-control study using data from a survey of elderly discharged patients conducted under the subsidy program of the Japanese Ministry of Health, Labour and Welfare. The questionnaires were mailed to 1,068 acute care hospitals located in the Kanto and Kansai region. The survey asked medical social workers or nurses, who were responsible for the discharge planning, to answer questions about the discharge of elderly patients from their hospitals. The survey included questions about discharge destination, economic status (how much the patients could afford for their care and living per month), family members living together, primary caregivers, physical status, and dementia status for each discharged patient.Results　We analyzed the data for 565 patients from 179 hospitals, of which 293 patients were discharged to their home and 272 patients were discharged to long-term care facilities. Patients who could afford to spend less than 100,000 yen per month were six times more likely to be discharged to their homes than patients who could afford to spend 100,000 to 150,000 yen per month (OR: 6.48, 95% CI: 2.50-16.79). Patients who could afford to spend more than 150,000 yen per month were 70% less likely to be discharged to their homes than patients who could afford to spend 100,000 to 150,000 yen per month (OR: 0.29, 95% CI: 0.12-0.69). Half of the patients who could afford to spend more than 150,000 yen per month were not discharged home, and instead selected private and expensive long-term care facilities.Conclusion　We observed an association between economic status and home discharge from acute care hospitals. As the monthly expenditure capacity of the elderly patients decreased, the likelihood that they were discharged to their homes increased. This suggests that elderly patients, who are economically disadvantaged, may select discharge to their homes due to limited options for discharge destinations that fit their budget. The Japanese government should arrange more low-cost facilities and home care services for low-income elderly patients.

The aging society has arrived, and home care options are being promoted. To date, because of an increase in the number of patients with higher disability levels in greater need of medical help and senior people living alone or in senior-person households, more patients are in need of discharge support. Many medical institutions cannot consider the option of staying at home and receiving home care services for such patients, and such patients often give up on going home. In the case of service recipients suffering from incurable diseases or disabilities and undergoing age-related changes, it is necessary that they decide on their own"where and how they want to live."For their decision to be respected, a key is collaboration with those who support patient discharge from the hospital and those who support patient home care. This paper explores a patient appropriate for level-3 care with brain hemorrhage and paralysis of the left half of the body. This patient required supportive and adaptive devices, a cane for walking, and constant observation. In consideration of the wishes of the patient and his family, he was allowed to go home.

Governmental policies recommend the palliative care at home for cancer patients. However, there are some barriers to discharge cancer patients from the hospital who want to receive end-of-life care at their homes. Anesthesiologists whose main job is to perform general anesthesia in the operating theater usually have little contact with general practitioners giving community palliative care. So it is important to communicate each other to make opportunities to discuss an organized system and care plan for these patients, and to improve information transfer.

Aim: To investigate the current status of elderly dementia patients with physical illnesses and identify optimal care strategies for this growing population., Methods: This retrospective study included elderly dementia patients who (i) received in-patient treatment for a physical comorbidity at the dementia ward of the Juntendo Tokyo Koto Geriatric Medical Center, and (ii) who were discharged from April 2009 to March 2011., Results: The study population was 390 patients (144 males, 246 females), with a mean [±SD] age of 80.5 [±8.1] years. Two hundred thirteen of the patients had Alzheimer's disease; the remaining 177 had other types of dementia. The comorbidities necessitating admission were: malignant neoplasms (n=65), respiratory conditions (n=57), genitourinary conditions (n=50), trauma or fracture (n=41), and other (n=177). Among the 239 subjects who were hospitalized from their homes and who were discharged alive, 157 (65.7%) returned to their homes. The hospital stays of patients who were discharged were significantly shorter (P<0.000) and their N-ADL scores were significantly better at admission (P<0.013) and at discharge (P<0.000). The proportion of subjects who were capable of oral ingestion was significantly higher among the patients who were discharged to their homes (P<0.025). The subjects who lived in their homes alone at the time of hospitalization were significantly less likely to be discharged to their homes (P<0.018)., Conclusions: Elderly dementia patients should ideally return home after hospitalization for comorbid illnesses. This was facilitated by minimizing their hospital stay. During in-patient treatment, efforts should be made to maintain their N-ADL levels and support their oral intake.

The purpose of this study was to investigate the effect of a discharge planning educational program on multidisciplinary team staff in a community. We provided training to nurses of a university hospital. The training covered an introduction to discharge planning, decision-making support, home care medicine and home nursing care, the medical social welfare system, and case review meetings. It was conducted every year from September through February between 2012 and 2015. Before and after the training, the awareness of nurses was evaluated by using self-administered questionnaires and the Discharge Planning scale for Ward Nurses(DPWN), and discharge planning satisfaction was measured using a visual analogue scale (VAS). The study process was reviewed and approved by the Ethics Committee of Tokyo Women's Medical University. The questionnaires were distributed to 96 nurses; of these, responses of 72 nurses(pre- and post-training)were analyzed(response rate: 75.0%). The average number of years of nursing experience was 8.5± 7.7. The total score of the DPWN and its subscales, as well as the VAS, with regard to satisfaction level significantly increased after the training(p<0.01), indicating that training improved nurses' awareness of discharge planning practices.

The objective of this study is to understand the issues and solutions considered by certified nurses(CN)in palliative care (hereinafter referred to as"palliative care CN)regarding discharge support and regional cooperation for cancer patients, and to discover the roles and responsibilities of palliative care CN. Data obtained from training sessions for 22 palliative care CNs was reconfigured and analyzed. As a result, problems related to discharge support and regional cooperation for cancer patients were classified into 13 categories and 3 core categories. The following roles for palliative care CN were proposed to promote discharge support and regional cooperation for cancer patients: (1) Inter-professional sharing of knowledge about patients and their families to reconcile the intentions of the patient and family members with predictions of progression of the illness; (2) Enable hospital nurses to obtain information about patients after discharge in order to establish a clear image for medical treatment; and(3) Support for ward nurses regarding cooperation to alleviate symptoms and offer medical care to patients who are highly dependent on medical care, and to become a point of contact for cooperation with visiting nurses.

The government has taken a variety of measures to actualize the basic philosophy of the policy for"shifting medical treatment under hospitalization to regional medical treatment". The problems associated with mental disorders requiring long-term psychiatric treatment and reducing psychiatric beds have been discussed from various viewpoints. Although the transfer of psychiatric medical treatment to regional medical treatment is taking place, it is true that some large barriers exist. According to research on the actual situation in 1954, 1,300,000 psychiatric disorders were estimated, including 350,000 disabilities requiring hospitalization, and mental beds available increased up to a maximum of 350,000 with government subsidies. In 1987, mental bed availability was controlled according to the local healthcare program. As a result, periods of psychiatric hospitalization became prolonged due to factors including social prejudice and the inadequacy of rehabilitation centers; it was called "social hospitalization". Nevertheless, it is true that private psychiatric hospitals have successfully provided various psychiatric medical services in order for people with disabilities to be able to live in the community. The Program for Dissolution of Social Hospitalization of Psychiatric Disabilities in 2000 started in Osaka. The Ministry of Health, Labour and Welfare started the Program for Hospital Discharge Promotion of Psychiatric Disabilities as a model program in 2003. This program was included in the Regional Life Support Program in Prefectural and City Governments, and expanded throughout Japan in 2006. The Regional Shift Support Special Action Program of Psychiatric Disabilities was started in 2008. The report of the "Symposium for Ideal Future Psychiatric Medical Welfare" as compiled in September 2009, and the target value was indicated there. Various measures were implemented in order to promote the basic philosophy for "shifting medical treatment under hospitalization to living in the community". In 2012, the Japan Psychiatric Hospitals Association, joined by the private psychiatric hospitals responsible for medical treatment under hospitalization, set forth their basic polity for "shifting medical treatment under hospitalization to regional medical treatment and medical care" as part of "Future Vision of Psychiatric Medical Treatment".

In the final stages of cancer, home care becomes difficult because the patients face reduced physical strength and energy, people around them have physical and mental fatigue, and available medical treatment options are exhausted. Although there are many underlying factors, prolonged depression is also mentioned as a cause of the difficulties of home care. This paper reports on one case in which we reaffirmed the most important factor of homecare - preventing a feeling of isolation for patients who wish to stay at home even if they are experiencing depression. Following in the steps of the many major hospitals that coordinate cancer treatment, we have posted multi-disciplinary staff at our Cancer Consultation Support Center and the Cancer Palliative Care Team to support a patient's lifestyle at home as long as possible even in the terminal stages of cancer with repeated shared decision-making with the patient and his/her family members.

After much debate about the nutritional management of patients at the time of discharge, the number of discharged patients receiving peripheral parenteral nutrition has increased. We investigated the nutritional management on discharge and the background of 2,636 patients discharged from Minoh City Hospital over 7 years from 2006. Of these, 55 patients (2%)received peripheral parenteral nutrition after discharge. In the years preceding 2010, ≤7 patients per year received peripheral parenteral nutrition after discharge, but this number increased to >10 after 2010. More than 60% of the patients were aged ≥80 years; more than 80% were discharged to a hospital. These patients had terminal-stage cancer or high-grade dysphagia, and they required end-of-life medical care. The patients' condition, knowledge of their care, and their view of life and death as well as the medical treatment environment influenced the choice of nutritional support. Correct information is necessary to take appropriate decisions regarding nutritional support.

Counseling for patients with cancer by a certified nurse in palliative care began in April 2011 in Minoh City Hospital. Counseling was provided immediately after a patient was informed by the treating physician of a primary diagnosis of cancer, a metastatic recurrence, or a decision to terminate cancer therapy. We examined the patient's support system after the counseling ended. The number of patients receiving end-of-life support with home or hospital care rapidly increased from 118 prior to the program's beginning to 186. The number of patients counseled was comparable to the rapid increase in their number(n=68). New cases in the outpatient department comprised 59% of all patients, of which, 45% began supportive counseling, with 43%of them ultimately returning home. Of the new cases receiving counseling in the hospital, 34%eventually returned home after discharge, and the highest percentage of discharges were to a palliative care unit or hospice program (48%). The initiation of counseling in the outpatient department allowed us to provide sufficient time to make decisions about appropriate places for end-of-life care. Cooperation with the patients' physicians was necessary to provide counseling from the outpatient department. Our findings suggest the importance of sharing the patients' medical and social information among the staff when necessary.

The Act to Partially Amend the Act on Mental Health and Welfare for the Mentally Disabled was passed on June 13, 2013. Major amendments regarding hospitalization for medical care and protection include the points listed below. The guardianship system will be abolished. Consent by a guardian will no longer be required in the case of hospitalization for medical care and protection. In the case of hospitalization for medical care and protection, the administrators of the psychiatric hospital are required to obtain the consent of one of the following persons: spouse, person with parental authority, person responsible for support, legal custodian, or curator. If no qualified person is available, consent must be obtained from the mayor, etc. of the municipality. The following three obligations are imposed on psychiatric hospital administrators. (1) Assignment of a person, such as a psychiatric social worker, to provide guidance and counseling to patients hospitalized for medical care and protection regarding their postdischarge living environment. (2) Collaboration with community support entities that consult with and provide information as necessary to the person hospitalized, their spouse, a person with parental authority, a person responsible for support, or their legal custodian or curator. (3) Organizational improvements to promote hospital discharge. With regard to requests for discharge, the revised law stipulates that, in addition to the person hospitalized with a mental disorder, others who may file a request for discharge with the psychiatric review board include: the person's spouse, a person with parental authority, a person responsible for support, or their legal custodian or curator. If none of the above persons are available, or if none of them are able to express their wishes, the mayor, etc. of the municipality having jurisdiction over the place of residence of the person hospitalized may request a discharge. In order to promote transition to life in the community by persons with mental disorders, efforts will be made to enhance psychiatric care for them, with guidelines to be developed to ensure the provision of medical care to persons with mental disorders. The revised law clarifies that members of psychiatric review boards shall be "persons with expert knowledge and experience pertaining to the health and/or welfare of persons with mental disorders." Provision is made for a review of conditions related to implementation of the revised law approximately three years after it takes effect, with measures to be taken as necessary based on results of the review. The main focus of this presentation will be the revisions to the system of hospitalization for medical care and protection, and the deletion of provisions relating to the system of guardianship.

Our nutrition support team (NST) designed the NST summary for cooperation among personnel providing medical care for nutritional management of high-need patients in our area. After the introduction of the NST fee under the health care system, the number of summary publications decreased. The requested NST fee is necessary for publication of a nutritional care plan and report upon patient discharge. We hypothesized that the nutritional care plan and discharge report were being substituted for the NST summary at the time of patient discharge. We retrospectively investigated 192 cases with NST fee. There were only 13 cases of overlapping publication, and the NST summary was necessary for 107 of 179 cases in which no NST summary had been prepared. Since the space on the report form is limited, it can provide only limited information. However, the NST summary can convey detailed supplementary information. Therefore, there is a high need for the NST summary, and publication of NST summaries for the appropriate cases must continue.

Discharge support, although provided for a limited time, is of vital importance in the acute phase care period. Such support is necessary to ensure continuity of care and treatment even after being discharged from the hospital. I acquired both the viewpoints of the family and the nurse of a patient who was about to be discharged from the hospital after cerebral hemorrhage. However, the patient's family and I were not able to decide on a home care plan or hospital-to-home transfer ahead of time because of the unstable condition of the patient, limited care power of the family, and varying discharge plans among the family members. I intended to help in the decision-making process, taking into consideration the patient's best interest. I evaluated the viewpoint of the family and was able to understand situations in which a family member, who assumes the role of a primary care giver, would need guidance in providing home care to the patient.

In the treatment of cancer, living at home for as long as possible is an important aspect. During home care, many patients experience symptoms of dementia, depression, adjustment disorder, and mental disorder. There are 3 critical stages: the initial announcement of the diagnosis of cancer, the announcement of the occurrence of relapse, and the announcement regarding the lack of effective treatment. Listening carefully to complaints of patients during all stages will be helpful. With regard to how palliative care for cancer patients is perceived, we encountered a case of a patient who showed adjustment disorders when his life expectancy was deemed too short. By paying attention to what the patient was saying, we were able to help the patient overcome the critical state and continue receiving home care. During the treatment of cancer, patients receive bad news several times. It is difficult to maintain mental stability at such times. As seen in this case, resolution of adjustment disorder in 10 days is very rare. However, the patient confessed that, during the course of treatment, psychological care was not given appropriately. The best treatments for cancer were provided. However, the patient did not know how to deal with anxiety. This is an example that elicits sympathy.

A discharge planning nurse at an acute care hospital conducted discharge planning for an elderly person with dementia who is in his/her 90s and his/her family. The nurse was involved in the choice of nutrition management method and was able to support the family's decision-making. The family had high expectations for oral ingestion, and there was disparity between those expectations and the actual state of the disease, in which aspiration occurred frequently. The nurse respected the family's wishes, but also helped the family to correctly understand the state of the disease and to make satisfactory choices about future daily life. In order to guarantee safety, the discharge planning nurse held a conference with people related to homecare, such as the home-visiting physician, the home-visiting nurse, and the care manager. As a result of the conference, that family was able to feel satisfied with and choose gastrostomy as the nutrition method. The current situation was better understood because information was shared with the community, and the confidence in the community was strengthened by giving consideration to the family's burden. It was reconfirmed that the cooperation of local staff members is useful in discharge planning.

We encountered cases of unresectable gastric cancer in which patients had difficulty with ingestion because of pyloric stenosis and diffuse invasion. We examined the improvement in the quality of life(QOL)of patients and the effect and usefulness of S-1 treatment in such cases. The median survival time(MST; 310 days)of patients who received S-1 as primary treatment was significantly longer than that(105 days)of patients who did not receive S-1 treatment(p=0.0001). Of the 25 patients who underwent gastrojejunostomy, S-1 was administered to 10 patients(MST: 384 days). The MST of patients who received drugs other than S-1 was 121 days. Thus, the MST of patients who did receive S-1 was significantly longer than that of patients who did not receive S-1. In univariate analysis, oral ingestion, performance status(PS), best supportive care(BSC), and S-1 administration were prognostic factors. Of these factors, oral ingestion(p=0.0278, hazard ratio[HR]: 2.992)and S- 1 administration(p=0.0002, HR: 14.956)were prognostic factors in multivariate analysis. Gastrojejunostomy is desirable for the treatment of cases of unresectable gastric cancer with poor ingestion. In addition, the use of postoperative chemotherapy with S-1 alone or with S-1 as combination therapy may help improve prognosis.

In Japan, abstinence has traditionally been considered the sole method of treatment for alcohol dependence. In recent years there have also been reports that a small percentage of alcoholics are able to regain control of their drinking, but thus far there have been few reports in Japan on reducing the amount of alcohol consumed in alcohol dependence. In the present study we therefore conducted a survey of outpatients who were examined on a certain day at 4 general hospitals in Okinawa Prefecture. Of the 421 examinees, 5% of the males and 4% of the females had a score of 20 or more on the Alcohol Use Disorders Identification Test (AUDIT) and were suspected of alcohol dependence. When those suspected of alcohol dependence were asked if they wanted to decrease their level of alcohol consumption, 90% of the males and 78% of the females replied that they wanted to reduce it. We also conducted a survey of the post-discharge outcome of alcohol-dependent inpatients at the National Hospital Organization Ryukyu Hospital. The Hospital is a psychiatric hospital that has a specialized unit for alcohol dependence, and treatment based on cognitive behavioral therapy is conducted there. The results for the outcome 1 year after their discharge from the Hospital of the 116 patients admitted for the treatment of alcohol dependence showed that 31% were able to remain abstinent, 61% were unable to remain abstinent, and 8% had died. The alcohol-related problems of some of those who were unable to remain abstinent had become mild, i.e., they had been able to return to work, their violent behavior while inebriated had improved, etc. Many alcoholics want to reduce the amount of alcohol they consume as a goal of treatment, and some of them actually are able to reduce their alcohol consumption. The details will be left to future research, but it may be possible for a reduction in alcohol consumption to be the goal of treatment for a certain type of alcoholics.

In collaboration between the in-hospital nutrition support team and infection control team, we attempted to standardize the management of infusion therapy. We report on a simple and effective at-home infusion therapy, after total parenteral nutrition(TPN)therapy, by using a Broviac catheter in a discharged patient with a severe skin condition. The patient was a man in his 50s who had amyloidosis. Because of dysphagia and complications of the digestive organs, TPN was chosen as the method for nutritional management. At the beginning the patient repeated infection and a trouble of the skin, but the insertion site was managed by the existing standardized manual. However, switching to a Broviac catheter improved the existing disease. Dermatopathy was improved and there was no catheter-related bloodstream infection under the new management method. Furthermore, the patient is now able to feed orally. Patients should be evaluated individually, and for the case that is hard to care with a manual, it is necessary to choose the best possible method.

The Medical Support Center(MSC)of the A university hospital encourages inpatients to leave the hospital and outpatients to live better at home. The medical social workers and the nurses cooperate to achieve these aims. The role of the nurses at the Medical Support Center is to collect information regarding the medical services and the welfare systems, and to provide the patients and their families with this information. We also educate the hospital staff to better understand the lives of the patients who leave hospital. We also provide cancer patients with information regarding the medical treatment available in the area, social welfare services, hospices, and palliative care, such that they can choose the method of treatment and an appropriate place to live.

We sent the reports and plans concerning nutritional management to the 81 facilities, such as a hospital, nursing home, or clinic of home care, and carried out the questionnaire to determine their level of understanding and utilization of the reports. Sixty-nine % understood the purpose of the survey, with 74% noting that the report served as a reference. The purpose of the report was relatively well understood in the hospital or nursing home environments, but was not sufficiently understood in the clinics. In addition, it became clear that several facilities involved with one patient. Therefore, it was necessary to send a report to each facility. The interest in the report concerning nutritional management was very high in a range of various medical workers. Sections such as "matters that require attention, a characteristic in the nourishment management", "dysphagia ", and "a nourishment management method" were considered useful by these workers. The nutritional evaluation of patients discharged may be difficult; therefore, information from reports on nutritional management may help to make a more informed decision on future nutritional management.

As I mentioned at the past 2 meetings, the incidence of depression in patients under treatment for cancer and the number of families bereaved due to cancer is estimated to be 50% or higher in the future. Thus, countermeasures for cancer are necessary. Here, we discuss the countermeasures used for 20 cancer patients treated at our hospital during the past 3 years.

It is important to predict the neurological prognoses of preterm infants as part of their normal follow-up. Previous reports have shown that conventional magnetic resonance imaging (MRI) and electroencephalography are useful in predicting neurological prognoses. Diffusion tensor imaging (DTI) is a relatively new method of evaluating the central nervous system (CNS) that can detect abnormalities quantitatively. We compared DTI at term-equivalent age in two extremely-low-birth-weight infants diagnosed with periventricular leukomalacia (PVL) with conventional MRI and DTI in three control extremely-low-birth-weight infants. DTI was analyzed using the free software, "Volume-one" and "dTVII SR." We compared the fractional anisotropy (FA) values at the corpus callosum, posterior limbs of the internal capsule, cerebral peduncle, and corticospinal tract using manual region of interest (ROI) analysis, and at the commissural fibers and corticospinal tract using tract-specific analysis. The FA values were lower in patients with PVL than in control infants at all measurement points, except the commissural fibers on tract-specific analysis. These measurement points showed no abnormality using conventional MRI. This suggests that DTI can detect CNS abnormalities that cannot be detected with conventional MRI. However, our sample size was very small and we examined only cases in which PVL was detected with conventional MRI. Further study is necessary to examine the correlation of DTI findings and neurological prognoses in infants who have no abnormality on conventional MRI.

In a case of patient who transfers from hospital-stay to homecare, a pre-discharge conference will be held on behalf of the patient, family and regional staff along with our hospital support guideline system. We would make sure at the conference whether a continued care provided to the patient will seamlessly be offered before and after the discharge. The transfer care arrangement was normally taken place while a patient was still at the hospital. We analyzed the interview evaluation done by the patient, family, and regional staff: three cases with a successfully transferred to the regional home were chosen because they attended the pre-discharge conference more than twice while they were at hospital. All cases had received an arranged care continuously. It seems that the arranged caring was appropriate for the patient and family.

There has been an increase in cancer patient referrals to our palliative care team during a cancer treatment. In order to help an end-of-life stage homecare cancer patient who becomes being depressed and the family being felt restlessness, a fine-tuned response, an early stage of revelation of the disease and treatment are essential to have a long lasting homecare environment. Based on the Basic Plan to Promote Cancer Control Programs, our hospital established a cancer consulting support center and a palliative cancer care team in June 2009, and staffed them with multidisciplinary personnel. With medical staffs involved as a team, we considered a shared decision making repeatedly in compliance with in-patient's wishes for home care. One of the problems we have experienced was that a patient would take a long time for a decision making due to the state of mental depression, even if the patient had an ability to think and evaluate oneself. For a medicinal treatment of cancer patient with the state of depression, steroid, interferon, hypertension drug, female hormone pill, anti-histamine medicine and anti-fungus agent will cause frequent side effects, but they are easy to get rid of the symptoms. It appears that 5-percent of the patients who had steroid administered 10 days ago have a tendency to have a high manifested risk in 40mg/day PURRE- DONIZORO/Japan calculated. In case of medication related depression, the symptom can be rather controlled quickly by a decrease in the amount of medication. On the other hand, there is a possibility that side effects may appear before anti-depression comes to effects in case of an ordinary depression case. And it takes 2-4 weeks for the medicine to be effective. Therefore, amid the cancer patient is being in the state of depression, a decision to transfer the patient for home care environment should be delayed. This is why we ought to investigate it as one of the problems in palliative care. In conclusion, due to a patient's inability to make own decision, or for a home care period to be not shortened, or we fail to make a right timing to for sending the patient to home, a careful daily observation and a fine-tuned response are desired for a sign of depression with the cancer patient.

Purpose: To clarify the characteristics of cancer and non-cancer in-patients receiving a registration system based home support., Methods: A total of 254 patients who were hospitalized from April 2009 to March 2010 were included for this observational study. An analysis was made by classifying the subjects into two groups: cancer group and non-cancer group., Results: A comparison of the two groups showed that the cancer patient group consisted of many men (p<0. 01). The average BI score in the cancer patient group tended to be high upon admission and discharge(p<0. 005). The nursing care level was low(p<0. 01), and both the average length of stay(p<0. 01)as well as the average number of admissions were low(p<0. 05). In case of readmission, both the number of days from the previous discharge until the current admission and the number of days from registration until admission were low(p<0. 01). With regard to the number of drugs administered to the cancer patient group(p<0. 01), the use of narcotics(p=0. 000)was high. Sedative measures(p<0. 01)and the percentage of patients receiving nursing instructions(p<0. 01)were also high. On the other hand, the ratio of patients receiving oral care(p<0. 05), nasolgastric-tube(p<0. 01)and PEG(p<0. 01)was low and few patients needed care in relation to respiration(p<0. 01). Dietary care, physical care, bedsores and falls were not statically significant between two groups. The hospital mortality rate was significantly higher (p<0. 01)in the cancer patient group., Conclusions: A comparison of cancer and non-cancer in-patients regarding the support of a home-based medical care provided through the ward revealed that both home nursing and home medical care were required. Both physical care and preventive support measures were also needed as well. Cooperation between the hospital and community needs should be addressed for an effective home-care support measure during a hospitalization.

Objectives: To prospectively investigate the relationship between the nutritional states of tuberculosis patients at the time of their admission to tuberculosis wards and their treatment outcomes., Patients and Methods: We observed body mass index (BMI), peripheral blood lymphocyte count, serum albumin concentration, and induration size in the PPD skin test of a total of 107 tuberculosis patients after they had been newly admitted to NHO Omuta National Hospital during the period from Aug. 2004 to Jul. 2006. Based on these indices, the patients were divided into four groups according to their nutritional states: severely impaired, moderately impaired, mildly impaired or normal., Results: It was shown that the worse the nutritional state was on admission, the higher the mortality rate from all causes including tuberculosis. There has been no relapse case in patients from this group who have completed tuberculosis treatment despite their poor nutritional states at the start of the treatment., Conclusion: This prospective study of the relationship between the nutritional states of tuberculosis patients on admission and their treatment outcomes reproduced the results obtained from a retrospective study that we had previously reported. The assessment method of the nutritional state that was used in our study was proven to be useful for predicting the prognosis of tuberculosis patients.