David LeCount Report

Length of Hospital Stays

Utilizing the hospital information derived from a number of the presentations and hospital sites visited, the following composite picture comes together regarding the lengths of stay. As previously stated, 47% of the people have been hospitalized for 5 years or longer. While in Japan the average length of stay in the hospital is 500 days, in the Hokkaido Prefecture, it is 222 days. The average length of stay in an excellent private hospital in Obihiro was 210 days; the shortest was one day and the longest had been there since 1969. Only 30% of the admissions were compulsory, and 70% were voluntary at this private hospital. Commensurate with the development of housing in the community and other community supports, their average length of stay is decreasing. At a private psychiatric hospital in Nagoya, the psychiatrist in charge thought the average length of stay was about a year. The people in this setting appeared to present as the most institutionalized. Some people had been there as long as 40 years. While the psychiatrist was quite clear as to how people were admitted, he seemed vague about the discharge process saying, "it was up to the patients." At the Kawaski Psychiatric Rehabilitation Center, four years was the longest stay. This seemed to be an excellent facility, in which people were individualized and treated with a great amount of respect. The professionals in Kawaski prided themselves on having fewer psychiatric beds per 10,000 people, and shorter average lengths of stay than the rest of Japan. At the Saitama Comprehensive Mental Health Center, the average length of stay for in-patient was stated as being three months.

Psychosocial rehabilitation

Attempts at psychosocial rehabilitation were evident in most of the hospitals visited. There was one hospital in which custodial care appeared to predominate, such as in the Nagoya private hospital. There, the nursing staff was observed mainly in the nursing station, and the patients were in the common area without staff attention. Most of the hospitals did have ancillary services, such as occupational therapy and other psychosocial rehabilitation activities within the hospital setting. The Saitama Comprehensive Mental Health offered the most structured ongoing activities within the hospital setting. Activities of daily living were taught in a didactic manner, as in a classroom setting. Structured routine work assembly tasks where attention and time on the task was also being taught. This rigorous training was a part of the daily milieu, preparing people for their eventual community placement. Based on my experience, there is the problem of generalization of such skills taught in the artificial institutional environment to that in the community, especially for those people who have the most severe psychiatric disorders. The evidence would support that the best place for people to learn community living skills is directly in the community and through the practical daily applications as a part of their natural routines.

Decreasing Hospital Utilization

There is evidence that in-patient utilization is decreasing from a high of 360,000, to between 330,000 - 340,000 today. The future national laws and initiatives should further impact on decreasing the use of hospitalization as the primary mode of treatment. The future directions stressed during the Tokyo seminar, at Obihiro, and Kawaski, point to a community direction. New legislation being proposed over the next five years places additional emphasis on community-based services. It will attempt to bring further parity for mental health services in keeping with what exists for physical disabilities, development disabilities (mental retardation), and care for the elderly. This equitability relates to new initiatives that will expand upon work opportunities, living arrangements such as in-home attendant care, an emphasis on psychosocial rehabilitation, and choice for the consumers - all within the context of the community.

With a decrease in hospital utilization, there comes the hope that some of this money will be realigned for community alternatives, and that more and more services will be community centered. The discussion did not occur regarding how empty hospital space would be utilized. The private hospital in Obihiro may provide some answer to this dilemma, as approximately one-third of the residents there were diagnosed with Alzheimers and other related forms of dementia. These residents were in advanced states of the disease, in which institutional care for their ongoing care and protection was necessitated. Given the aging population in Japan, it is apparent that many more people will be in need of institutional care due to the infirmities of aging. Hospitals may be appropriate settings for people who, in the latter stages of their illness, can no longer be accommodated for in-home and day-services.

There does not appear to be a master plan or blueprint for the country to follow. There remained some frustration and confusion among professionals about the lack of direction from a national perspective, as well as obtaining more funding to promote community focused services. Some questioned the authenticity of the national statistics available pertaining to the money being spent for psychiatric in-patient services and the number of people placed in these settings. As a result of these comments and my observations, I will be including information in this report pertaining to downsizing hospitals from a funding and diversion strategies perspective. I will also include ways to promote community practices.

Community Practice

In my visit, I observed uniformity in community practice throughout Japan. In comparison to the hospital industry, the communities have very sparse staff and resources. In comparison to our community mental health system in Madison, what I observed in Japan is where we were at over two decades ago. The number of people in the hospital is analogous to the U.S. in the 1950s when there were 560,000 inpatient due to mental illness. To Japan's credit, however, it appears there is a conscious effort to see that some support is provided before a person is discharged from the hospital; a practice that did not always occur throughout our country. There were many fine and creative workshops and working opportunities represented, but very few emphasized integrated work forces, a practice that strongly needs to be encouraged.

Current practice in Japan is that psychiatric care in many instances continues to stem from the discharging hospitals. The case management may also emanate from the hospital in many instances. Workshops were the primary daily activities being made available to the consumers. Reportedly, there are 1,400 community workshops and 500 group homes throughout Japan. While there has been a dearth of national and prefecture funding for community resources, some funding has been made available in more recent years for work opportunities and living arrangements. While most practices at the local levels appear to be primary piecemeal, with agencies working independently, some communities have assumed individual initiatives in bringing welfare, public health, psychiatric centers, and the hospitals together to promote interagency communication and working together on behalf of the consumers. Examples of this were represented in Obihiro, Kawaski, and the Yadokerinosato in Omiya.