Presentation on theme: "Alzheimer’s Association Japan"— Presentation transcript:
1Alzheimer’s Association Japan Noriyo WashizuCase Managementin DementiaAlzheimer’s Association Japan
2conflicts of interest to report. Conflict of Interest Disclosure Noriyo Washizu, Master of Social WelfareHas no real or apparentconflicts of interest to report.
3Alzheimer’s Association Japan Hello everyone.★ I’m Noriyo Washizu from Alzheimer’s Association Japan.★ It’s a great honor to be here to speak to such distinguished people from aroundthe world in this beautiful city San Juan.Today I will talk about the case management in dementia through our experience in Japan.As many of you know, Japan has the highest ratio of elderly population and the longest life expectancy in the world.Currently in many countries the number of elderly and people with dementia is increasing rapidly.I would like to share our experience to build a dementia-friendly world.I hope my presentation will help you understand how important case management is for living well with dementia.Alzheimer’s Association Japan
4Outline Fundamental issues in case management Part 1:Fundamental issues in case managementDefinitionKey issues Part 2:Case management of dementia in JapanThe history of the elderly/dementia care and case managementIntroduction of recent approaches for case management in dementiaJ-DECS (Health care decision making support for people with dementia)Kyoto integrated dementia care plan 2013 to2017・ This is a brief outline of my presentation.I would like to divide my presentation into two parts.The First, fundamental issues in case management.The second, case management in dementia in Japan.The second part includes the history of the elderly and dementia care in Japan and current approaches related to case management in dementia and a real story.
51. Definition 2. Key issues in general /dementia Fundamental issues in case management1. Definition2. Key issuesin general /dementiaLet me start with part 1, fundamental issues of case management.
6Definition By The Case Management Society of America By Japan MHLW “Case management is a collaborative process of assessment, planning, facilitation, and advocacy for options to meet an individual’s health needs through communication and available resources to promote quality cost – effective outcomes.”By Japan MHLW“Case management（Care management ) is the effective, ongoing, and collaborative process and system to fulfill the client’s well-being life in the community by application and improvement of services and developing the social resources.”First, the definition.Many health and social care organizations have their own definition of case management.They are worded differently in some degrees, but they have common factors.Here I would like to show two examples of them.★ The first one is a definition by the Case Management Society of America which is quoted in ADI Alzheimer’s Report 2013.★The second one is by the Ministry of Health, Labor and Welfare Japan.Let me point out that in Japan we mostly use the term “care management” for “case management”Here I use the term “case management” for care management in Japan to make my presentation simple.・ By 厚生労働省「利用者が地域社会による見守りや支援を受けながら、地域での望ましい生活の維持継続を阻害するさまざまな複合的な生活課題（ニーズ）に対して、生活の目標を明らかにし、課題解決に至る道筋と方向を明らかにして、地域社会にある資源の活用・改善・開発をとおして、総合的かつ効率的に継続して利用者のニーズに基づく課題解決を図っていくプロセスと、それを支えるシステム」
7Keywords of Case Management Social resourcesSｋｉｌｌｓAssessment& planningAdvocacyThrough these definitions, the common key words in case management are ★Social resources, ★Skills( assessment・planning) ★Advocacy, ★collaboration,★ and Effectiveness.CollaborationEffectiveness
8Five key issues in case management in dementia EthicsContinuitySocialresourcesCase managementDementiaWhen we think of case management in dementia specifically, we have to keep in mind five key issues.They are 1.Ethics 2.Social resources 3 Family 4.integration 5.Continuity.I will talk about each.IntegrationFamily
9derived from Hyper cognitive culture EthicsAutonomyBeneficenceNon-MaleficenceJusticeDifficulty inindication ofintensionPerson with dementiaFirst, the Ethics.A person with dementia has difficulty in indicating intension and decision making.So in the case management in dementia we have to pay keen attention to four principles of ethics: autonomy, beneficence, justice and non-maleficence.In addition there is stigma derived from hyper cognitive culture.Dr. Stephen G. Post says in his thoughtful book The Moral Change of Alzheimer Disease“I -think –therefore -I am –culture” that is to say Hyper cognitive culture, emphasizes rationalism and economic productivity.We should change the world view of <I think therefore I am>to the view of <I will feel and relate, while disconnected by forgetfulness from my formermyself, but still I am.>Stigmaderived from Hyper cognitive cultureDifficulty indecisionmaking
10Utilization & Innovation of Social resources Initial ImpactUtilization &Innovation ofSocial resourcesBroad range Care NeedsThe next is social resources.To think of the social resources for dementia, there are three issues.First is The initial ImpactThe challenge of dementia emerged over the last 30 years and has been rapidly growing.We have not developed enough social resources for dementia care.Second is Broad range of care needs.People with dementia need care in all areas of life, such as medical, nursing, social, personal and spiritual.Third , the process of the disease is apt to be prolonged and fluctuating.We have to utilize effectively and also innovate the resources to meet the special needs of people with dementia.Prolongation&Fluctuation
11Physical/Mental/Financial FamilyCare PractionerSpokespersonAdvocatorFamily mattersSocial lifeJobPhysical/Mental/FinancialImpactFamily is also a crucial issue.Dementia care is long-term and given mainly by families. For example, In Japan, more than half of people with dementia beyond the middle stage are cared for at home.★Families need to take central roles as< an actual care practitioner> as <a spokesperson> as <an advocator>.★Also, the family caregivers are apt to be sandwiched between jobs and family responsibility.Alzheimer’s report in 2013 noted the impact of caregiving in dementia is physically, mentaly, and financially higher than care giving in non-dementia.Burn out
12Integration Client at home Home helper Dental hygienist Bathing Meal DeliveryClient at homeRehabilitationNext is integrationPeople with dementia need care in all areas of life and receive various types of services daily.For example, the chart is the case of my home visiting nursing patient with dementia and living alone.Six service providers and a clinic are involved in his care and 6 staff or more visit him each day.If the services are fragmented the clients are confused and subsequently worsen.DoctorNurseDay care center
13Continuity Awareness Moderate Mild End of life Next is Continuity of care★Generally the course of dementia involves a long process .★The types and amounts of care should be changed according to the condition.★However, people with dementia are vulnerable to changes in the environment.To avoid the exacerbation by rapid change, it is important to anticipate the next stage for smooth passage.AwarenessModerateMildEnd of life
14Five key issues in case management in dementia EthicsContinuitySocialresourcesCase managementDementiaTo conduct case management in dementia, these five key areas should be kept.IntegrationFamily
15Symphony of living well with dementia This is the image of case management.I think case management can be compared to the performance of a symphony.A solo player is a client and member players are the people surrounding , such as family and various professionals. And the conductor is the case manager. The conductor should coordinate each part to create a beautiful harmony.Up to here , I have talked in general terms about case management in dementia.Let me move on to part 2.
16Case management in Dementia in Japan Here I will introduce the up-to date case management in Japan.But before let me talk about the history of elderly &dementia care in Japan.The history helps to understand the current condition.Past and Present
17The History of Elderly Care and Case Management in Japan 2010 ~Integrated community care systemCase managementfocused on the whole community2000 ~2010Start and Development of Long Term care InsuranceCase managementwithinLong term Care Insurance1980~2000Preparation for the aging societyNoCase managementThe history of elderly care in Japan can be divided into four periods.★The first is from 1960 to 1980, family care or institutionalization by law.There was no social resources for the elderly care and no case management.★The second is from 1980 to 2000, preparation for the aging society to promote qualitative and quantitative expansion with trials and errors.★The third is from 2000 to 2010, the start and development of long-term care insurance and case management.★The fourth is after 2010, when the case management is required to focus on the whole community.1960~1980Family care/Institutionalization/HospitalizationNoCase management
18Major policies & elderly population ratio *Integrated community carepolicy*5year plan for dementia care*LTC insurance*Future plan forElderly care*Dementia supporternational campaign31.6%*Health careact for elderly*Gold Plan*new Gold plan*Gold plan 2123.0%Universal health insurance & pension systemSocial welfare service act for Elderly17.4%This graph shows major policies for the elderly and the aging population ratio over time.In early ‘60, Japan achieved universal health insurance, a universal pension system and enacted the elderly Social Welfare Service Act.These three form infrastructure for the aged society but just at the beginning.From 1960 to1980 was the period of family care and limited Institutionalization by the government.Aged care was assumed to be the family’s duty.There were no social resources and case management for elderly care and the shattered families sent their parents to elderly hospitals as a last resort.There elderly were forced to be bedridden to the end of their lives in horrible circumstances.It was during this period that Alzheimer’s Association Japan started as a family caregiver, peer support group. (in 1980)AAJ12.1%9.1%7.1%5.7%Family care & institutionalization preparation& trials case management super care management
19As you can see, this is a patient restrained in his bed. These pictures between the 1970’s~1980’s are taken from the book “ The elderly hospital” written by Kazuo Okuma, a famous journalist in1988.The book raised an alert over the elderly issues.Restrained patient in his bed – From the book “The elderly hospital” By Kazuo Okuma, 1988
20Lunch time at a hospital for the elderly The lunch time of the elderly hospital From “The elderly hospital” By Kazuo Okuma, 1988
21From the book “The elderly hospital” By Kazuo Okuma, 1988 Another example of RestraintFrom the book “The elderly hospital” By Kazuo Okuma, 1988
22The history of aged care & elderly population ratio *Integrated community carepolicy*5year plan for dementia care*LTC insurance*Future plan forElderly care*Dementia supporternational campaign31.6%*Health careact for elderly*Gold Plan*new Gold plan*Gold plan 2123.0%Universal health insurance & pension systemSocial welfare service act for Elderly17.4%★From 1980 to 2000 was the period of preparation towards the coming aging society.The impact of the increasing elderly population and the soaring medical costs, caused by hospitalization of the elderly, drove the development of systems and infrastructure, supported by the economic growth.The development was facilitated by three national plans.But aged care was still managed mostly by families and in a few cases provided by the government in a uniform way.Institutional care was focused on efficiency and rationality.Meanwhile in the middle of the 90’s new attempts, such as group homes and assisted living were started by the influence from the North Europe.12.1%9.1%7.1%5.7%Family care & institutionalization preparation& trials case management super care management
23Increasing of Aged Care Services The graph shows the increasing number of home helpers and residential facility beds promoted by three national plans.Gold Plan New Gold Plan Gold Plan 21
24The picture is from a text book published by the Japan broadcasting Corporation. The scene is from the first hospital for dementia patients established in1984 by Dr. Ken Sasaki, one of the pioneers of the dementia care.People were just walking around the special corridor for wandering.It was a safe way to wander, but at that time we did not comprehend why they were wandering.
25The same hair style and uniform. It was easy to keep clean The same hair style and uniform. It was easy to keep clean. There were no furniture in the bed rooms to avoid the risk of injury.
26Permanent admission for reasons of wandering, The reasons for the hospitalization were wandering, hallucinations and aggression etc.Permanent admission for reasons of wandering,hallucination, and aggression, etc
27The history of aged care &elderly population ratio *Integrated community carepolicy*5year plan for dementia care*Dementia supporternational campaign31.6%*LTC insurance*Future plan forElderly care*Health careact for elderly*Gold Plan*new Gold plan*Gold plan 2123.0%Universal health insurance & pension systemSocial welfare service act for Elderly17.4%★ I would like to move on to the years from 2000 to In this period, the elderly population ratio was over 17%.12.1%9.1%7.1%5.7%Family care & institutionalization preparation& trials case management super care management
282000 The start of long term care insurance Clients decision making & Case ManagementIncrease ofelderly population In need of long term careDecline of family function・Nuclear family・Aging of family cares・Women’s social advancementImpact of Social hospitalization・Increasing of the health cost・Bed blockingXLong Term Care InsuranceIn 2000, the Long term care insurance came into force after the period of 20 years preparation.There are mainly three background factors.First, increasing elderly population in need of long term careSecond, declining family function, came from developing of nuclear family system, and women’s social advancement.Third, the impact of social hospitalization, such as health cost and bed blocking.★Long term care insurance brought in three matters.★One, the change from the traditional family care to the social care systemTwo, case management for all service users Three, clients decision making in using the services.Social care resourcesCase managementClients decision making
29The finance of the long term care insurance Service ProviderServices10% of Co-payment90 % of the costPayment for Accommodation & MealsTax(50%)This chart is just a general over view of a very complicated financial system of long term care insuranceAll people over 40 are required to pay a mandatory premium.Users(Persons certified in need of Long Term Care )Premium（50％）Paid by persons over 40
30How to use the long term care services <In-facility>Health care facilitiesSpecial nursing homeSanatorium medical facilities<In-home services >Home visit helpAt- home Bathinghome visit nursingHome visit rehabilitationDay care serviceShort –stay admission serviceProvision or subsidy for care equipmentSubsidy for home alternationMultifunctional care in small homesGroup homes for People with dementia<Preventive care services>ApplicationInvestigationDoctor’s diagnosisJudgmentCare need CertificationCase (care) ManagementThis chart indicates how to use the long term care service.For more information, please visit Ministry of health, labor and welfare website.
31The number of case managers and work place (Each case manager works with under 40 clients)13,5677,629Community careIntegrated communitycare centerAged care facilities87,223This graph shows the number of case manager and their work place in all over JapanThe credential of case managers is stipulated by Long term care insurance law.Candidates are required to gain 5 years experience prior to the qualifying exam.
32The history of aged care & elderly population ratio *Integrated community carepolicy*5year plan for dementia care31.6%*LTC insurance*Future plan forElderly care*Health careact for elderly*Gold Plan*new Gold plan*Gold plan 2123.0%Universal health insurance & pension systemSocial welfare service act for Elderly17.4%★Let’s move on to after 2010 to the present and futureIt ‘s a period of promotion for integrated community care and specific plan for community dementia care to meet a super aging society.Case management is required to focus on the whole community.12.1%9.1%7.1%5.7%Family care & institutionalization preparation& trials case management super care management
33Aging situation in Japan Over 65 population ratio(2013)25.0 %Life expectancy(2012)Male 79.94FemaleThis is the current aging situation in Japan.
34Increase in the number of the elderly living alone In over 30% of the elderly were living alone .
35The number of elderly persons & ratio with dementia higher than moderate (in millions)4.618.104.22.168.8This graph shows the number of elderly persons with dementia higher than moderate level.★The Ministry of Health, Labor and Welfare reported the total number of the elderly with dementia is 4.62 million and the number of people with Mild cognitive impairment is 4million in 2013.
36Further Increasing Aging Population The ratio of aged 75 or older Persons with dementiaSingle/Couple households of aged 65 +Demand ofIntegrated community care & Specific strategy for dementia careWith the further development of aging society, over 75 population, the number of people with dementia, and single or couple households of the elderly, are increasing rapidly beyond estimation.★The long term care insurance has worked well but it is still insufficient for thesuper aging society.Also specific measures for dementia care is required.★In 2012, the Ministry of Health, Labor, and Welfare announced the five year planfor dementia .And the following year the policy of an Integrated community care was announced.Case management is required to coordinate and innovate the social resources in the community holistically.・ Also Community development became the urgent issue. National campaign ofDementia supporter caravan started in 2004, is an example.It has been conducted successfully and there are more than 4million supporters over Japan in 2013. As of a dementia supporter, everyone who took 90 minutes course about knowledge of dementiaand how to support people with dementia as a citizen can be dementia supporter.★Integrated community care system policy in 2013★Five –year plan “measures against dementia 2013~2017”LTC
37Integrated community care system policy by the governmentGOALIntegrated management of the services of medical care, social care and welfare24/7 care setting within a radius of 30 minutes of travel timeComprehensive Regional Support CenterCooperationSmall-scale multifunctional care facilityThis chart describes the concept of the integrated care policy by the government.It aims to set up a 24/7 medical, social and welfare care within a radius of 30 minutes of travel time in order to support the elderly to live in their community.The case management is required to bring in the whole community centering around the client.Visiting nurse stationNursing homeHomeDaycare centreCommunity activitiesVolunteer
38“Change the flow of dementia care” Government’s 5-year Plan“Change the flow of dementia care”Community care servicesHome doctorShort term treatment in psychiatric hospitalizationLiving in the communityLong Term HospitalizationIntegrated community care centerDementia medical centerInitial Phase intensive care teamEarly, proactive, preventive approachThis is the overview of the government 5 year plan “measures against dementia” launched in 2012.The dementia care has been improved little by little from 1960 with many trials.But there are still many cases of long term admission in psychiatric hospitals.The aim of the plan is “change the flow of dementia care”.First, long term institutionalization should to be changed to living in a comfortable & familiar environment in their community.Second, post crisis intervention should be changed to an early, proactive, preventive approach.Post Crisis Intervention
39The Kyoto Community Dementia Care Model Government measuresPWD and carers’ perspectiveUnder two central government policies, many local governments have started their own particular measures.Among them, I would like to introduce two associated projects of the Kyoto community dementia care model derived from 1350 comments analyzed by the Delphi technique and many discussions.They are important projects for integrated case management in dementia.
40People with dementia Explanation Decision Making? Understand ? Yes is yes?Decision Making?Firstly ,J-DECS (Health care decision making support for people with dementia in Japan).In case management in dementia, health care decision making is one of the most important and difficult issues.★People with dementia have difficulty in communication ,understanding an decisionmaking.It might result in withholding or excessive, or involuntary medical treatment.J-DECS has started to solve this problem.Withholding/Excessive/InvoluntaryTreatment
41Target http://j-decs/org Dr. J Narumoto email@example.com Health care decision making support for people with dementia in JapanDr. J NarumotoTarget1.Assessment tools of capacity of decision making for patients with dementia2.Guidelines and Materials to help the elderly for health care decision making3.Decision making process model for patients with decision making difficultyJ DECS is a project being studied by the specialists of medicine, welfare, legal experts, and Alzheimer’s Association Japan members.The target are to develop capacity assessment tools, the dementia and elderly friendly material for explanation, and decision making model.・ For more information, Please visit the website or mail to Dr. Jin Narumoto on theslide.
42Kyoto Integrated Dementia care path map Integrated community care support center/Case ManagerAlzheimer’s Association・ NPO ・ Council of Social Welfare ・ Local governmentAssisted Living/ Private Residential HomeLTC Welfare FacilityLTC Health Care FacilityGroup HomePersonal Care/Welfare/HousingSocial resourcesInitial Phase Intensive Support TeamMemory CaféWelfare Center for ElderlyDistrict Welfare OfficeClub of the AgedAdult Guardian shipMultifunctional in-home care /Short StayDay care CenterHome helper/Meals DeliverySpecial Daycare CenterPeople in the community (+Dementia Supporter )Family membersPerson with dementia at homeMedical & NursingDementia Specialist/ Specialized Medical Center /Dementia Support Dr.General Practitioner /Home visitingHome visit Nursing/Rehabilitation/PharmacyNext is the Kyoto dementia care path map. It was innovated by Dr.Takechi, Department of Geriatrics, Kyoto University Graduate School.★The center part indicate a person with dementia at home ,family and people in the community . Bottom line is the course of the disease.★Social resources in the community are tabulated.★The box on the top is support group, and governmental agency.★The top half shows personal care and welfare services and housing.The dark orange boxes indicate residential services.★The bottom half shows Medical services.The dark blue boxes indicate admission services.The map with the names of the social resources in the client’s area gives a visual overview of the flow of the care to a person with dementia, the family and the care team members.General Hospital, Nursing HomeMedical Center for DementiaPsychiatric hospital treatmentAwareness Mild Moderate Severe End of Life
43Integrated community care support center/Care Manager Alzheimer’s Association・ NPO ・ Council of Social Welfare ・ Local governmentpersonal Care/Welfare/HousingSocial resourcesKyoto Integrated Dementia care path MapAssisted Living/ Private Residential HomeLTC Welfare FacilityLTC Health Care FacilityGroup HomeInitial Phase Intensive Support TeamMemory CaféWelfare Center for ElderlyDistrict Welfare OfficeClub of the AgedAdult GuardianshipMultifunctional in- home care /Short StayDay care CenterHome helper/Meals DeliverySpecial Daycare Center for DementiaPeople in the community (+Dementia Supporter )Family membersPerson with dementia at homeMedical & NursingDementia Specialist/ Specialized Medical Center /Dementia Support DoctorGeneral Practitioner /Home visitingHome visit Nursing/Rehabilitation/PharmacyThis is the example of use the Kyoto care path map. It can be used entire process of case management, such as assessment, care planning, a conference, and a case study as well.★The gray arrows indicate services used.★The red arrows are services being used.★The yellow arrow will be service used in the future.This can be an effective case management tool.General Hospital, Nursing HomeMedical Center for DementiaPsychiatric Hospital/Hospital for dementia treatmentAwareenss Mild Moderate Severe End-of-Life
44Kyoto Integrated Dementia Care Path Map Audit outcomein 2017I can expect a cure.I receive the appropriate services for younger onset dementia.I have a comfortable place to stay.I can receive appropriate medical services.I had early diagnosis and started treatment.People understand my difficulty in communication and respect my wishes.Kyoto’s integrated dementia care model achievements will be evaluated in 2017.The UK’s “National Dementia Strategy final year audit outcome will be used as a reference.Evaluation will be completed by the feedback from all involved about the points appearing on the picture.I spend active life with the understanding & support from all people around me.I have a role as a community member.I & my family are well supported and feel peace of mind.
45Story ofMr. SakaiHere is the final section of my presentation, A story of Mr.Sakai, a members of Alzheimer’s association Japan.I think he will explain an example of case management in dementia in Japan now.He was a capable businessman and also a contributor to the community.At age 58, Mr. Sakai began to often make mistakes at work.At age 60, the company required him to have a medical examination.Then he was diagnosed with Alzheimer’s disease and started medication.
46When he was 62 he retired because of the Alzheimer’s disease. Over the following 3 years he attended a painting group and enjoyed tennis with the assistance of club members.His wife explained his condition to neighbors, friends, and all acquaintances.Everyone was very supportive. This slide is his painting.She also knew of the Alzheimer’s Association Japan monthly caregivers meeting through the newspaper and attended every month with him.We had fun with him at the meeting and weekend trip. He was a great singer. The problem was once he had a microphone , he never passed it and kept singing.
47At 64, his condition worsened and he went out frequently day and night. Sometimes she asked the police to stop him from going out at midnight.At 65, he started to attend a day care center.At the day care center he was stable but at home he was often aggressive and agitated.But he stayed at home using the maximum long term care insurance and welfare services coordinated by his case manager.
48At 66~67 he got lost and was found afar off by the police . It was a time for a crisis intervention.He was admitted to the hospital twice for his treatment and respite care for his wife for one month each.At 68, after being hospitalized his condition was relatively stable.But his wife was completely exhausted although she wanted to take care of him at home.Despite the case manager’s effort it was difficult to find more services because of his physical and mental condition, such as his refusal to be cared for, aggression, and restlessness in an unfamiliar environment.Ｈis case manager brought in the new system, “nursing home sharing.” Two people use one fixed room every other month in rotation.He and his wife had a good time both at home and at the familiar nursing home for over one year.The picture is his pet “Fu.” Fu helped his wife take care of him and comforted both of them.
49At 69, the disease gradually worsened and his condition deteriorated. His wife still wanted to look after him at home but it was impossible. Through conferences his family decided to have him admitted to the nursing home where he did the home sharing.She visited him every other day and they enjoyed being together.One afternoon in June 2013 he enjoyed his favorite ice cream with his wife at the nursing home café as usual. Suddenly he became unconscious and fell down.After two days in the hospital he passed away.Now she is living alone. She said when I visited her the other day “I just remember his smiling face and thank for all people involved in his care”
50Conclusion In conclusion Let’s me summarize the main points of my presentation.First, to achieve living well with dementia, case management is absolutely essential.But, it cannot function without social resources.Case management and social resources are all-in-one.We should develop them simultaneouslySecond ,the social resources and case management are the backbone of dementia care. Their principles should be set by a national plan and details should be streamlined by each community to suit each reality.Third, the keen attention to the ethics to protect the human rights of people with dementia should be kept through a whole process of resource building and case management.Because they are always at risk of being ignored their existence and dignityWe have learned from our experiences, through trial and errors.However, we are still in midstream to the goal and facing the many social and economic challenges. We desire to cooperate with people involved in dementia care around the world, just like all of you here,Finally in closing, I would simply like to say, let’s work together for living well with dementia.★Thank you very much.ReferenceADI. Alzheimer’s Report 2013Dr. Jin Narumoto J-DECDr. Hajime Takechi Aging as a positive phenomenonDr. Toshio Mori The guidebook for younger onset dementia care. Kyoto integrated regional care promotion organizationKazuo Okuma Reportage on the elderly hospital. P19, P99. Asahi NewspaperPost,S.G,2000.The moral challenge of Alzheimer Disease, P5, The Johns Hopkins University pressKazuo hasegawa.2012.Dementia care, Vol.1.Japan broadcasting corporationKyoto Integrated regional care promotion organization.2013, Kyoto integrated community dementia care policy.Japan ministry of Health, Labour, and Welfare Annual Health, Labour, and Welfare- social security-