Based on progress in home visits for rehabilitation and health guidance since 1979, the trend after the Nursing Care Insurance Law was enforced in 2000 was investigated. In home visits for rehabilitation, cooperation with many related organizations is required, and reorganization of the network built before the enforcement of the said Law is needed. The role of each home visiter for rehabilitation is being formed and cooperation with care managers is being strengthened. The tendency that the participation of the local government may decrease can't be denied. Connection with the hospital and the local government should be maintained, and a new community-based network needs to be built.
Rehabilitation aspects ; Community ; Management ; network ; Encounter due to convalescence

Following the revision of nursing care remuneration in FY 2015, our health service facility for the elderly made improved support available based on the outcomes of rehabilitation case conferences (RCCs) we convened for users of visiting rehabilitation services. In this study, we conducted a survey to investigate the implementation status of the RCC outcomes by respondents,including service users, their family members, and healthcare professionals,at our facility and the changes observed in service users who participated in the RCCs.Survey items inquired about the basic attributes of service users, RCC topics discussed, status of participation in the RCCs by occupation,and independence in activities of daily living (ADL) of elderly disabled people.The topics covered in the RCCs were classified using the International Classification of Functioning,Disability,and Health.In total,85 of 108 people who needed nursing care (34 men, 51 women; mean age 81.4±9.4 years;mean duration of service use 16.3 months) participated in the RCCs.The majority of topics covered in the RCCs concerned ADL and environmental factors,and more than half of the respondents participated in RCCs several times.Because ADL and environmental factors were discussed most,it can be said that the RCC concerning visiting rehabilitation services for users living at home is an effective means of expanding ADL and instrumental ADL. An advantage of holding RCCs is that the users themselves can clarify the current status and future goals. Also, from the service provider perspective, multidisciplinary cooperation becomes easier and helps to further improve support for users.