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Poster Abstracts

Self-management Support to Prevent Recurrences of Stroke by Multidisciplinary teams: The Integrated Care Initiative in K-city, Japan


Masaaki Otaga

Natinal institute of Public Health, JP
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The cost of the Long-Term Care Insurance System in Japan has been constantly rising since its implementation in 2000 due to rapid aging throughout the county. In such context, what are expected from local municipalities, as executors of the system, are; to prevent the elderly from falling into fragility and starting to demand care, to reconstruct the delivery system of medical and social care for the elderly with chronic conditions and to improve management capability of each local municipality in order to realize those changes.

Summary of the initiative:

K-City is a city with about 30,000 people and located in a suburb of Japan. In this city, 20% of the elderly requiring the Long-Term Care had experienced stroke as their direct causes of care, and the readmission rate within a year since discharge was up to 30%, which was high among municipalities in Japan. For this reason, K-city launched a model project to support stroke patients after their discharge and to prevent their re-hospitalization by close collaboration and multidisciplinary team work (Self Management Team) between hospitals, primary care providers since April 2014. Each member of the team had created a flow chart of what had to be done by October in the same year and, until today, those charts have been used in practice along with PDCA cycle under supervision of the municipal government.

Targeted population and stockholders:

The population of K-city is 33,226, and that of the elderly is 9,699 (29.2%), and the percentage of people who officially need Long Term Care is 14.4%. The subject group of the Self Management was defined to be those with level 2 or less in the certification of Long Term Care. Those who are involving in this project are doctors and nurses in hospitals, care managers in the counseling and support centers in the community, public health nurses, and staff of the municipal government.

Highlights (Innovation, Impact and Outcomes):

By the end of September 2018, only 1 out of 8 participants (8 - 21 months after discharge) in this model project had been re-hospitalized. The sharp drop of this number indicates that the Self Management support project has been successful, at least to certain extent.

Conclusions and key findings:

The model project in K-City was realized by the initiative of the local government which took a role of management in integration of clinical practices across different specialist groups. As the result, it successfully presented a methodology to overcome segmentation between medical and nursing care services which had been considered a significant problem. Furthermore, it provided the first evidence in Japan to claim the Self Care management support contributes to preventing recurrence of patient's disease. K-City also achieved the highest score in the county, 577 out of 612, in a new evaluation system to measure capability of management functions related to the Long Term Care insurance among local municipalities which started since 2018. This result shows that the management capability in a local government has a significant impact on promotion of integrated care in its local community.


How to Cite: Otaga M. Self-management Support to Prevent Recurrences of Stroke by Multidisciplinary teams: The Integrated Care Initiative in K-city, Japan. International Journal of Integrated Care. 2021;21(S1):263. DOI:
Published on 01 Sep 2021.


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